Peninsula Community Health

The Safe Management of Laundry and Linen

Title:

The Safe Management of Laundry and

Linen

Procedural Document Type:

Policy

Reference:

CG-IC-P17

CQC Outcome:

Outcome 8

Version:

VERSION 2

Approved by:

Infection Prevention and Control Committee

Ratified by:

Clinical Quality and Safety Committee

Date ratified:

7th August 2012

Freedom of Information:

This document can be released

Name of originator/author:

Sue Wright

Name of responsible team:

Infection Control Team

Review Frequency:

3 Years dependent on legislation

Review Date:

7th August 2015

Target Audience:

Staff, patients, carers, CHESS

Executive Signature (Hard Copy Only):

Quality care, closer to you

Registered in England and Wales No: 7564579
Registered office: Peninsula Community Health CIC,
Sedgemoor Centre, Priory Road, St Austell PL25 5AS

www.peninsulacommunityhealth.co.uk

Peninsula Community Health is a not for profit

Community Interest Company responsible for
providing NHS adult community health
services
in Cornwall and the Isles of Scilly

Contents
1
2
3
4

8
9

10
11
12

Introduction ........................................................................................................ 3
Definitions .......................................................................................................... 3
Duties ................................................................................................................. 3
Good Practice Principles .................................................................................... 3
4.1 Personal Protective Equipment.................................................................... 3
4.2 Hand hygiene............................................................................................... 4
4.3 Laundering process ..................................................................................... 4
4.4 Storage. ....................................................................................................... 4
4.5 Transportation and collection ....................................................................... 4
4.6 Incident Reporting........................................................................................ 5
Categorisation and segregation of linen ............................................................. 5
5.1 Clean / Unused Linen .................................................................................. 5
5.2 Soiled / Infected Linen ................................................................................. 5
5.3 Dirty / Used Linen ........................................................................................ 5
5.4 Infested clothes............................................................................................ 6
Other Laundry Items .......................................................................................... 6
6.1 Bed linen ...................................................................................................... 6
6.2 Personal items ............................................................................................. 6
6.3 Uniforms / Work wear .................................................................................. 6
6.4 Manual handling equipment ......................................................................... 7
6.5 Mop heads ................................................................................................... 7
Ward level Laundering/Service User Laundry Areas.......................................... 7
7.1 Environment................................................................................................. 7
7.2 Washing Machine ........................................................................................ 8
7.3 Dryer ............................................................................................................ 8
7.4 Iron .............................................................................................................. 8
7.5 Sluice Facilities ............................................................................................ 8
7.6 Laundry Products......................................................................................... 9
7.7 During outbreaks.......................................................................................... 9
Use of linen within community settings............................................................... 9
Risk Management Strategy Implementation....................................................... 9
9.1 Implementation & Dissemination.................................................................. 9
9.2 Training and Support ................................................................................... 9
9.3 Document Control & Archiving Arrangements.............................................. 9
9.4 Equality Impact Assessment ...................................................................... 10
Process for Monitoring Effective Implementation ............................................. 10
Associated Documentation............................................................................... 10
References....................................................................................................... 10

Please Note the Intention of this Document

This document provides instruction on effective linen and laundry management, to minimise
the risk to patients and staff.
Review and Amendment Log
Version No

Type of Change

Date

Description of change

Formatting

June 2012

Formatting into new template

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1 Introduction
Infection can be transferred from used items of clothing, linen and the environments in which
they are laundered / stored. Therefore effective laundry management is essential to prevent
cross infection between patients and to protect staff that transport and handle used
laundry/linen.
Although in general linen and patient clothing, should be sent off site to be laundered. This
policy recognizes that there are agreed circumstances, where laundering of patient clothing may
take place at ward level by service users or staff.
Policy Aims:

