Facilities and Estates

Cleaning of the Environment: Standard Operating Procedure

Document Control Summary

Status: New

Version: v1.0 Date: September 2015

Author/Title: E O,Brien – Hotel Services Manager

Author/Title: Mary Mandle – Hotel Services Manager
Author/Title: Trish Purfit - Facilities Manager
Owner/Title: Kenny Laing - Deputy Director of Nursing

Approved by: Policy and Procedures Committee Date: 18/02/2016

Ratified: Policy and Procedures Committee Date: 18/02/2016

Related Trust Strategy Provide high quality services, built on best known practice and
and/or Strategic Aims evaluated through service user and carer feedback and clear
process and outcome measures

Implementation Date: January 2016

Review Date: January 2019

Key Words: Clean, safe, PLACE

Associated Policy or All Facilities services Standard Operating procedures

Standard Operating
Procedures
 Cleaning of the Environment SOP/February 2016

CONTENTS

1. INTRODUCTION ........................................................................................................ 3
2. PURPOSE .................................................................................................................. 4
3. SCOPE....................................................................................................................... 4
4. RESPONSIBILITIES .................................................................................................. 4
4.1 Executive Director ................................................................................................ 4

4.2 Director of Infection Prevention and Control ...................................................... 5

4.3 Facilities Services Professional Lead ................................................................. 5

4.4 Senior nurses and Matrons .................................................................................. 5

4.5 Supervisors with responsibility for Facilities Support worker .......................... 5

4.6 Infection Prevention and Control Team.............................................................. 6

4.7 All Staff .................................................................................................................. 6

5. STANDARD OPERATING PROCEDURES ............................................................... 6

6. KEY OBJECTIVES .................................................................................................... 6
6.2 Monitoring ............................................................................................................. 7

7. GOOD PRACTICE MEASURES FOR INFECTION PREVENTION AND CONTROL . 7

8. PATIENT INVOLVEMENT ......................................................................................... 8
9. MODERN MATRON / MANAGERIAL INVOLVEMENT ............................................. 8
10. PROCESS FOR MONITORING COMPLIANCE AND EFFECTIVENESS .................. 9
11. REFERENCES ........................................................................................................... 9

Change Control – Amendment History

Version Dates Amendments

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 Cleaning of the Environment SOP/February 2016

1. INTRODUCTION
This document has been developed in conjunction with the Infection Prevention and Control
Team.

Ensuring all clinical and non clinical areas are clean and safe is an essential component in
the provision of effective healthcare. A clean and tidy environment is an outward
demonstration 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.

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.

The NHS plan identified a need to develop National Cleaning Standards applicable to all
hospitals in England. The NHS National standards of cleaning were therefore introduced in
April 2001. These standards, which are outcome based, were produced by experts and
professionals in the fields of cleanliness and infection control.

It is recognized in the standards, that the cleanliness of any hospital environment is

important for infection control and patient well-being and that cleaning staff play an important
role in quality improvement, in the confidence the public has in its hospitals and in reducing
hospital acquired infections.

There is now a higher profile on improving cleanliness in hospitals and this is now a key
element of how each hospital’s performance is judged. This is assessed in a number of
ways and features in Care Quality Commission inspections and performance assessments
also demonstrated year on year in PLACE (patient lead assessment of the care
environment).

In December 2004, “Revised guidance on Contracting for Cleaning” was issued reinforcing
the 2001 “NHS National Standards of Cleanliness” with strong advice from the Department
of Health that these be adopted. Therefore the Cleaning policy must have regard for the
NHS plan requirements and the future Trust cleaning policy.

In December 2006 a revised cleanliness standards document: “The national specifications

for cleanliness in the NHS: a framework for setting and measuring outcomes” was issued.
The revision took account of the “Matrons Charter”, the Healthcare Commission’s
“Standards for Better Health” and the “Code of practice for the prevention and control of
health care associated infections” introduced under the Health Act 2006 (Revised 2008).
This includes the need to incorporate the recommended minimum cleaning frequencies in
the “Revised guide to contracting for Housekeeping”. Furthermore there is a requirement to
include a strategic cleaning plan and cleaning responsibility framework. To ensure delivery
of this Trusts have a duty under the “Health Act 2008” to appoint a lead manager for
cleaning and make their arrangements for cleaning publicly available. In June 2009 a
Revised Health Care Cleaning Manual designed to help NHS Trust meet their obligation to
aid the delivery of high quality effective and safe Health Care premises.

