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IC/276/10 Linen Policy

BASINGSTOKE AND NORTH HAMPSHIRE NHS FOUNDATION TRUST

Linen Policy

IC/276/10

Owner

Name

Hazel Gray

 

Job Title

Senior Infection Control Nurse

Final approval

Name

Infection Control Committee

committee

 

Date of meeting

5 March 2010

Authoriser

Name

Dr Nicki Hutchinson

 

Job Title

Director Infection Prevention and Control

 

Signature

  Signature
 

Date of authorisation

05/03/2010

Review date

(maximum 3 years from date of authorisation)

2013

Audience

(tick all that apply)

Trust staff NHS General public

Standards

Standards for Better Health

C4a

 

NHSLA

 

Reviewed in accordance with The Health and Social Care Act 2008:

Code of Practice for health and adult social care on the prevention and control of infections and related guidance published 16 December 2009

Summary

This linen policy outlines how linen should be handled and transported around the Trust and ensures Health and Safety and Infection Control Guideline are followed.

0

Implementation Plan

Summary of changes

New Policy

Action needed and owner of action

IC/276/10 Linen Policy

All staff that uses the linen service must adhere to the Trust policy.

All staff must ensure that all linen is segregated and sent back to trust linen supplier in the correct linen bags depending on the condition of the linen, i.e. infected/fouled linen must be placed in red alginate bag before being placed in red plastic bag.

1

Contents

IC/276/10 Linen Policy

   

Page

Number

1.0

Introduction

3

2.0

Aim of the Policy

3

3.0

Organisational Role and Responsibilities

3

3.1

All staff

3

3.2

Managers

3

4.0

Performance Management

3

5.0

Training

3

6.0

General Linen

4

6.1

Rental Items/Issues

4

6.2

Clean Linen Delivery

4

6.3

Linen Stocks/Issue Levels

4

6.4

Soiled Linen Collections

4

6.5

Infected/Foul Linen

4

6.6

Linen contaminated with chemotherapy waste

4

7.0

Curtains

5

7.1

Curtain Changes

5

7.2

Soiled Curtain Collection

5

8.0

Pillows

5

9.0

Mops

5

10.0

Garments/Workwear/Boiler suits

6

10.1

Chefs Wear

6

10.2

Scrub Suits

6

10.3

Theatre Drapes & Gowns

6

10.4

Rejects

6

11.0

Bags

6

12.0

Safe Management of Linen

7

12.1

Protection when handling used linen

7

12.2

When and how to dispose of used linen

7

12.3

Preparation and staff protection

7

12.4

Procedures

7

13.0

How to dispose of soiled/foul/infected linen

7

13.1

Preparation and staff protection

7

13.2

Procedures

7

14.0

Linen Transportation

8

14.1

Preparation and staff protection

8

14.2

Procedures

8

15.0

Advice for relatives on taking laundry home to launder

8

15.1

Preparation

8

15.2

Procedures

8

 

References

8

 

Appendix A: Linen Segregation Procedure

9

 

Appendix B: Laundry Service Procedures

10

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IC/276/10 Linen Policy

1.0 Introduction

It has been shown that used linen, within healthcare settings, in particular, can harbour large numbers of potentially pathogenic microorganisms. Therefore, it is important that the appropriate precautions are taken to ensure contamination to/from linen does not occur as this might then lead to transmission of microorganisms to people or to the environment potentially causing infection. Such important precautions apply to all stages of linen management: storage, handling, bagging, transporting, and laundering.

The provision and management of Linen Services is an important function to enable sustainable delivery of patient care. By complying with this policy staff will facilitate the continued delivery of these services, minimising risks to health & safety, complying with infection control requirements and ensuring best value for the Trust.

2.0 Aim of the Policy

The Aim of the policy is to outline how linen should be handled to minimise the risk of cross infection.

3.0

Organisational Role and Responsibilities

3.1

All staff

Have a responsibility to safely manage linen that they use whilst delivering care

Have the responsibility to report any exposure incidents that occur related to contaminated linen and to take appropriate measures to avoid these in the first instance

Have a responsibility to undertake training on relevant aspects of the management of linen

Have a responsibility to display available posters clearly demonstrating the actions to be taken to manage linen safely

3.2

Managers

Have the responsibility to ensure local risk assessments are carried out where necessary, and ensure appropriate personal protective equipment (PPE) is available to staff. They should also ensure immunisation programmes are offered appropriately and any incidents that occur are reviewed and subsequent actions taken where appropriate

Have the responsibility to ensure staff are aware of training sessions and facilitate their attendance

Responsibility for the operational management of the linen services policy is that of Estates and Facilities Domestic & linen Service and the Trust’s chosen provider Service Group

4.0

Performance Management

The General Manager Facilities and Domestic & linen Manager will ensure this policy is implemented efficiently and that the ICT is informed of any infection control non-compliance incidents

To monitor compliance to the policy spot checks will be undertaken by the ICT at ward level on an ad hoc basis to ensure linen is segregated appropriately and any discrepancies will be fed back to the ward managers

The ICT will provide advice and support on safe handling of infected linen

5.0

Training

Segregation of linen will be part of mandatory training for all staff who handle or deal with linen throughout the Trust.