To provide guidance to minimize the risk of contamination during the ward level laundry
process.
To provide guidance to minimize the risk of injury and infection when dealing with linen.
To eliminate possible injury to laundry workers, and damage to washing machines and
dryers, from dangerous items such as sharps.
To provide guidance for service users, visitors and carers

2 Definitions
Clean Linen - Any linen that has not been used since it was last laundered.
Soiled Linen -Used linen which is soiled with blood or any other body fluid; and all linen used
by a patient with a known infection (whether soiled or not)
Personal Protective Equipment - PPE is defined in the Regulations as all equipment which is
intended to be worn or held by a person at work and which protects him against one or more
risks to his health or safety

3 Duties
This section includes an overview of individual roles, departmental and committee duties
including levels of responsibility:
3.1 Managers
Undertake local risk assessments i.e. identification of Personal Protective Equipment,
adherence to safe practices, environment and immunisation programme, provide training for
staff.
3.2Staff
To undertake training, follow policy and report any incidents.

4 Good Practice Principles

4.1 Personal Protective Equipment
4.1.1 Gloves and aprons should be available and meet the same standards as gloves used for
other caring activities, because of the risk of exposure to blood and any other body fluids. Care
should also be taken to reduce the risks of latex sensitisation.

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4.1.2 Abrasions and cuts should be covered with a water proof dressing and gloves worn.
4.1 3 After handling used linen personal Protective Equipment should be disposed of
immediately and hand hygiene performed

4.2 Hand hygiene

4.2.1 Hand hygiene should be performed after handling any used linen and prior to handling
clean linen.

4.3 Laundering process

4.3.1 Linen and personal clothing should be removed with care, and not be shaken as this may
result in the dispersal of potentially pathogenic micro - organisms and/or skin scales into the
environment.
4.3.2 The exposure of susceptible wounds should be avoided within 30 minutes of bed making.
4.3.3 Appropriate clean bags must be available as close to the point of use as possible. Staff
must not carry linen/laundry without it being placed into a bag.
4.3.4 Linen should be placed immediately in the appropriate bag/receptacle, not placed upon
the floor. Staff should never place or empty bags of linen onto the floor or care surfaces to sort
the linen into categories this presents an unnecessary risk of contamination, especially during
care delivery. Linen should be separated into categories ready for decontamination at source,
negating the need for additional handling within the laundry.
4.3.5 Bags must be less than 2/3 full and capable of being secured. All bags should be tied
when filled, before transporting
4.3.6 Used bag/receptacles should be appropriately securely stored.
4.3.7 Linen must not be wrapped together, when disposing of it into a receptacle, place each
item in individually.
4.3.8 Staff should ensure that sharps or other extraneous items are not discarded into
linen bags receptacles.

4.4 Storage.
4.4.1 Clean and dirty laundry must be separated.
4.4.2 Infected or soiled linen should be tied & tagged & taken to the designated area. Laundry
bags holding used linen should not be left unsealed / tied for long periods e.g longer 24 hours.
4.4.3 All clean linen must be stored off the floor in a clean, closed cupboard, and must be
segregated from used / soiled linen. It must not be stored within the sluice or bathroom. Linen
cupboard doors must be kept closed to prevent airborne contamination.

4.5 Transportation and collection

4.5.1 Laundry cages surfaces must be smooth and impermeable.
Workers collecting used laundry bags should use appropriate PPE, i.e. gloves & aprons

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4.5.2 Dirty linen and clean linen must not be transported in the same bag/receptacle/storage
cage.
4.5.3 Cleaning of cages Synergy Responsibility However, receiving units should monitor the
cleanliness of cages on a regular basis, any concerns report to laundry monitoring meeting
4.5.4 Cleaning of vehicles Synergy Responsibility However, receiving units should monitor
the cleanliness of vehicles on a regular basis, any concerns report to laundry monitoring
meeting.