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 Cleaning of the Environment SOP/February 2016

2. PURPOSE
The aim of the cleaning policy is to provide direction in respect of the cleanliness of the
Trust’s site, and to provide the basis from which the Trust can provide staff, patients and
visitors with a clean, safe environment. In providing this service the Trust shall be conscious
of the requirement that the service needs to be provided in a manner that gives added value.

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 Trust's Strategic and Operational Cleaning
Plans. It is stressed however that all employees have a responsibility for caring for this
environment.

Recognising that cleanliness is everyone’s responsibility the aim of the strategic

cleaning plan is to:

 Provide direction in maintaining and improving cleanliness standards across South

Staffordshire & Shropshire Healthcare Foundation NHS Trust, and our partners’
premises where we have a responsibility for Facilities & Estates services ensuring a
clean, comfortable and safe environment for patients, clients, visitors, staff and
members of the general public.
 Increase patient confidence whilst using our services in relation to environmental
hygiene and the organisational commitment to reduce the incidence of healthcare
associated infection.
 The opportunity to improve cleanliness standards in terms of the national standards
of cleanliness and patient lead assessment of the care environment (PLACE)

3. SCOPE
This policy embraces all cleaning activities within the Trust and it will be written into the
service specifications with other Facilities Management providers that they must adopt it as
part of their terms and conditions. This will include not only elements traditionally cleaned by
the Hotel support worker such as floors, walls, sanitary ware etc, but also those elements
traditionally undertaken by the Estates department such as external areas, vents, ceilings
etc. In addition to this, patient equipment traditionally cleaned by ward staff will be included.
Refer to Cleaning and Disinfection of Non-Sterile Equipment Policy

This policy will also take account of other relevant Trust policies such as Control of Infection,
Waste Management, and Health & Safety and will also reflect national standards, for
example, NHLA PLACE, the Code of Practice for the Prevention and Control of Healthcare
Associated Infections (2008) and the Matrons Charter.

4. RESPONSIBILITIES

4.1 Executive Director

The Chief Operating Officer/Director of Nursing has the executive role for cleaning
with responsibility to ensure:-

 Cleaning standards are in place and adhered to throughout the Trust

 A cleaning Policy and Policy is in place and kept updated for significant changes
 The Trust complies with national requirements with respect to cleaning
 Effective monitoring arrangements are in place to assess cleaning performance
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 Cleaning of the Environment SOP/February 2016

4.2 Director of Infection Prevention and Control

The DIPC has the executive role for infection prevention and control including the
responsibility to, challenging inappropriate clinical hygiene practice

4.3 Hotel Services Professional Lead

It is the responsibility of the Facilities Services Professional Lead to:-

 Take the overall operational lead for Housekeeping throughout the Trust
 Ensure compliance with the NHS standards of cleanliness and minimum
frequencies
 Involve senior nursing staff and Infection Control Nurses in all decisions involving
the setting of SLA s and specifications
 Provide Quarterly Cleanliness reports to the board and record.
 Overview the audit and monitoring programme, annual ERIC
 Ensure all legislation and all NHS standards are implemented
 Manage and support the PLACE (patient lead assessment of the care
environment)

4.4 Senior nurses and Matrons

It is the responsibility of the Modern Matrons to:-

 Lead on a culture of cleanliness in clinical areas

 Set and monitor standards in conjunction with others
 Maintain inter-professional working with the Facilities & Estates Managers
 Agree cleaning standards for their areas
 Make sure that standards are met in conjunction with the Facilities & Estates
Managers
 To support cleaning staff in achieving required standards