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6.0 General Linen

6.1 Rental Items / Issues

IC/276/10 Linen Policy

All stock and Issue figures will be amended on a continuous basis responding to changes in operational requirements e.g. outbreak situations

6.2 Clean Linen Delivery

Linen will be packed into linen roll cages the day prior to issue, identified and stored in the A level linen room outer area.

Portering & designated linen staff will move the roll cages from the A level linen room to a general area within each floor / departmental area each morning.

Linen services staff will top up each ward / departments linen store directly, with the identified linen issue quantities in line with the identified delivery frequencies.

Linen services staff will return all empty linen cages to the linen room for use the following day. (To comply with infection control requirements, linen cages are to be used for clean linen only. They are not to be used for soiled linen, rubbish or to move any other items)

6.3 Linen Stock/Issue Levels

Linen stock and issue levels will be constantly reviewed based on continuing usage patterns within each ward I department, and amended by either increasing or decreasing the quantities. Agreed ward/department quantity lists will be maintained and serviced with variation to quantity being communicated as instructed.

Ward / Departmental staff may request additional quantities I items of linen in response to local ad hoc requirements, by speaking to linen services staff when they are topping up the linen stocks or by contacting the linen room on ext 5043.

6.4 Soiled Linen Collections

Soiled linen is to be placed in the supplied white plastic linen bags for each category of linen. The soiled linen bag colour scheme is attached as appendix A.

Portering or designated Linen Staff will collect soiled linen on a regular basis via dedicated linen wheeled bins, from all ward / departmental areas.

All soiled linen collected should be taken to the soiled linen area, within the A Level linen room and deposited in the ‘trust linen supplier’ provided cages, in the appropriate areas as identified. All soiled linen from all areas of the hospital should be in the soiled linen area before 3am each morning to ensure that the maximum linen is available for trust linen supplier to collect each day. (To comply with infection control requirements all soiled linen is to be stored within the A Level linen room soiled linen area only, no other areas of the hospital are to be used as collection points for soiled linen)

Trust linen supplier will collect all soiled linen from the A Level linen room early morning Monday to Friday. Additional arrangements will be made to allow for the removal of soiled linen on Bank Holidays.

6.5 Infected/Fouled Linen

All Infected/fouled linen is to be placed in a red soluble bag (alginate), which should then be placed within a red plastic bag (as per the soiled linen bag colour scheme)

Collections of infected linen in red bags should follow the same procedure as for soiled linen.

6.6 Linen contaminated with chemotherapy waste

If spillage has penetrated the bed linen place it in a yellow bag and dispose of as cytotoxic waste. Hospital linen that is potentially contaminated with cytotoxic drugs should never be returned to the hospital laundry. The mattress should then be cleaned using warm soapy water. Once dried the bed may be remade with

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IC/276/10 Linen Policy

clean linen. If the mattress is affected seek further guidance from health and safety advisors.

7.0 Curtains and window Blinds

All curtains and window blinds supplied conform to all relevant regulations on fire retardancy and fabric performance. The ICT should be informed of any change and consulted on specifications

7.1 Curtain Changes

To ensure compliance with infection control procedures, curtains across all areas with be changed by linen services staff on a rotating 3 month schedule.

To ensure that the above detailed scheduled changes take place, ad hoc changes due to infection will be undertaken by the designated staff who undertake deep cleaning of areas.

Standard curtain panels are available in the linen room for ad hoc changes. These can be accessed by contacting the linen room on ext 5043 between 8am & 5pm Monday to Friday, outside of these hours curtains will be available in the linen room for collection by EFM Portering staff via bleep 1201.

7.2 Soiled Curtain Collection

All soiled/infected curtains are to be placed within a red alginate bag and then a red plastic bag

Paperwork is not required to accompany curtains sent for laundering.

Collections of curtains in red bags should follow the same procedure as for soiled I fouled linen detailed above.

8.0 Pillows

All pillows used MUST have a protective cover on it that can be wiped down

Any pillow cover that becomes torn should be placed in a clear plastic bag (NOT

a trust linen supplier bag) and placed in the sluice area for collection by the linen room staff.

Any pillow that becomes contaminated or stained and which cannot be wiped clean must be double bagged at the ward area and the word ‘condemned’ written on the bag. This should then be placed in the sluice area for collection by the linen room staff.

Pillows MUST NOT be disposed off at ward area by nursing staff.

9.0 Mops

Single undyed Kentucky string mops will be issued as standard rental items to each area in quantities as required.