4.6 Incident Reporting

Any incidents where linen is not managed safely and appropriately should be reported through
the incident reporting system. This might include when sharp items have been found in linen or
where clean linen is found to be dirty. Laundry that has been sent off site and is found to be
soiled should be packaged in Purple colour bag for return to laundry as well as filling in the
appropriate reject documentation for Synergy.

5 Categorisation and segregation of linen

It is the responsibility of the person disposing of the linen to ensure that it is segregated
appropriately. All linen can be categorized into the following three groups:
5.1 Clean / Unused Linen
5.1.1 Any linen that has not been used since it was last laundered.
5.1.2 If taken into an isolation room and not used, linen must then be laundered as per
soiled/infected linen see 5.2
5.1.3 Clean linen must be in a good state of repair, as tearing or roughness can damage the
patients skin. The condition of linen in use should be monitored by the laundry contractor and
by staff.
5.2 Soiled / Infected Linen
5.2.1 This is any used linen which is soiled with blood or any other body fluid; and all linen used
by a patient with a known infection (whether soiled or not).
5.2.2 All soiled / infected linen must be placed in a red soluble alginate bag, then a red bag,
then inside a white plastic laundry bag. The soluble bag must be placed directly into the
washing machine to minimise contact and prevent transmission of infection to laundry staff or
contamination of the environment. The red bag and the outer white plastic bag should be
disposed of as clinical waste (Synergy responsibility).
Infected laundry /linen should be sent to the offsite laundry service
5.3 Dirty / Used Linen
5.3.1 All used linen other than that listed above.

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5.3.2 All linen that falls within this category must be placed within a clear plastic laundry bag.
5.3.3 This system of categorisation applies whether the items are being laundered on-site or by
the laundry contractor.
5.3.4 Used linen bags must be stored in a secure area (either inside or outside), away from
public access, whilst awaiting collection.
5.4 Infested clothes
Should be treated as infected and the same process applies.

6 Other Laundry Items

6.1 Bed linen
All hospital bed linen must be laundered by the laundry contractor.
6.2 Personal items
6.2.1 All personal items of clothing which cannot be taken home by visitors / relatives may be
laundered on-site. Subject to, completion of a risk assessment by the Matron.
6.2.2 Personal items must be bagged as above, before being transported to the laundry room.
Each patients items must be bagged and washed separately on the appropriate cycle.
6.2.3 If soiled items are taken home by relatives for laundering, no pre-washing or soaking of
the item must take place in the clinical area. If alginate bags are provided for use in domestic
machines, they must be the type with a dissolvable seam, as fully soluble bags may cause
blockage. Soiled items should not be left for more than 24hours before laundering.

6.3 Uniforms / Work wear

6.3.1 Uniforms and clothes of clinical staff must be changed daily.
6.3.2 They should be washed at home, on the hottest wash appropriate for material (with a cold
pre-wash if soiled). Check RCN guidelines for temps/ see dress code policy
6.3.4 If a uniform becomes contaminated with blood or body fluid, it must be changed for a
clean one as soon as possible. It may therefore be necessary to keep a few spare uniforms at
each site. The contaminated item should be placed in an alginate bag.
6.3.5 If alginate bags are provided for use in domestic machines, they must be the type with a
dissolvable seam, as fully soluble bags may cause blockage.
6.3.6 Clean washing machines and tumble driers regularly and maintain to manufacturers
instructions
6.3.7 Tumble dry and iron, reduces any residual micro organisms.
6.3.8 Where necessary in order to avoid overloading, wash uniforms separately from other
clothes. This enables a more effective rinse cycle.