4.5 Supervisors with responsibility for Facilities Support worker

It is the responsibility of the Housekeeping Supervisors to:-

 Ensure there are sufficient fully trained staff in place and oversee and record the
training
 Monitor staff sickness, annual leave, employee development reviews and rotas
 Follow policy and procedure with guidance from Human Resources
 Follow disciplinary procedures with guidance from Human Resources
 Maintain and adhere to NHS standards of cleanliness oversee the monthly
monitoring of cleanliness within the wards and departments
 Work closely with the infection prevention and control team, Facilities & Estates
Managers, Modern Matrons and Ward Managers
 Control departmental budgets, overseeing ordering, staffing levels and other
financial costing
 Implement ward specifications and rotas
 Ensure there is an appropriate supply of equipment, including cloths and
chemicals taking into account infection control and Health & Safety Regulations.
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 Cleaning of the Environment SOP/February 2016

4.6 Infection Prevention and Control Team

It is the responsibility of the Infection Control Team to:-

 Advise on the contracts for linen and clinical waste

 Contribute to the monitoring of the cleanliness standards
 Participate in working groups in relation to all aspects of cleanliness, such as
Modern Matrons
 Act as a resource for staff
 Approve cleaning products
 Contribute to inspections such as PLACE
 Report concerns formally through the Infection Control Committee
 Carry out annual infection control training for cleaning staff

4.7 All Staff

It is the responsibility of all staff to:-

 Treat their working environment with respect, keeping it tidy and easy for cleaning
staff to access
 Refrain from littering or other careless activity likely to degrade the environment
 Report to their manager, other appropriate staff or the Facilities & Estates Help
Desk any concerns regarding cleanliness or tidiness standards in buildings or on
the Trust and our partners sites

5. STANDARD OPERATING PROCEDURES

This policy will be supported by the Facilities services Standard operating procedures which
provide guidelines which staff are expected to follow to ensure a clean environment fit for
purpose to minimise risks to patients, visitors and staff from infectious diseases.

6. KEY OBJECTIVES

The Facilities Services team have in place local arrangements for cleaning of public areas,
departments and wards throughout the hospital agreed with the infection prevention and
control team. The local agreements set out the range of services to be provided, the times
and frequencies at which cleaning will take place and who is responsible for providing them.

The supervisors carry mobile phones/ pagers to enable effective communication in dealing
with spillages and accidents across the sites.

At an operational level each member of Facilities services staff employed on cleaning duties
has the right level of training, the appropriate equipment, knows what needs cleaning and
when and is properly supervised to ensure that the right things get done to the required
standard at the required time.

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 Cleaning of the Environment SOP/February 2016

6.1 The Facilities and Estates Directorate take cleanliness seriously by

 Ensuring high standards of cleanliness are maintained

 Working in partnership with Infection Prevention and Control Teams,
Matrons, Ward Sisters & Charge nurses
 Setting clear local standards (reflecting national Standards of Cleanliness
guidance) and policies
 keeping cleanliness high on the Trust agenda
 Developing patient feedback surveys and act on feedback
 Encouraging patient representatives to lead on PLACE visits as well as
Matrons and Facilities and Estate meetings
 Ensuring patients receive treatment in an environment that is clean safe and
welcoming
 Ensuring that staff responsible for cleanliness are appropriately trained &
developed through:-

o Induction Training
o Mandatory training
o On-the-job training & support
o Supervisory, managerial and leadership development training
o Certificated competence of operatives (NVQ)

6.2 Monitoring
High standards of cleanliness are maintained and that any slippage is recognised
and corrected through:-

 Working to national targets that measure performance over a range of factors

 Ensure Managerial and technical audits are on a scheduled programme
including infection control and estates
 Empower Matrons, Ward Sisters and charge Nurses to be involved in
maintaining and ensuring a clean environment.

7. GOOD PRACTICE MEASURES FOR INFECTION PREVENTION AND CONTROL

The Facilities Services Team works in close partnership with the Infection Prevention and
Control Team and are involved in the development and implementation of local standard
precaution protocols & procedures following any outbreak of infection. (See outbreak
policies)

The Trust uses the NPSA National colour coding system for cleaning materials and
equipment. The colour coded system is used to prevent cross contamination and forms part
of the housekeeping induction programme and relates to all cleaning equipment and cloths.