Mops will be issued to each area of the hospital on an exchange basis, replacing each areas quantity of soiled mops with clean.

Linen Services staff will deliver the exchange quantity of mops to each agreed area daily Mon to Fri with double quantities issued at weekends.

Soiled Mops should be individually bagged in the supplied ‘clear’ plastic bags. These bags should then be placed in the supplied mop container / bag identified with the area name.

Portering staff on a daily basis should collect the identified container I bag containing the soiled bagged mops and transport to the identified area within the linen room.

Linen services staff will count each bagged mop for each area and reissue clean mops to replace these in each area.

All soiled mops will then be collected by trust linen supplier for laundering to thermal disinfection standards.

is the responsibility of the cleaning staff in each area to ensure that all soiled mops are returned to the linen room for laundering. (Under no circumstances should soiled mops be placed in domestic or clinical waste bags)

It

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IC/276/10 Linen Policy

10.0

Garments I Work wear/Boiler suits

Garments I work wear requiring industrial laundering with be issued as rental items to each individual staff member on an exchange basis.

Staff should take their soiled garments I work wear to the A Level linen room between 8AM and 5PM Mon to Fri, where linen services staff will exchange each item for a clean replacement.

10.1

Chefs Wear

Chefs Wear requiring industrial laundering will be issued as rental items to each individual staff member on an clean issue and dirty exchange basis.

Staff deposit their soiled Chefs wear into the designated linen bins located in the Catering departments changing areas for cleaning by the designated service provider.

10.2

Scrub Suits

Pool issue scrub suits will be issued to all areas requiring these items in the range of sizes required as per the procedure for general linen detailed above.

Soiled scrub suits should only be placed in white (or red alginate followed by red plastic bag if heavily soiled or if infected) bags as per the procedure for general linen items detailed in above. (Under no circumstances should scrub suits be placed in green bags)

10.3

Theatre Drapes & Gowns

Microfibre theatre drapes and gowns will be provided as rental items to theatres as required.

All drapes and gowns will be supplied sterile direct from trust linen supplier.

Containers containing sterile drapes and gowns will be delivered by trust linen supplier to the A level linen room. Linen service staff will sort each container into the correct area.

Portering staff will distribute each container of sterile drapes to each area identified.

Theatre staff are responsible for ordering replacement stock of theatre drapes and gowns to their agreed stock levels direct from trust linen supplier. Contact information is as issued to each department and is also available by contacting the A Level linen room on ext 5043.

Soiled drapes and gowns should be placed in green bags only. These green bags should be placed in the trust linen supplier cages used for delivery, and stored in a suitable area to await collection. (Under no circumstances should theatre drapes and gowns be placed in any other colour than green bags)

Portering staff will collect all cages of drapes and gowns, which are, bagged in green bags, along with all delivery boxes. All cages and boxes are to be taken to the A Level linen room soiled linen area and placed in the appropriate identified location, to await collection.

10.4

Rejects

Reject Bags will be issued to all areas

Any items that are unsuitable for use (stained / holed etc.) should be placed in the reject bag. (Under no circumstances should rejected items be placed in any soiled linen bags)

11.0

Bags

Plastic soiled linen bags are supplied via trust linen supplier.

Additional supplies of all soiled linen bags can be obtained by contacting the linen room on 5043.

To comply with manual handling requirements, and also to ensure undue strain is not placed on the plastic bags, do not over fill the bags (as a guide fill to 2/3s full to allow for tying the bag opening).

6

12.0 Safe Management of Linen

12.1 Protection when handling used linen

IC/276/10 Linen Policy

A

disposable plastic apron should always be worn when handling used linen (and

disposable gloves where linen is soiled/foul), e.g. during bed making.

Hold used linen away from yourself to avoid contamination of clothing from linen

Hand hygiene should be performed following handling of used linen (see Hand Hygiene Policy)

12.2 When and how to dispose of used linen

12.3 Preparation and staff protection:

Ensure appropriate and clean bags/receptacles, e.g. linen skips, are available as close to the point of use as possible

Personal protective equipment (PPE) should be worn appropriately to ensure contamination from used linen does not occur, e.g. disposable plastic apron and gloves if handling used linen.

12.4 Procedures:

Place used linen immediately into a designated bag/receptacle

Separate used linen carefully. Place each item directly into the designated bag/receptacle. (However, if linen is soiled/foul, it should be managed separately, see - How to dispose of soiled/foul linen)

Never place/drop linen on the floor or on other surfaces, which may be touched

frequently as this could lead to contamination, especially during care delivery e.g.

a locker/table top

Staff should avoid shaking linen as this may result in the dispersal of potentially pathogenic microorganisms and/or skin scales into the environment

Used linen bags/receptacles should never be overfilled

After handling linen, staff should ensure they dispose of any PPE appropriately

Hand hygiene should be performed following handling of linen

13.0 How to dispose of soiled/foul/infected linen:

13.1 Preparation and staff protection:

Ensure appropriate and clean bags/receptacles e.g. linen skips are available as close to the point of use as possible

Personal protective equipment (PPE) should be worn appropriately to ensure contamination from used linen does not occur, e.g. disposable plastic apron and gloves if handling linen

13.2 Procedures:

Linen soiled or contaminated with blood or other body fluids or from infected patients, should be placed directly into a water-soluble/alginate bag (these are red in colour) to prevent any further handling and potential contamination, particularly for those performing laundering procedures. This bag indicates that linen is soiled/foul. The bag should be secured using a neck tie

Separate the linen carefully.