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6.4 Manual handling equipment

Patients should have either their own hoist sling or a disposable sling until discharge from
hospital. This should be laundered or disposed of, as appropriate. Patients should have their
own sliding sheet if required, which should be laundered on discharge from hospital. Where
there is any soiling of fabric items, they must be laundered immediately and must not be
washed by hand in the department. Manufactures instructions should be followed if the ward is
using a non disposable hoist sling.
Manual handling equipment must be sent to the laundry in the appropriate colour bags as per
section 5 above

6.5 Mop heads

Must be sent to the laundry, and should not be washed on site.
Mop must be sent to the laundry in the appropriate colour bags as per section 5 above

7 Ward level Laundering/Service User Laundry Areas

Laundry should be processed off the ward unless there is a local agreement between the ward
manager, facilities estates and infection control. The Infection Prevention & Control team must
be involved in the planning and design of any new launderettes.

7.1 Environment
7.1.1 A laundry area should be designated for that purpose only, and no other activities carried
out there.
7.1.2 The walls and floors must be washable, sealed and internal decoration to an acceptable
standard.
7.1.3 The area should have a dirty area that flows through logically to the clean.
7.1.4 There must be provision of separate hand decontamination facilities, including hand
hygiene basin with lever taps and no plug or overflow, liquid soap, paper towels, pedal operated
bins.
7.1.5 All necessary Personal Protective Equipment should be provided i.e. gloves, aprons
7.1.6 Food and drinks should not be allowed in the laundry area.
7.1.7 Hand sluicing of personal contaminated clothing by staff should not be allowed as there is
a high risk of areolation of body fluids with potential infection risks to staff.
7.1.8 Machines should only be used for patient clothing and not other items such as mops.
7.1.9 Clean laundry should not be stored in the launderettes.
7.1.10 There must be an agreed cleaning schedule for the launderette

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7.2 Washing Machine

7.2.1 All washing machines must comply with HSG (95) 18 should be checked prior to purchase
to ensure that they have the specified programme ability to meet the disinfection standards.
Heat sensing systems should be tested weekly, recorded and calibrated accordingly.
7.2.2 Washers must have a sluice and disinfection cycle.
7.2.3 Regularly washing items below 65C without using a bleaching agent may allow biofilms to
build up in the machines Washing machines should be disinfected weekly by running a hot
programme without a load (the hottest programme possible on the individual machine). This
should be documented along with the testing cycle information.
Weekly Controls Assurance Test must be carried out on an empty cycle at the hottest possible
temperature for the individual machine. A surface temperature monitoring system at 71 degrees
Centigrade should show that this minimum temperature has been reached. This should be
recorded and the adhesive monitoring tab should form part of that record.
7.2.4 The machines should be sited on a plinth so that pumps can be omitted, (these are a
potential cross infection risk)
7.2.5 Care of the machine follow manufacturers instructions, including regular servicing.
7.2.6 Many micro-organisms will be physically removed, by the detergent and water, during the
washing cycle. Washing at high temperatures will allow the temperature of the water to disinfect
the items. Any remaining micro-organisms are likely to be destroyed by tumble drying and
ironing.
7.2.7 Machines should not be overloaded.

7.3 Dryer
7.3.1 An industrial dryer should be used which is regularly serviced.
7.3.2 A service log should be maintained.
7.3.3.Dryers must be vented to the outside
7.3.4 Care of the machine follow manufacturers instructions.
7.3.5 The tops and sides should be kept free of items.

7.4 Iron
7.4.1 Care of the iron follow manufacturers instructions.
7.4.2 Look at the label and check the temperature of your iron.

7.5 Sluice Facilities

7.5.1 Under no circumstances should a manual sluice facility or sluicing basin be used or
situated in the laundry.

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6.5.2 Manual soaking/sluicing must should not be carried out. The pre-wash/sluice cycle in the
washing machine should be used after removing any solids. It should be rinsed in the washing
machine first at a low temperature as high temperature will bake in blood etc.

7.6 Laundry Products

Control of Substances Hazardous to Health (COSHH) sheets and product data sheets should
be referred to in order to ensure the safe management of solutions being used for laundering.
Manufacturers instructions should also be adhered to.

7.7 During outbreaks

In event of an outbreak the use of the laundry area should be discussed with the Infection
Prevention & Control team.

