report to trust board - northern devon healthcare nhs trust · • patient and staff comfort are...

Report to Trust Board

Date Tuesday 22 July 2008

Agenda Item P3

Title Laundry Policy

Sponsor Iain Roy, Director of Facilities

Prepared by Lisa Wright, Facilities Contract Manager

Presented by Lisa Wright, Facilities Contract Manager

1 Purpose and Key Issues To present the Laundry Policy for ratification by the Trust Board. The policy applies to all clinical staff who deal with laundry, facilities staff and Sodexo staff. The policy aims to: • Ensure the linen and laundry service operates efficiently and effectively to

reduce the risk of hospital acquired infection, to maintain patient and staff comfort and to manage the service within limited resources

• Ensure the supply of a linen and laundry service to comply with Health Guidance HSG (95) 18, Hospital Laundry Arrangements for used and infected linen.

Implementation of this policy will ensure that: • The laundry service operates efficiently and effectively. • Hospital acquired infections will be reduced. • Patient and staff comfort are managed within limited resources.

2 Equality and Diversity Implications

The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. No adverse impacts have been identified from this policy. Positive impacts have been identified with regard to providing a robust framework to ensure a consistent approach across the whole organisation to cover the general principles of the handling and usage of linen goether with a guide to when items of linen should be sent for laundering..

3 Legal Implications The legal implications have been considered and none have been identified.

4 Patient, Public and Staff Involvement

Consultation has taken place with clinical, community, Sodexo and management staff.

Best Care, Highest Standards, Right Place

Laundry Policy Northern Devon Healthcare Trust Trust Board 22 July 2008

5 Controls and Assurances

The Laundry Policy was given first approval by the Infection Prevention and Control Committee in April 2008. The policy was given final approval at the Clinical Services Executive Committee in May 2008.

6 Cost Implications

There are no cost implications.

7 Potential risk to the organisation

If the laundering policies are not robust, the Trust will be at medium risk of adversely affecting patient safety and care. Risk score 9 (Consequence = 3 x Likelihood = 3).

8 Recommendations

The Trust Board is asked to RATIFY the Laundry Policy.

Facilities Department of 29


Strategic Objectives Ten strategic objectives were agreed by the Trust Board in May 2007 to support the Trust’s mission statement “Best Care, Highest Standards, Right Place”. The strategic objectives have been developed to ensure there is a shared understanding and common purpose throughout the organisation about the Trust’s strategic direction and what needs to be delivered.

X Patient Safety X High Quality Services

Efficient & Effective Strategic Partnerships

Listening and responding to the needs of patients Modern and Effective Infrastructure

Deliver Care in the most appropriate setting Public Health

Integrate Health and Social Care X Robust and Sustainable

Standards for Better Health The Core and Developmental Standards for Better Health have been developed by the Healthcare Commission. Compliance with the Standards throughout the year form a part of the Trust’s Annual Health Check.

C1a Incident Reporting C7e Equality & Diversity C16 Patient Information

C1b Safety Alerts C8a Whistle blowing C17 Patient & Public Involvement

C2 Child Protection C8b Personal Development Programmes C18 Access to Services –

Equality & Choice

C3 NICE – Interventional procedures C9 Records Management C19 Access to Services –

Emergency care

X C4a Infection Control C10a Employment Checks C20a Security and Health & Safety

C4b Medical Devices C10b Professional Codes of Conduct C20b Patient Privacy &

Confidentiality

C4c Decontamination C11a Recruitment X C21 Hospital Cleanliness

C4d Medicine Management C11b Mandatory Training C22a Public Health – Health inequalities

C4e Waste Management C11c Professional Development C22b Public Health – D of

PH report

C5a NICE – Technology appraisals C12 Research & Development C22c Public Health -

Working with partners

C5b Clinical Supervision & Leadership C13a Dignity & Respect C23 Public Health – Health

promotion

C5c Clinical Professional Development C13b Consent to treatment C24 Major Incident

Planning

C5d Clinical Audit C13c Use of Confidential Information X D1 Patient Safety – Risk

reduction

C6 Healthcare bodies co-operating together C14a Complaints - Information D2a Clinical Effectiveness –

Best practice

C7a Corporate Governance C14b Complaints – Non-discrimination D13a Public Health – Health

inequalities

C7b Finance & Probity C14c Complaints – Service improvements D13b Public Health –

National guidance

C7c Clinical Governance X C15a Patient Food Standards

C7d Performance X C15b Patient dietary requirements




Document Control Report

Title Laundry Policy Author Lisa Wright, Facilities Contract Manager Version Date

Issued Status Comment

1.0 1999 Final Approved

2.0 2003 Final Approved

2.1 April 08 Revised Infection Control Committee 3.0 May 08 Final Clinical Services Executive Committee for approval 3.1 Jun 08 Revision Final amendments to ensure Corporate Identity

requirements Main Contact Lisa Wright Facilities Contract Manager Facilities Department North Devon District Hospital Raleigh Park Barnstaple EX31 4JB