Staff should NOT shake the linen as this may result in the dispersal of potentially pathogenic microorganisms and/or skin scales into the environment

The alginate bag once tied should be placed into a red plastic bag.

Soiled/foul linen should not be rinsed or sorted prior to it being laundered,

Never place/drop linen on the floor or on other surfaces which may be touched frequently as this could then lead to contamination especially during care delivery e.g. a locker/table top

Bags should never be over filled

After handling linen, staff should ensure they dispose of any PPE appropriately

Hand hygiene should be performed following handling of linen

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IC/276/10 Linen Policy

14.0

Linen Transportation

14.1

Preparation and staff protection

PPE should be worn appropriately to protect those transporting linen, e.g. gloves

Measures should be in place to ensure that linen for use arrives clean e.g. department or company agreements.

Inspections should be carried out on those transporting linen e.g. auditing of vans or trolleys to ensure these are clean and that cages are used for storage of linen in these settings with clear separation of clean and dirty linen

14.2

Procedures

 

Bags containing used linen that have not been properly secured should not be lifted

Personnel transporting used linen should not open linen bags/receptacles/cages nor should they handle linen

If a sharps injury is sustained from an item found during transport of linen, the trust’s standard procedure as per Sharps contamination injuries Policy, should be followed.

Clean and used linen should never be transported in the same bag/receptacle/storage cage. Instead, there should be designated bags/receptacles/storage cages for each

Clean hands should only handle clean linen. The linen should be stored in a designated, clean area with minimal handling until required for use

Hand hygiene should be performed after handling used linen bags/receptacles/cages and prior to handling clean linen

15.0

Advice for relatives on taking laundry home to launder

15.1

Preparation

 

Staff should explain key elements of standard infection control precautions e.g. PPE, hand hygiene, to relatives/friends prior to them taking linen home to launder

15.2

Procedures

These additional points should also be raised:

Dispose of plastic bag(s) used to carry items promptly

Launder items using as high a temperature as possible and as per machine instructions

Use normal washing powder

Tumble dry where possible (following manufacturers guidance)

Iron according to manufacturers’ instructions. A hot iron is best if possible

Hand hygiene should be undertaken following handling of items

Where hand rinsing of heavily soiled items is absolutely necessary, this should be carried out by fully submersing the items to avoid potential aerosolisation/splashes while rinsing. Ensure splashing is minimised particularly when throwing away used water

Generally, personal items do not need to be separated for washing unless soiled

References

1. National Health Service Executive. Hospital Laundry Arrangements for Used and Infected Linen. HSG (95)18 Leeds: NHSE; 1995; 4.

2. Standard Principles for preventing hospital-acquired infections Journal of Hospital Infection (2001) 47(Supplement): S21–S37

3. Wilson J et al (1999), Infection Control in Clinical Practice. Bailliere Tindall London 1999.

4. Damani N.N. (2000), Manual of Infection Control Procedures: 2nd Edition, Greenwich Medical Media Ltd. London.

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Appendix A

Linen Segregation Procedure

Appendix A Linen Segregation Procedure Used/slightly soiled linen from non-infected patients must be placed into a

Used/slightly soiled linen from non-infected patients must be placed into a WHITE plastic laundry bag

LINEN SEGREGATION PROCEDURE

INFECTED & HEAVILY SOILED LINEN ONLY
INFECTED &
HEAVILY SOILED
LINEN ONLY

Used linen which has been in contact with infected patients OR is heavily contaminated with body fluids should be placed into a RED SOLUBLE BAG (alginate) and securely tied before being placed into a RED PLASTIC BAG

USED THEATRE LINEN ONLY
USED
THEATRE
LINEN ONLY

Used linen must be placed into a GREEN PLASTIC BAG linen that has been heavily contaminated with body fluids must be placed into a RED SOLUBLE BAG (alginate) prior to going into a GREEN PLASTIC BAG

IC/276/10 Linen Policy

ALL BAGS SHOULD BE NO MORE THEN 2/3 FULL NO LINEN SHOULD BE PLACED INSIDE A YELLOW CLINICAL OR DOMESTIC WASTE BAG ENSURE ALL SHARP ITEMS ARE REMOVED PRIOR TO PLACING LINEN INTO BAG