8 Use of linen within community settings

8.1 Fabric sheets and blankets must only be used within community health care settings if a
laundry service is available. Laundry should be changed at least daily, and if soiled.
Alternatively, disposable sheets and pillow cases may be purchased. Paper couch roll should be
used as a covering for examination couches and changed between each patient.
8.2 Examination couches and pillows must have intact impervious coverings, so that they are
not contaminated in the event of a spillage of blood or body fluids.

9 Risk Management Strategy Implementation

9.1 Implementation & Dissemination
Staff will be made aware of the procedures to follow through local induction.

9.2 Training and Support

All staff handling linen/laundry should receive appropriate training to carry out these
duties efficiently and safely. Training will be delivered through the Matrons and
Sisters Meetings and they will cascade to appropriate staff and through the Infection
Control Committee.

9.3 Document Control & Archiving Arrangements

Once ratified, this policy will be loaded to the documents library. Any previous
versions will be electronically archived by the Policy Administrator in the electronic
Policy Drive Archive Folder.
A signed hard copy of the policy will be forwarded to the Policy Administrator and an
electronic copy will be saved by the Policy Administrator in the electronic Policy
Drive. Further copies of current and archived policies can be obtained from the
Policy Administrator including versions in large print, Braille and other languages.

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9.4 Equality Impact Assessment

Peninsula Community Health 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.
As part of its development, this strategy and its impact on equality have been
assessed. The assessment is to minimise and if possible remove any
disproportionate impact on employees on the grounds of race sex, disability, age,
sexual orientation or religious belief. No detriment was identified.

10 Process for Monitoring Effective Implementation

This policy will be monitored through an annual audit undertaken by the infection control team
and link practitioners, as set out in the annual programme. The tool to be used is the Infection
Prevention Society - Handling and Disposal of linen auditing tool.
The results of the audit will be reported to the Infection Control Committee alongside any
recommendations.

11 Associated Documentation
This document references the following supporting documents which should be referred to in
conjunction with the document being developed.

Infection Control Policies

Staff Screening, Immunisation & Communicable Diseases Policy Occ Health Policy
Dress Code and Uniform Policy
Manual Handling Policy
The Policy for the Identification and Management of Latex Allergy.
Incident Reporting Policy
Cleaning Policy and Manual

12 References

The Health and Social Care Act 2008

The Health and Safety at Work Act 1974
The Control of Substances Hazardous to Health Regulations (2002)
HSG (95)18 Hospital laundry arrangements for used and infected linen.
The Personal Protective Equipment Act 2002
The Infection Control Guidance for Care Homes (DOH June 2006)

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Appendix 1 Risk Assessment Record

Directorate:

Speciality:

Ward / Dept:
Brief description of physical location covered:

Hazard, Problem or Concern: (Something which has the potential to cause harm/damage)
Cross contamination through the ineffective laundry management

Risk: (What has/will cause the hazard to be realised and what could the impact be if realised)
a. Laundry areas inappropriate, floors walls unable to clean effectively,
b. The room is cluttered and used for storage.
c. Unable to work with clean dirty flow.
d. Washing machines do not meet specific temperatures and are not checked, serviced.
e. Items are not washed at high enough temperatures.
f. No Policy or unit protocol in place.
g. No audit programme or education for staff.
h. No Hand wash sink available.
i. Heat labile linen can not be washed at the required temperature for the heat disinfection process to
take place, as they are likely to be damaged at the thermal disinfection temperatures.
j. Staff Uniform policy that informs staff how to launder uniforms.
k. Storage facilities do not meet Infection Control standards.
l. Equipment does not comply with current infection control standards
m. The designated area for laundry does not meet infection Control standards.
n. Cleaning protocols are not agreed.
Please submit any supporting documentation with this form