Tel: Direct Dial - 01271 311821 Tel: Internal – 3821 Fax: 01271 322433 Email: [email protected]

Lead Director Director of Facilities Document Class Policy

Target Audience All clinical staff, Facilities staff and Sodexho staff

Distribution List Matrons Charter Group & Infection Control Team

Distribution Method TarkaNet

Superseded Documents Trust Laundry Policy issued 2003 Issue Date June 2008

Review Date June 2010

Archive Reference Facilities Path G:/Facilities/Hotel Services/Linen Filename Laundry Policy v3.1

Laundry Policy Northern Devon Healthcare NHS Trust Trust Board 22 July 2008

Contents

Section Page

1 Introduction 3

2 Purpose 3

3 Responsibilities 3

4 General Principles – all types of linen 3

5 Normal/ Used Linen 4

6 Fouled/ Infected Linen 4

7 Theatre Linen 4

8 Patients’ Personal Clothing 5

9 Return to Sender RTS 6

10 Rejected Linen 7

11 Uniforms 7

12 Domestic Equipment 7

13 Linen Usage 8

13.1 Sheets/ Pillows/ Blankets 8

13.2 Towels 8

13.3 Patient Gowns 8

13.4 Slide Sheets 8

13.5 Patient Hoist Slings 8

13.6 Canvasses 8

13.7 Scrub Suits 9

14 Failure of Normal Service 9

15 Development of the Policy 9

15.1 Document Development Process 9

15.2 Equality Impact Assessment 9

16 Consultation, Approval and Ratification Process 9

16.1 Consultation Process 9

16.2 Policy Approval Process 9

16.3 Ratification Process 10

17 Review and Revision Arrangements including Document Control 10

17.1 Process for Reviewing the Policy 10

Facilities Page 2 of 29



Section Page

17.2 Process for Revising the Policy 10

17.3 Document Control 10

18 Dissemination and Implementation 10

18.1 Dissemination of the Policy 10

18.2 Implementation of the Policy 10

19 Document Control including Archiving Arrangements 11

19.1 Library of Procedural Documents 11

19.2 Archiving Arrangements 11

19.3 Process for Retrieving Archived Policy 11

20 Monitoring Compliance With and the Effectiveness of the Policy 11

20.1 Process for Monitoring Compliance and Effectiveness 11

20.2 Standards/ Key Performance Indicators 11

21 References 11

Appendices

A Bagging Procedure 12

B Theatre Bagging Procedure 13

C Return to Sender Docket Procedure 14

D South West Laundry Consortium Contingency Plans 15

E Checklist for the Review and Approval of Procedural Documents 19

F Plan for Dissemination and Implementation of Procedural Documents 21

G Equality Impact Assessment Screening Form 23


1 Introduction

This document sets out Northern Devon Healthcare NHS Trust’s system for the management of Laundry and Linen. It provides a robust framework to ensure a consistent approach across the whole organisation and covers the general principles of the handling and usage of linen together with a guide to when items of linen should be sent for laundering.

2 Purpose

The purpose of this document is to ensure the linen and laundry service operates efficiently and effectively to reduce the risk of hospital acquired infections, to maintain patient and staff comfort and to manage the service within limited resources.

The fundamental requirements of this policy for the supply of a linen and laundry service are to comply with Health Guidance HSG (95) 18, Hospital Laundry Arrangements for used and infected linen.

Implementation of this policy will ensure that:

• The laundry service operates efficiently and effectively

• Hospital acquired infections will be reduced

• Patient and staff comfort are managed within limited resources

This policy applies to all clinical staff who deal with laundry, facilities staff and Sodexho staff.

3 Responsibilities

3.1 Role of the Director of Facilities

The Director of Facilities is responsible for overall compliance with the policy.

3.2 Role of the Author

The Facilities Contract Manager must attend monthly meetings with contractors, highlight any performance issues and monitor compliance with this policy.

3.3 Role of Staff

All staff are responsible for ‘bagging’ used linen in the correct manner in line with this policy.

3.2 Sodexho Linen Staff, Community Hotel Services Staff and Nurses

Sodexho linen staff, Community Hotel Services staff and Nurses are responsible for providing clean linen to all areas.

3.3 Sodexho Porters and Community Hotel Services Staff

Sodexho Porters and various Community Hotel Services staff are responsible for collecting used linen from all areas, as long as it has been bagged and closed correctly.



3.4 Line managers

Line managers of Sodexho linen staff, Community Hotel Services Staff, nursing staff and Sodexho porters (i.e. all staff who ‘bag’ used linen) are responsible for ensuring their staff are aware of and compliant with the Laundry Policy on appointment to the Trust.