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APPENDIX B

IC/276/10 Linen Policy

Basingstoke and North Hampshire NHS Foundation Trust

Laundry operational procedures for the BNHFT

1 st April 2008

EFM Domestic and Laundry Service

Content

Heading

Section

Purpose

1.0

Overview of service

2.0

Arrangement for thermal infestation/infection control

3.0

Appendix

 

1. Sunlight service schedule HSG (95)18 and KPI

 

2. Service requirement

3. PASA cost schedule

4. Laundry returns procedure

5. Sunlight BCP and escalation data

IC/276/10 Linen Policy

1.0 Purpose

This procedure document details the Basingstoke and North Hampshire NHS Foundation Trust’s (BNHFT) Laundry and linen service arrangements. This includes the contracted services provision for laundry and its respective governance and compliance with HSG(95)18.

2.0 Service overview

Healthcare linen provided by external laundry contract

External linen supplier delivers clean stock to site determined by volumes ordered or agreed by Trust

to site determined by volumes ordered or agreed by Trust Storage and distribution of linen is

Storage and distribution of linen is operated by the Trusts EFM Laundry team supported by the Porter team for site distribution

team supported by the Porter team for site distribution Storage and distribution of linen stock at

Storage and distribution of linen stock at ward level is controlled by the ward team along with collection and return of dirty and faulty stock to designated collection points

of dirty and faulty stock to designated collection points Dirty and faulty linen is collected and

Dirty and faulty linen is collected and returned to the EFM laundry team for collation and return to external linen supplier

team for collation and return to external linen supplier External linen supplier collects dirty stock and

External linen supplier collects dirty stock and launders as per schedule (HSG(95)18

The Trusts EFM laundry team manages

Contract performance management with external supplier

Stock control and distribution of stock

Safe delivery and return of clean and dirty stock

Support of linen service users in the Trust to ensure performance of service

Attendance at the Trusts ‘Cleaner Hospital committee’

Liaison with IC team and Health and Safety team on operational issues

Carry out annual ‘duty of care visit to supplier/contract providers operation. Appendix ? Duty of care visit report.

This is led by the:

EFM domestic and Laundry manager

Laundry Supervisor

Linen room team

3.0 Arrangement for thermal infestation/infection control

The Trust’s contracted service provider ‘Sunlight Ltd’ operate to ensure compliance with HSG(95)18 the below statement is provided as part of the operating protocols of the laundry service contract at the BNHFT.

Sunlight Ltd operational governance of HSG (95)18

EFM/Laundrydoms/Proc/2008

IC/276/10 Linen Policy

3.1 Thermal disinfection of laundry

We comply with HSG(95)18, which gives guidance on infected linen and notifiable diseases.

We would conform to relevant guidance from the Trust’s Control of Infection Officer where appropriate.

The wash process will be designed to maintain at least two wash cycles. The first will attain a temperature of 32 degrees centigrade. The second will attain a temperature of 71 degrees centigrade or more which will be maintained for at least five minutes. Additional time at this temperature will be added for heavily soiled work.

At least one sluice cycle will proceed the high temperature washes and controls will be so set on the machine as to ensure the programme timer does not proceed until the set temperature has been reached. The timer will stop each time the temperature falls below the set level.

Depending on the classification Peroxide or Chlorine bleach will be used.

The final load each day in every washing machine will be of a classification that will allow Chlorine bleach to be used during the rinse cycle. No work will be left in washing machines overnight. CBW's will be thermally disinfected before the start of work each day.

3.2 The prevention of subsequent re-infection

We comply with HSG(95)18, and refer to working practices, i.e. restricting movement of staff from clean to dirty areas, gowning protocols and proper receptacles for storage of work in process, trolley disinfection procedures, covering trolleys with polythene and vehicle cleaning and disinfection routines.

3.3 The processing of fouled articles

We comply with HSG(95)18, and would advise additionally there are designated areas within the sorting room, a designated processing washer extractor, sealed drains and vent to atmosphere for the processing of infected articles. Work that is delivered in alginate bags with surrounding red bag is processed unopened, which is then thermal disinfected in washer extractor and then reprocessed again using the normal wash procedure.

EFM/Laundrydoms/Proc/2008

Appendix 1

IC/276/10 Linen Policy

NATIONAL FRAMEWORK AGREEMENT FOR THE PROVISION OF LAUNDRY AND LINEN SERVICES TO THE BNHFT

Service Specification

Contents

Section

1 Overall service options

(a)

Wash and return

(b)

Linen Hire

(c)

Total Linen Management

(d)

Hire of CE marked, reusable barrier theatre textiles

2 Service standard

(a) For service options 1a,1b and 1c

3 Collection and delivery for all service options

4 Storage for all service options

5 Packaging for all service options

6 Processing of articles of laundry

(a)

For service options 1a,1b and 1c

(b)