Please identify one of the Corporate objectives which will be affected by the risk
identified:
X Objective 1 Achieve excellent service ratings from clients and regulators
Objective 2 Include clients, cares and members in service design
Objective 3 Develop our workforce to meet service needs
Objective 4 To achieve best value and generate a surplus to invest in our services
Objective 5 Diversify and develop services to increase income or meet needs
Objective 6 Provide services from high quality facilities
Objective 7 Promote green working and reduce travel, carbon and waste
Objective 8 Work with our partners in our communities to create life opportunities
Control Measures already in Place: (What is already in place to prevent the hazard being
realised)
Bulk of laundry sent to outside laundry services.
All linen enclosed as soon as possible in impermeable bags and handled with minimum disturbance
All dirty laundry categorised and sealed within correctly colour coded laundry bag, 2/3 full or less, sealed
with swan neck and ties

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Standard Precautions used

Dirty linen kept in agreed appropriate designated area
All sharp items are removed prior to placing in linen bags.
The exposure of susceptible wounds should be avoided within 30 minutes of bed making
Clean and dirty laundry must be transported in vehicles used solely for that purpose, interiors cleaned
following transporting of dirty linen, and clean linen covered with a washable or disposable plastic.
Advice gained from the Infection Prevention & Control team.
Are the control measures in place adequate?
YES/NO
Risk Evaluation: (Please use the 5x5 scoring matrix to assess consequence, likelihood and Priority)
Consequence
Please circle

1 2 3 4 5

Likelihood 1 2 3 4 5

Priority L M H C

Patients
Staff
Visitors
People
Y
Y
Y
affected
Name, Designation of person completing the risk assessment:

Name:
Designation:

Contractors
Y

Others

Date:

Without further control measures in place, is the identified risk:

Acceptable?

Unacceptable?

What alternative options are there that could be considered to reduce the risk?
What is the preferred option to reduce this risk?

Section 2 to be processed through local network process for managing risk

Action Required
By
Time Scale for Completed
Whom completion
Policy Ratification

SW

Resources Required: (Please include cost and recurring costs)

Low resource implication Approx 15.00 per annum per ward
If the above actions are taken, is the residual risk acceptable?

YES

Please recalculate the risk score with the recommended control measures taken into consideration

Consequence

1 2 3 4 5

Likelihood 1 2 3 4 5

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Priority L M

H C
This Assessments
recommended actions and
priorities are
agreed/declined

Please give details

At which forum?

Please give details

Position:

Signature:

Date

Who owns the risk

identified?
At what level has this risk
been entered onto the Risk
Register?
Date for Review

Name:

Position:

Please give details

A copy of This Risk Assessment Record, Should be held locally and accessible to staff.
A copy should be forward to the Risk Management Dept for the central library.
Advice on Risk Assessment may be obtained from the Risk Management dept Ex 1019

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Equality Impact Assessment Tool

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

Yes
No X
1.

Comments

Does the document/guidance affect one

group less or more favourably than another
on the basis of:

Race

Ethnic origins
travellers)

Nationality

no

Gender

no

Culture

no

Religion or belief

no

Sexual orientation including lesbian, gay,

transgender and bisexual people

no

Age

no

Disability - learning disabilities, physical

disability, sensory impairment and mental
health problems

no

2.

Is there any evidence that some groups are

affected differently?

no

3.

If
you
have
identified
potential
discrimination, are there any exceptions
valid, legal and/or justifiable?

no

4.

Is the impact of the document/guidance

likely to be negative?

no

5.

If so, can the impact be avoided?

N/a

6.

What alternative is there to achieving the

document/guidance without the impact?

N/a

7.

Can we reduce the impact by taking

different action?

N/a

no
(including

gypsies

and

no

If you have identified a potential discriminatory impact of this procedural document, please refer it to
the Equality and Diversity lead, together with any suggestions as to the action required to
avoid/reduce this impact.
For advice in respect of answering the above questions, please contact the Equality and Diversity
lead.

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