4 General Principles – all types of linen

All used linen must be placed in an appropriate colour coded bag according to the colour coding chart displayed in every sluice, (please refer to appendix A)

Used linen must always be bagged at the bedside never carried through the ward to the sluice.

Skip bags must never be more than 2/3 full.

Used linen handling should conform to the specifications of Health Service Guidance (95) 18 as outlined in this policy.

Staff must ensure they wear personal protective equipment when dealing with used linen.

Staff must always wash their hands after dealing with used linen and/ or after removing personal protective equipment.

Staff must ensure that items such as needles, syringes, instruments and other foreign objects are not placed in laundry bags.

No purchase of washing machines will take place without formal agreement by the Facilities Managers.

Regarding purchase of items requiring laundering, only items that withstand the intensive laundry process may be purchased.

All Trust owned items must be sent to the external contractor for laundering. The internal laundrette is provided principally for patients’ clothing items.

Regarding labelling, all items, including curtains, must be clearly labelled. The Sewing Room/ Hotel Services Department will label items.

Breaches to this policy must be recorded and communicated via the Incident Reporting process.

5 Normal/ Used Linen

Normal/ used linen must be placed in a white skip bag and secured. The bag must not be filled to more than 2/3 full, (please see appendix A).

Supplies of white skip bags will be available in all areas where linen is used. Further supplies may be obtained from the Linen Room, Sodexho Zone Coordinator or Community Coordinator.

Plastic aprons must be worn whilst handling normal/ used linen.

Hands must be washed after disposing of linen and after removing apron.



6 Fouled/ Infected Linen

This is linen that has either been contaminated by blood or any other body fluids or linen from suspected or known infectious patients. If unsure, please seek advice from Infection Control.

Fouled/ infected linen must be placed in a water soluble bag, tied and placed in a red linen skip bag and secured. The bag must not be filled to more than 2/3 full, (please see appendix A).

Supplies of both water soluble bags and red skip bags will be available in all areas where linen is used. Further supplies may be obtained from the Linen Room, Sodexho Zone Coordinator or Community Coordinator.

Plastic aprons and gloves must be worn whilst handling fouled/ infected linen.

Hands must be washed after disposing of linen and after removing aprons and gloves.

7 Theatre Linen

Theatre drapes and gowns must be placed in a green skip bag and secured. The bag must not be filled to more than 2/3 full, (please see appendix B).

Pillowcases, sheets, blankets and scrub suits must be placed in white skip bags and secured. The bag must not be more than 2/3rds full, (please see appendix B).

Fouled/ infected pillowcases, sheets, blankets and scrub suits must be placed in a water soluble bag, tied and placed in a red linen skip and secured. The bag must not be filled to more than 2/3 full, (please see appendix B).

Canvasses are to be placed in clear plastic bags, but if they are fouled/ infected, they must be placed in a water soluble bag first then placed in a clear plastic bag. The bag must not be more than 2/3rds full.

Supplies of water soluble, green, red and white skip bags will be available in all Theatres. Further supplies can be obtained from the Linen Room or Zone Coordinator

Plastic aprons and gloves must be worn whilst handling Theatre linen.

Hands must be washed after disposing of linen and after removing gloves and aprons.

8 Patients’ Personal Clothing

The Trust offers a limited personal clothing service to those patients who do not have relatives, friends or carers to do their laundry for them. All staff responsible for admitting patients must emphasise this, including to patients from residential homes.

Patients’ personal clothing will not be sluiced or washed and dried at ward level. Nursing staff must remove large amounts of organic matter with a gloved hand. Once the organic matter has been removed, the item(s) must be secured in a water soluble bag and placed in a clear plastic bag and secured.

Staff must ensure that patient’s personal clothing is not placed in the same skip bags as the flat linen. All patients’ personal clothing that the Trust agrees to launder is dealt with according to the principles set out in this section.



Items of clothing for hospital laundry must be checked by ward staff for suitability. “Dry clean only” or delicate garments must not be sent for laundering

Where clothing is identified for Trust laundering, these items must be labelled prior to laundering.

Staff should liaise with the Sewing Room, Zone Coordinator or Community Coordinator regarding all items that require labelling on patient admission. Any items that are laundered prior to labelling are at risk of: (a) being lost; (b) delaying the laundry service provision.

Patients’ personal clothing to be laundered by the Trust must be placed in a clear plastic skip bag and secured. Fouled items should be placed in a water soluble bag in the first instance, tied and then placed in a clear plastic bag and secured.

Where relatives/ friends or carers are laundering soiled items of patient clothing, the items should be placed in a water soluble bag, tied and placed into another bag. It is very important that relatives are advised that the water soluble bag and clothing should be placed in the washing machine intact.