 The cleaning manual including cleaning schedules, frequency of cleaning and

cleaning responsibilities used by the Trust are all agreed with the Infection
Prevention and Control Department
 All Facilities services staff including Management and Supervisors are trained in the
use of appropriate infection prevention and control policies and procedures.
 Designated Facilities & Estates Management are members of the Infection Control
Committee.
 In the event of an outbreak there are defined protocols to follow and clear lines of
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 Cleaning of the Environment SOP/February 2016

communication between housekeeping, ward managers and the Infection control

department.

8. PATIENT INVOLVEMENT
The patient is central to all services provided by the Trust and it is vital that the Facilities
Services Department works in partnership with patients and their representatives to ensure
high standards of cleanliness are achieved and maintained throughout. Patients and or
their representatives will lead on the Patient lead assessment of the care environment.

9. MODERN MATRON / MANAGERIAL INVOLVEMENT

It is fundamental in line with the Matrons Charter (An Action Plan for Cleaner Hospitals) that
a cleanliness culture is established within their areas and that the patient environment is well
maintained, clean and tidy and free from clutter. The Matron and/or Sister/Manager in
charge of a clinical area should ensure that the environment is organised in such a way as to
facilitate effective working e.g. logical storage systems and excess storage should be
avoided. Whilst specific reference is made to Modern Matrons where wards/clinical
departments do not have a dedicated Modern Matron then the Department/Ward Manager is
responsible for the principles outlined in the Charter.

 Designated Facilities & Estates managers will attend Matron meetings as deemed
necessary
 Matrons/Patient Service Management/Clinical Departmental Managers are actively
encouraged to monitor performance on cleanliness with the managerial audit team
 Matrons/Patient Service Management/ Clinical Departmental Managers are involved in
agreeing the cleaning input levels and frequencies of cleaning
 Matrons are involved in the Patient Lead assessment of the care environment.

Deep Cleaning
.
Deep cleaning is not different cleaning, and it does not alleviate the need for ongoing
cleaning; instead, it is a more enhanced programme of cleaning, often using new
equipment or specialist skills. It allows for the consideration of cleaning activities that
are difficult to deliver, while maintaining levels of service in busy areas, and it
addresses problems that may have built up over time.

As well as specialist cleaning, it may be appropriate to replace items that cannot be

cleaned satisfactorily, or to replace damaged finishes to make subsequent cleaning
easier.

A well-designed care environment encourages good practice and is easier to clean

and maintain.

The contractors will work with the housekeeping and ward teams to ensure the work
is carried out with little or no disruption to patients.

Risk assessments and method statements will be submitted before any work is
undertaken and they must report to Facilities & Estates to sign in.

Their work shall be constantly monitored by the housekeeping supervisors to ensure

compliance with The National Specifications for Cleanliness in the NHS.

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 Cleaning of the Environment SOP/February 2016

To provide an audit trail documentation will be completed and signed off by the
contractor and the Ward/Dept/Housekeeping Manager

10. PROCESS FOR MONITORING COMPLIANCE AND EFFECTIVENESS

The monitoring of standards is central in 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 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.

The overall performance target set for the Trust is between 90-95%. All areas are
monitored in accordance with the national auditing tool and an action plan is produced to
correct any areas falling below the required standard of cleanliness.

In addition annual Patient lead assessments of the care environment assessments are
carried out lead by patient’s representatives, services users, Health Watch, Governors and
Senior Member of the Facilities & Estates Directorate.

11. REFERENCES
The National standards of cleanliness’ 2001 and the subsequent ‘Standards of Cleanliness
in the NHS’, ‘A framework in which to measure performance outcomes’ 2003
‘National Minimum Cleaning Frequencies’ regime
‘Winning Ways’ – working together to reduce Healthcare Associated Infection in England
2003
‘The Matrons Charter’ 2004
‘The NHS Healthcare Cleaning Manual’ 2004 Revised cleaning Manual 2009.
‘Health Act 2006‘ – ‘Code of Practice for the Prevention and Control of healthcare
Associated infection ‘(2006) Revised 2008
‘Going Further Faster’ Implementing the Saving Lives delivery programme (sustainable
change for cleaner, safer care)
‘Improving Cleanliness and Infection Control – Department of Health Document November
2008

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