For service option 1d

7 Standard of finish for all service options

8 Quality assurance and control for all service options

9 Key Performance Indicators

10 Documentation-management information

11 Contingency planning

12 Emergency supplies (major incident)

Schedule 1

HSG (95) 18

Schedule 2

Performance standards

Schedule 3

Menu of services

Schedule 4

Key finish definitions

Schedule 5

Standards of finish

EFM/Laundrydoms/Proc/2008

IC/276/10 Linen Policy

Standard service requirements

1 Service options The Contractor shall provide laundry and linen services based on all or some of the following service options:

(a)

Wash and return which consists of:

A laundering and finishing service

Collection and delivery to and from NHS clients

All linen owned by client trust

Product mix may include:

 

(a)

Flatwork

(b)

Uniforms

(c)

Theatre linen (traditional cotton based products)

(d)

Patient Clothing (personal & non personal)

(b)

Linen hire which consists of:

A laundering and finishing service

Collection and delivery to and from NHS clients

All linen owned by contractor with the exception of wash and return

Contract may comprise an element of wash and return (see above)

Provision of linen articles that may include:

(a)

Flatwork

(b)

Uniforms

(c)

Patient Clothing (personal & non personal)

Curtain Hire

This service is to supply curtains with additional options to fit and take down as required, in accordance with participating trusts’ requirements. All curtains to be flame retardant in accordance with HTM87.

The unit costs for curtain hire to be shown in a two tier format that consists of a separate charge, per metre, for hire of the curtain and an associated charge for laundering as a wash and return item.

(c)

Total linen management which consists of:

A laundry and finishing service

All linen owned by contractor with the exception of wash and return

Contract may comprise an element of wash and return (see above)

Collection of soiled linen from each ward and department

Delivery to each ward and department of clean linen

Sewing Room Service (optional)

Provision of linen articles that may include:

 

(a)

Flatwork

(b)

Uniforms

(c)

Theatre linen (traditional cotton based products)

(d)

Patient Clothing (personal & non personal)

(d)

Hire of CE marked, reusable barrier theatre textiles, which consists of:

Provision of a laundry and finishing service for theatre textiles that meet the requirements of the European Medical Devices Directive 93/42

Collection and delivery to and from NHS clients

EFM/Laundrydoms/Proc/2008

IC/276/10 Linen Policy

Provision of CE marked reusable barrier theatre textiles in compliance with EN

13795

Theatre top up service (optional)

In view of the wide range of drapes and gowns available, offerors are requested to list a sample range of high usage product lines e.g. top 20 items, together with the maximum price the NHS would pay for those product lines.

Under this framework agreement trusts’ will use this information as the basis of identifying their bespoke requirements. Participating trusts will then use this to secure more detailed information both in terms of products and prices that reflects local needs

2

Service standard for service options1a, 1b and 1c

(a)

The Contractor shall supply a service to HSG 95(18), as a minimum standard; to

ensure that service standards are reflective of the aims associated with relevant

Government “best practice” e.g. Peat standards.

Organisations appointed to the

national framework agreement will be expected to comply with all future government guidance, regulations and standards in the provision of this service. To assist interpretation of these standards, a copy of HSG (95) is attached in Schedule 1.

3

Collection and delivery for all service options The Contractor shall collect all used/infected linen from specified storage facilities, at times agreed with NHS clients. All clean articles of laundry shall be delivered by the Contractor to agreed delivery points within an agreed time frame.

Used/infected articles of laundry must be transported, stored and sorted in containers and in accommodation separate from those used for clean linen and must not at any time come into contact with clean linen.

Clean articles of laundry shall be transported in containers and vehicles that have been appropriately cleaned by the Contractor before each occasion on which they are used. Each stillage/roll cage will be appropriately covered.

4

Storage for all service options The Contractor shall operate and maintain appropriate storage and handling systems for all linen held within their facility. The storage areas must provide for the segregation of clean and used/infected articles of laundry and prevent the damage or soiling of clean articles of laundry from any source.

5

Packaging for all service options Clean articles of laundry must be packed in such a manner as to prevent re-soiling.

6

Processing of articles of laundry

(a)

For service options 1a, 1b and 1c

All articles of laundry must be washed, thermally disinfected unless the fabric or product does not allow for this, in which case chemical disinfection is allowed.

Laundering must be undertaken in accordance with HSG (95)18, relevant statutory requirements and reflect good industrial practice.

(b)

For service option 1d

C.E marked barrier theatre drapes and gowns (medical devices) are to be laundered from the soiled side via a barrier washing machine into a clean room certified and

EFM/Laundrydoms/Proc/2008

IC/276/10 Linen Policy

validated to ISO 14644 Class 8 Clean Room. There they are to be dried, inspected, folded and packed for sterilisation. Entry and exit to be controlled via an airlock system, with staff changing and washing facilities.