Staff must check there are no personal items, e.g. glasses or watches, left in pockets prior to these items being sent for laundering.

The bags should never be filled to more than 2/3 full.

Staff must ensure that patients’ personal clothing is not placed in the same skip bag as the flat linen. All patients’ personal clothing processed by the Healthcare service is to be laundered on Trust premises at North Devon District Hospital and Bideford Hospital.

Supplies of water soluble and clear plastic bags will be available in all appropriate areas. Further supplies can be obtained from the Linen Room, Zone Coordinators or Community Coordinator.

Aprons must be worn whilst handling normal/ used patients’ clothing and apron and gloves must be worn whilst handling fouled/ infected patients’ clothing.

Any items received that are unsuitable for machine washing should be returned immediately to the ward from which they were received.

All Community Hospitals must follow the above steps and then place their clear plastic bags into hospital colour coded bags. Tyrrell, Lynton and Gables send their linen to NDDH while the other Trust Community Hospitals and sites send their linen to Bideford Hospital.

Hands must be washed after disposing of patients’ clothing and after removing aprons and gloves.

Regarding Losses and Compensations, the Trust will take all due care and attention to ensure patients’ personal clothing is returned in a similar condition as it was received.

9 Return To Sender (RTS)

All RTS items are owned by the Trust and are not part of the general linen hire pool. Therefore, failure to identify these items before use may result in a delay or possible loss of items to your ward or department.



All Trust owned items to be sent to the external contractor for laundering will be sent to the Sewing Room in the first instance to be labelled prior to use.

Normal/ used items, except curtains, will be placed in a blue skip bag and secured. The bag must not be more than 2/3 full, (please see appendix A).

Fouled/ infected items will be placed in a water soluble bag, tied and placed inside a blue linen skip bag and secured. The bag should not be filled to more than 2/3 full.

Complete a Sunlight docket detailing information of items in the bag together with the amount, retain 2 copies and place the rest of the docket inside the document wallet. Remove all of the backing from the document wallet and stick to bag. The bag must not be more than 2/3 full, (please see appendix C).

Curtains, normal/ used must be placed in a brown linen skip bag and secured. The bag must not be filled to more than 2/3 full, (please see appendix A)

Curtains that are fouled/ infected must be placed in a water soluble bag, tied and placed inside a brown linen skip bag and secured. The bag should not be more than 2/3 full.

A docket must also be completed for curtains as detailed above.

10 Rejected Linen

Linen that is not suitable for patient use, i.e. damaged, torn or stained, must be placed in clear skip bags and secured, (please see appendix A).

Supplies of clear skip bags will be available in all areas where linen is used. Further supplies may be obtained from the Linen Room, Sodexho Zone Coordinator or the Community Coordinator.

11 Uniforms

Staff uniforms to be sent to the external contractor for laundering must be labelled by the sewing room staff in the first instance. If the label is fading, please return it to the sewing room for re-labelling. Any unmarked/ poorly marked uniforms are unlikely to be returned by the laundry contractor (Sunlight Laundry).

Normal/ used uniforms must be placed in a blue skip bag and secured. The bag must not be filled to more than 2/3 full, (please see appendix A).

Fouled/ infected uniforms will be placed in a water soluble bag, tied and placed inside a blue linen skip bag and secured. The bag should not be filled to more than 2/3 full.

Complete a docket (as above) detailing information of items in bag together with the amount, retain 1 copy and place the rest of the docket inside the document wallet. Remove all of the backing from the document wallet and stick to the bag. The bag must not be filled to more than 2/3 full, (please see appendix C).

Users of scrub suits provided by Sunlight Laundry follow steps 5 and 6

Uniforms other than scrub suits provided by Sunlight Laundry which have been visibly contaminated with any amount of blood or other body fluids must be changed immediately. Procedure for fouled/ infected uniforms (above) must be followed.



It is not mandatory for staff uniforms, except Sunlight Laundry’s scrub suits, to be sent routinely to the external laundry contractor. For the majority of wards/ departments, it is acceptable for uniforms to be washed by staff at home. Exceptions to this include any uniform contaminated with any visible amount of blood or other body fluids.

Home Laundering of Uniforms

It is recommended that uniforms are washed at 60o C for 10 minutes or at the hottest temperature recommended for the fabric.

After washing, uniforms may be dried and ironed as normal.

12 Domestic Equipment

Hotel Services are responsible for bagging cloths and mops.

Used mop heads must be placed into net bags if microfibre, while normal mop heads are to be placed in clear plastic bags, tied and laundered on site.

Used microfibre cloths will be placed into net bags, tied and laundered on site. These must be laundered separately to mop heads.

Manufacturers laundering requirements must be followed.

The same applies to the Trust Community Hospitals but the net bag must be placed into the colour coded skip bag for your hospital and secured.

Tyrrell Hospital, Lynton and Gables mops, cloths and patient clothing is sent to North Devon District Hospital Laundrette. All other Community Hospitals and other sites send mops, cloths and patient clothing to Bideford Hospital.

13 Linen Usage

The following section provides guidance for staff and indicates when linen should be sent for washing.

Sheets/ Pillows/ Blankets

The above items must be changed when:

• A new patient is placed in a bed

• The linen is soiled/ wet

• Every day, i.e. the used top sheet is transferred to the mattress, on the following day the mattress sheet will be bagged (as per appendix A), therefore no sheet will be used for more than 2 days.

Towels

The above item must be changed:

• Daily if used

• If soiled/ wet

Patient Gowns




• After each patient

• If soiled/ wet

Slide Sheets


• Between new patients

• When soiled/ wet

Patient Hoist Slings


• After patient use


Canvasses


• After each patient

Scrub Suits


• Daily


14 Failure of Normal Service

Please refer to appendix D for contingency plans for:

• Failure of Sunlight Facility

• Adverse Weather

• Major Incident

15 The Development of the Policy

15.1 Document Development Process

As the author, the Facilities Co-ordinator is responsible for developing the policy and for ensuring stakeholders were consulted with.

Draft copies were circulated for comment before approval was sought from the relevant committees.

15.3 Equality Impact Assessment



The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. An Equality Impact Assessment Screening has been undertaken and there are no adverse or positive impacts (Appendix E).

16 Consultation, Approval and Ratification Process

16.1 Consultation Process

The author consulted widely with stakeholders, including:

• Matrons Charter Group • Infection Control Team • Sodexho • Community Hotel Services • Infection Prevention and Control Committee Consultation took the form of a request for comments and feedback via email. Hard copies were available on request.

16.2 Policy Approval Process

Initial approval of the policy was sought from the Infection Prevention and Control Committee on 22 April 2008.

Final approval was sought from the Clinical Services Executive Committee meeting in May 2008.

16.3 Ratification Process

The policy will be ratified by the Trust Board in July 2008.

17 Review and Revision Arrangements including Document Control

17.1 Process for Reviewing the Policy

The policy will be reviewed every two years. The author will be sent a reminder by the Tarkanet Support Officer four months before the due review date. The author will be responsible for ensuring the policy is reviewed in a timely manner and that the reviewed policy is initially approved by the Infection Prevention and Control Committee and then given final approval by the Clinical Services Executive Committee and ratified by the Trust Board.

All reviews will be recorded by the author in the Document Control Report.

17.2 Process for Revising the Policy

In order to ensure the policy is up-to-date, the author may be required to make a number of revisions, e.g. committee changes or amendments to individuals’ responsibilities. Where the revisions are minor and do not change the overall policy, the author will present the revised version to the Infection Prevention and Control Committee for approval.

Significant revisions will require final approval by the Clinical Services Executive Committee and ratification by the Trust Board.

All revisions will be recorded by the author in the Document Control Report.



17.3 Document Control

The author will comply with the Trust’s agreed version control process, as described in the organisation-wide Guidance for Document Control.

18 Dissemination and Implementation

18.1 Dissemination of the Policy

After ratification by the Trust Board, the author will provide a copy of the policy to the Tarkanet Support Officer to have it placed on the Trust’s intranet. The policy will be referenced on the home page as a latest news release.

Information will also be included in the weekly Chief Executive’s Bulletin which is circulated electronically to all staff.

An email will be sent to senior management to make them aware of the policy and they will be responsible for cascading the information to their staff.

In addition, staff will be informed that this policy replaces any previous versions.

18.2 Implementation of the Policy

Line managers are responsible for ensuring this policy is implemented across their area of work.

Support for the implementation for this policy will be provided by the Facilities Contract Manager and Linen Zone Coordinator.

19 Document Control including Archiving Arrangements

19.1 Library of Procedural Documents

The author is responsible for recording, storing and controlling this policy.

Once the final version has been ratified, the author will provide a copy of the current policy to the Tarkanet Support Officer so that it can be placed on Tarkanet. Any future revised copies will be provided to ensure the most up-to-date version is available on Tarkanet.

19.2 Archiving Arrangements

All versions of this policy will be archived in electronic format within the Facilities policy archive. Archiving will take place by the Facilities Co-ordinator once the final version of the policy has been issued.

Revisions to the final document will be recorded on the document control report. Revised versions will be added to the policy archive held by Facilities.

19.3 Process for Retrieving Archived Policy

To obtain a copy of the archived policy, contact should be made with the Facilities Contract Manager.

20 Monitoring Compliance With and the Effectiveness of the Policy

20.1 Process for Monitoring Compliance and Effectiveness



Monitoring compliance with this policy will be the responsibility of the Facilities Contract Manager. This will be carried out by regular audits by the Linen Zone Coordinator and Facilities Contracts Co-ordinator.