7 Standard of finish for all service options All clean articles of laundry, including CE marked barrier theatre drapes and gowns, on each occasion they are supplied shall be thoroughly clean and fresh, free from infection, in good usable condition and a good state of repair and in every respect fit for immediate use.

8 Quality assurance and control for all service options The Contractor will provide evidence of its’ own quality assurance and control procedures including any accreditations to ISO standards or equivalents. A quality assurance plan is required to ensure that systems and procedures are in place to guarantee that services are provided according to the standards laid down within the Contract, on each and every occasion throughout the Contract Period.

9 Key Performance Indicators The service provided will be in accordance with the standards specified and will meet those ‘key performance indicators’ detailed in Schedule 2

10 Documentation- management information Documentation must be adequate to identify and control all articles of laundry being

held or processed by the Contractor and to substantiate invoices.

documentation must be sufficiently detailed and capable of manipulation to enable

computer modeling and management forecasting to be undertaken by NHS clients.

Additionally

11 Contingency planning The Contractor must put in place appropriate contingency plans, prior to the commencement of Contract. The Contingency Plan is to detail how the Contractor proposes to allow for the continuance or earliest resumption of services in the event of an emergency or breakdown of normal services. This contingency response is to cover all areas of service and must be 100%operational within 24hours of each service failure.

12 Emergency supplies (major incident)

The Contractor must maintain sufficient supplies of linen to cover unforeseen increases in demand. Such emergency supplies must be accessible within 1 hour, 24 hours a day, 7 days a week.

Schedule 1

HSG (95) 18

Hospital Laundry Arrangements for Used and Infected Linen

EFM/Laundrydoms/Proc/2008

Health Service

Guidelines

Hospital

Laundry

Infected Linen

Executive Summary

Arrangements

for

Used

and

The provision of adequate laundry services is a fundamental requirement of direct patient care and a major feature among a hospital’s man activities which contribute to its commitment to meet Patient’s Charter standards of quality services. “Hospital Laundry Arrangements for Used and Infected Linen” sets out the recommended procedures to help meet this commitment. In particular it covers the handling and laundering of linen; the importance of securing the disinfection of used and infected linen; and the basic principles of infection control.

Background

The NHS has an obligation under the Health and Safety at Work Act to take steps to prevent the risk of infection to staff handling and laundering linen. There is also a need to deal with the potential for harm to staff and damage to linen by a failure to separate “sharps” from dirty linen before it is placed in laundry bags.

Action

NHS managers are asked to draw the accompanying guidance to the attention of all staff, including contract staff, which may need to apply it.

Managers should ensure that relevant legislation, including the requirements of the Registered Homes Act in respect of laundry from small units, is complied with.

Management should adopt procedures to ensure that patients and staff are not put at risk of infection from used and infected linen.

Management should ensure that all staff, and laundry contractors, responsible for handling or laundering linen are appropriately trained.

The advice contained in the HSG should be incorporated into contracts where laundry services are not provided in-house.

The help of the Society of Hospital Linen Services and Laundry Managers, in conjunction with the industry technical association, FCRA in drawing up this guidance is acknowledged.

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IC/276/10 Linen Policy

HSG(95)18

Laundry

Arrangements for Used and

Hospital

Infected Linen

This

which

December 1992

replaces

expired

21 April 1995

HC(87)30

on

1

IC/276/10 Linen Policy

LAUNDERING PROCEDURES TO SECURE DISINFECTION OF USED AND INFECTED LINEN

1.

INTRODUCTION

1.1

This guidance, which should be applied to all laundry facilities including launderettes and on-premise laundries associated with small units, is issued to promote practices which will reduce the possible risk of infection to laundry staff during the laundry process and to secure the disinfection of used and infected linen. These practices will also help to eliminate possible damage to linen and laundry equipment from the failure of staff to separate potentially dangerous items (“sharps” in particular) from dirty linen before it is placed in laundry bags.

1.2

It is essential for a laundry and its associated operations to ensure that it provides health care units with adequate and timely supplies of the necessary requirement of clean items. This is a major feature in the many aspects of a hospital’s activities which also helps them to meet their “Patients Charter” commitment of providing quality services. Even minor variations in the levels of service provided can have serious consequences.

1.3

The main problems demonstrating the need for revised advice involve the sorting and categorising of linen. Although handling of foul linen is undesirable there is a need to separate articles requiring different treatment and to detect sharp objects that may damage the whole load. This is a particular problem when dealing with linen from some units e.g. geriatric and psychiatric where up to 80% of its linen is in the foul or infected category. The separation of soiled and foul linen is often not carried out in the wards and items likely to damage linen, or machines, are commonly found in pockets of garments or accidentally placed in the laundry bag. Positive efforts should be made to encourage ward and theatre staff to use the bagging procedures as in Appendix A and to avoid putting extraneous items into laundry bags. Linen from patients with diseases likely to be transmissible to staff should be transferred to a washing machine without handling by the laundry operative.