20.2 Standards/ Key Performance Indicators

Key performance indicators comprise:

• 100% target compliance in all areas with Sunlight audit, bags audited on a daily basis

• 100 % target compliance in all areas with staff complying with policy

21 References

• Department of Health (2007) Uniforms and Work-wear, an Evidence Base for Developing Local Policy



Appendix A – Bagging Procedure


White Bag

Normal/ Used Linen Sheets, blankets, pillowcases (ie. flat linen)

Brown Bag Blue Bag

Return to Sender e sheets, uniforms,

Return to Sender Curtains Only Yellow slid w ite h

coats etc. (ie. hospital owned items)

Fouled/ Infected Linen

Inner - water soluble bag Outer - red skip bag

Rejected Linen For torn, damaged and

stained. NOT FOR SOILED LINEN

Clear plastic bag

Laundry Policy (v3.1) Northern Devon Healthcare NHS Trust

Appendix B – Theatre Bagging Procedure

Drapes & Gowns Return to sender items i.e. yellow slide sheets

Blue Bag Green Bag

Inner- water soluble bag

All items infected must be placed in a water soluble bag and document completed

White Bag Outer - red skip bag

Fouled/ Infected Linen i.e. scrub suits, blankets, towels, sheets etc Normal soiled used linen

i.e. towels, blankets, scrub suits

Rejected Linen For torn, damaged and

stained. NOT FOR SOILED LINEN

Return to Sender Curtains Only

Clear plastic bag Brown Bag




Appendix C – Return to Sender Docket Procedure

Please ensure the documentation provided is completed correctly

1. Place soiled item into BLUE plastic bag.

2. Infected heavily soiled items should be placed into a Water Soluble Bag prior to placing in Blue Bag.

3. Complete a Personal Laundry Parcel Service Docket as shown above. Failure to complete a docket will result in the item being lost or delayed in return.

4. White and blue copy of completed docket to be placed inside document wallet and stuck to Blue Bag.

5. Pink docket to be retained by person completing docket until item is returned from laundry.


Appendix D - South West Laundry Consortium Contingency Plans

The following four scenarios have been identified as potential failures in the laundry service. The plans have been devised in partnership between members of The Laundry Consortium and Sunlight. Four potential scenarios are considered below, for easy reference a summary of contact numbers follows at the end.

1. FAILURE AT SUNLIGHT FACILITY 2. ADVERSE WEATHER 3. MAJOR INCIDENT 4. PANDEMIC FLU

SCENARIOS

1. FAILURE AT SUNLIGHT FACILITY.

This relates to the potential risk of a key Sunlight facility being lost due to fire or failure of essential utilities.

Sunlight Actions:

• Bonded stock available to continue supplies within 12 hours • Use of other group laundry facilities, increase shifts, use of agency staff • Consider deployment of staff to operational facilities • If necessary consider purchasing additional stocks from Sunlight supplies • If necessary, the Sunlight Commercial Division could be called to provide

additional linen.

Trust Actions:

• Nominated Trust linen reps to liaise to establish any immediate / foreseeable shortfalls. This may require an extra ordinary consortium meeting.

• If necessary, Trusts should consider sourcing disposable linen. Contact details:

- NHS Logistics:

Normal working hours tel: 01773 724061

Out of hours tel: 01773 724000

North Devon District Hospital District number is 32

Linen Room requisition point is 320737

NHS Logistics emergency response is 5 hours for a medical emergency



• NB. Trusts should consider:

- the method of disposing of disposable linen i.e. clinical waste - the collection of linen / segregation - storage space

• Linen managers should notify their customers of the situation. Customers should be diligent in the use of all linen.

• If problems continue with supply, consider additional service from alternative suppliers:

- RD&E - Tel: 01392 411611

- Bournemouth - Tel: 01202 303626

- Synergy - Tel: 01332 387100

2. ADVERSE WEATHER This relates to the risk of severe weather interrupting Sunlight’s transportation arrangements.

Sunlight Actions:

• Consider alternative routes to hospital • Depending on severity, liaise with emergency services to aid distribution • Consider use of alternative plants if adverse weather is localised

Trust Actions:

• The Trust may need to consider liaison with Local Authority Emergency Planning Teams for additional blankets and sheets

• The Trust may wish to consider (if necessary) the use of Trust owned washing machines to launder some items.

• Manage stocks carefully (approx 2 days stock at Trust), Trusts should check this buffer stock.

• Liaise with Sunlight with regard to stock levels. • NB. Linen usage will reduce at Trusts if patients are unable to attend hospital.

Customers should be diligent in the use of linen.

3. MAJOR INCIDENT

This plan relates to a scenario whereby any one Trust is affected by a major incident with multiple casualties i.e. a major incident is declared.

Sunlight Actions:

• On notification of major incident at any Trust, Sunlight, in consideration with individual Trusts, shall mobilise additional stocks. This could be via:

- Other Sunlight Facilities - Bonded stock

• Dependent upon urgency, Sunlight should consider police assistance for transportation



Trust Actions:

• Emergency contacts and telephone numbers for Sunlight are as follows: - Tel: Depot Manager - 07814464732 - Tel: Account Manager - 07976562548 - Tel: Leicester Manager – 07966212767

• Notify Sunlight of major incident and request additional laundry • Consider requesting additional items from neighbouring Trusts

4. PANDEMIC FLU

This relates to a confirmed outbreak of pandemic flu at any single Trust or group of Trusts.

Sunlight Actions:

• Prepare to provide additional water soluble and red bags for affected Trusts • If Sunlight have staff shortages they should consider:

1. Increase working hours of fit staff 2. Use of agency staff 3. Use of alternative facilities including commercial and work wear

facilities if required. 4. Usage of bonded stock 5. Movement of staff between facilities

• All staff in contact with infected linen should wear PPE as required.

Trust Actions:

• In the event of a confirmed outbreak the Trust shall:

- notify Sunlight of the situation at the earliest possible opportunity. Trusts may consider requesting additional water-soluble bags and red bags.

- assume all linen is potentially infected. Thus all linen is to be placed in a water-soluble bag and then into a red bag for pooled Items. Blue bags should be used for R.T.S. or Green bag for Theatre items.

- seal all bags at point of care.

- on no account over fill water soluble bags or laundry bags i.e. to more than 2/3 volume.

- ensure that all handling of linen will be carried using PPE i.e. gloves and apron.

- ensure that hand hygiene will be carried out following removal of gloves and apron.

- in addition to usual routines, change curtains for infected patients occupying single rooms.



- consider use of additional rental Curtains from Sunlight, if needed. Tel: Account Manager 07976562548

- source disposable curtains, if needed, via Marshall Contracts 01217835777.

- use paper sheeting for all patient examination couches and ensure they are changed after each patient. The paper must be disposed of via clinical waste stream.

- use pooled scrub suits for all staff in direct contact with patients, if determined by the Trust’s turn around time for processing uniforms.

Summary of Contact Numbers

Service Company Telephone Number

Laundry (normal working hours)

Sunlight 01884 38254

Rental curtains Sunlight 0797 6562548

Linen Emergency Sunlight Depot Manager 0781 4464732

Account Manager 07976 562548

Leicester Manager 07966212767

Alternative Linen Supplier Royal Devon & Exeter NHS Trust

Royal Bournemouth Hospitals Trust

Synergy

01392 411611

01202 303626

01332 387100

Disposable Linen NHS Logistics Normal hours 01773 724061

Out of hours 01773 724000

Disposable curtains Marshal Contracts 0121 7835777



Appendix E - Checklist for the Review and Approval of Procedural Documents

To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval.

Title of document being reviewed: Yes/No/ Unsure Comments

1. Title

Is the title clear and unambiguous? Yes

Is it clear whether the document is a guideline, policy, protocol or standard?

Yes

2. Rationale

Are reasons for development of the document stated?

Yes

3. Development Process

Is the method described in brief? Yes It is an update of an existing policy

Are people involved in the development identified?

Yes

Do you feel a reasonable attempt has been made to ensure relevant expertise has been used?

Yes

Is there evidence of consultation with stakeholders and users?

Yes

4. Content

Is the objective of the document clear? Yes

Is the target population clear and unambiguous?

Yes

Are the intended outcomes described? Yes

Are the statements clear and unambiguous? Yes

5. Evidence Base

Is the type of evidence to support the document identified explicitly?

Yes

Are key references cited? Yes

Are the references cited in full? Yes

Are supporting documents referenced? N/A

6. Approval

Does the document identify which committee/group will approve it?

Yes

If appropriate have the joint Human Resources/staff side committee (or equivalent) approved the document?

N/A



Yes/No/ Title of document being reviewed: Comments Unsure

7. Dissemination and Implementation

Is there an outline/plan to identify how this will be done?

Does the plan include the necessary training/support to ensure compliance?

8. Document Control

Does the document identify where it will be held?

Yes

Have archiving arrangements for superseded documents been addressed?

Yes

9. Process to Monitor Compliance and Effectiveness

Are there measurable standards or KPIs to support the monitoring of compliance with and effectiveness of the document?

Yes

Is there a plan to review or audit compliance with the document?

Yes

10. Review Date

Is the review date identified? Yes

Is the frequency of review identified? If so is it acceptable?

Yes

11. Overall Responsibility for the Document

Is it clear who will be responsible for co-ordinating the dissemination, implementation and review of the document?

Yes

Individual Approval If you are happy to approve this document, please sign and date it and forward to the chair of the committee/ group where it will receive final approval. Name Lisa Wright Date Designation Facilities Co-ordinator

Committee Approval If the committee is happy to approve this document, please sign and date it and forward copies to the person with responsibility for disseminating and implementing the document and the person who is responsible for maintaining the organisation’s database of approved documents. Name Date Designation

Acknowledgement: Cambridgeshire and Peterborough Mental Health Partnership NHS Trust



Appendix F - Plan for Dissemination and Implementation of Procedural Documents

To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval.

Acknowledgement: University Hospitals of Leicester NHS Trust.

Title of document: Laundry Policy

Date finalised:

Previous document already being used?

Yes (Please delete as

appropriate)

Dissemination lead: Print name and contact details

L. Wright Ext. 3821

If yes, in what format and where?

Electronic – Tarkanet – format preceding this format

Proposed action to retrieve out-of-date copies of the document:

Remove and replace on Tarkanet

To be disseminated to:

How will it be disseminated, who will do it and when?

Paper or

Electronic

Comments

Dissemination Record - to be used once document is approved.

Date put on register / library of procedural documents

Date due to be reviewed

Disseminated to:

(either directly or via meetings, etc)

Format (i.e. paper or

electronic)

Date Disseminated

No. of Copies

Sent

Contact Details / Comments



Implementation Plan

Task Details Responsibility

Implementation

Training & Support

Completed by:

Name Designation Trust Northern Devon Healthcare NHS Trust Date




APPENDIX G– Equality Impact Assessment Screening Form

Equality Impact Assessment Screening Form

Title Laundry Policy

Author Lisa Wright, Facilities Contract Manager

Directorate Facilities

Team/ Dept. Facilities

Document Class Policy

Document Status Revision

Issue Date May 2008

Review Date May 2010

1 What are the aims of the document?

This document sets out Northern Devon Healthcare NHS Trust’s system for the management of Laundry and Linen. It provides a robust framework to ensure a consistent approach across the whole organisation and covers the general principles of the handling and usage of linen together with a guide to when items of linen should be sent for laundering.

2 What are the objectives of the document?

The purpose of this document is to ensure the linen and laundry service operates efficiently and effectively to reduce the risk of hospital acquired infections, to maintain patient and staff comfort and to manage the service within limited resources.

The fundamental requirements of this policy for the supply of a linen and laundry service are to comply with Health Guidance HSG (95) 18, Hospital Laundry Arrangements for used and infected linen.

3 How will the document be implemented?

Implementation of this policy will ensure that:

• The laundry service operates efficiently and effectively

• Hospital acquired infections will be reduced

• Patient and staff comfort are managed within limited resources

This policy applies to all clinical staff who deal with laundry, facilities staff and Sodexho staff.

4 How will the effectiveness of the document be monitored?

Monitoring compliance with this policy will be the responsibility of the Facilities Contract Manager. This will be carried out by regular audits by the Linen Zone Coordinator and Facilities Contracts Co-ordinator.

5 Who is the target audience of the document? All clinical staff, facilities staff and Sodexho staff

6 Is consultation required with stakeholders, e.g. Trust committees and equality groups? Yes

7 Which stakeholders have been consulted with? • Matrons Charter Group • Infection Control Team



• Sodexho • Community Hotel Services • Infection Prevention and Control Committee

8 Equality Impact Assessment Please complete the following table using a cross, i.e. X. Please refer to the document “A Practical Guide to Equality Impact Assessment”, Appendix 3, on Tarkanet for areas of possible impact. • Where you think that the policy could have a positive impact on any of the equality

group(s) like promoting equality and equal opportunities or improving relations within equality groups, cross the ‘Positive impact’ box.

• Where you think that the policy could have a negative impact on any of the equality group(s) i.e. it could disadvantage them, cross the ‘Negative impact’ box.

• Where you think that the policy has no impact on any of the equality group(s) listed below i.e. it has no effect currently on equality groups, cross the ‘No impact’ box.

Equality Group

Positive Impact

Negative Impact

No Impact Comments

Age x

Disability X

Gender X

Race /

Ethnic Origins

X

Religion

or Belief

X

Sexual Orientation

X

If you have identified a negative discriminatory impact of this procedural document, ensure you detail the action taken to avoid/reduce this impact in the Comments column. If you have identified a high negative impact, you will need to do a Full Equality Impact Assessment, please refer to the document “A Practical Guide to Equality Impact Assessments”, Appendix 3, on Tarkanet. For advice in respect of answering the above questions, please contact the Equality and Diversity Lead.

9 If there is no evidence that the document promotes equality, equal opportunities or improved relations, could it be adapted so that it does? If so, how? No.

Completed by Name

Lisa Wright

Designation Facilities Contract Manager Trust Northern Devon Healthcare NHS Trust Date 14/04/08