1.4

The local control infection committee should use this advice when determining local policy procedures. It should also take into account HC(91)33 – Decontamination of contaminated equipment, linen or other surfaces contaminated with hepatitis B and/or Human Immunodeficiency Virus (HIV). The committee could also usefully urge staff not to send sharp items with linen to the laundry.

1.5

All staff handling linen should receive appropriate training to carry out their duties efficiently and safely.

2.

CATEGORIES OF LINEN

2.1

It is recommended that linen (in this document “linen” refers to all articles for laundering) should be divided by staff in wards and departments into three categories.

2.1.1

Used (Soiled and Foul) – all used linen, irrespective of state, but on occasion contaminated by body fluids or blood, apart from linen from infectious patients, those suspected as being infectious and linen covered by 2.1.2 and 2.1.3. Handling policy for used (soiled and foul) linen will be determined at local level with advice from the local infection control committee whether the foul linen is to be categorised with the used or infected linen.

2.1.2

Infected – linen from patients with or suspected of suffering from enteric fever, and other salmonella infections, dysentery (Shigella spp), hepatitis A, hepatitis B, hepatitis C and carriers, open pulmonary tuberculosis, HIV infection, notifiable

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IC/276/10 Linen Policy

diseases and other infections in hazard group 3 COSHH 1994 Approved List of Biological Agents (see Advisory Committee on Dangerous Pathogens) and other infections specified by the infection control officer as hazardous to staff. Linen from patients infected with hazard group 4 organisms (haemorraghic fever viruses such as Lassa Fever) must be steam-sterilised by autoclaving within the group 4 containment unit before laundering – see Memorandum On The Control of Viral Haemorraghic Fevers, HMSO 1986. It is most important that linen likely to infect staff should be put immediately into a water-soluble bag or bag with a water-soluble stitched seam or membrane which will release its load in the wash process and which is sealed with an appropriate soluble tie and labeled as to its origin. The containers should be correctly coloured in accordance with the amended SIB(10)20. (See Appendix A.)

2.1.3 Heat-Labile – fabrics damaged by the normal heat disinfection process and likely to be damaged at thermal disinfection temperatures.

3.

DISINFECTION OF USED (SOILED AND FOUL) LINEN

3.1

This category accounts for the vast majority of used linen from hospitals. For transportation, such linen should be placed into polythene or nylon/polyester laundry bags, colour coded in accordance with Appendix A. Bags must be securely fastened before being sent to the laundry. Care should be taken to prevent linen or foul seepage (body fluids or blood) escaping from laundry bags and contaminating other items or staff. Use of a water-soluble bag as a liner is recommended.

3.2

The washing process should have a disinfection cycle in which the temperature in the load is maintained at 65°C (150°F) for not less than 10 minutes or preferably at 71°C (160°F) for not less than 3 minutes. With both options, “mixing time” must be added to ensure heat penetration and assured disinfection. For machines of conventional design and a low degree of loading (for example, below 0.056 kg/litre) 4 minutes should be added to these times to allow for mixing time. For machines with a heavy degree of loading (for example, above 0.056 kg/litre) it is necessary to add up to 8 minutes. A sluice cycle should be included as necessary when dealing with foul linen.

3.3

All washing machines should be checked prior to purchase to ensure that they have the specified programming ability to meet the above disinfection standards, and on commissioning to ensure compliance with disinfection standards. The special requirements for continuous batch washing machines are set out in paragraph 8.

3.4

All washing machines should be fitted with accurate heat sensors. The sensing elements must be correctly placed to register the true wash temperature, i.e. the temperature of the wash water in contact with the load. Wash temperatures should be subject to a monitoring system and heat sensing systems should be tested at six weekly intervals and calibrated accordingly. Records should be kept of the six weekly testing and the necessary calibration.

3.5

Categorisation of linen should be done at local level with the appropriate coloured coded containers. However, water soluble bags or bags with a water-soluble stitched seam or membrane are recommended for heavily fouled linen.

DISINFECTION OF INFECTED LINEN

4.1 Linen in this category should not be sorted, but should be sealed in a water-soluble

bag or bag with a water-soluble stitched seam or membrane immediately on removal from the bed or before leaving a clinical department. This primary container should then be placed in a nylon or polyester bag with the appropriate colour code in accordance with Appendix A and labelled if considered necessary locally. The inner

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IC/276/10 Linen Policy

bag should be transferred to the designated washer extractor without opening, followed by the outer bag which should be washed in a similar fashion. Due to the potential for blockages and a need for staff to enter the machine in this even, under no circumstances should infected linen be processed in a batch continuous washing machine.

4.2

The provision of a designated storage area should not be necessary but infected linen should be stored under secure conditions prior to treatment.

4.3

The recommendations on the washing process for used linen regarding the thermal disinfection stage, set out in paragraph 3.2, also apply to the process for infected linen.

4.4

The temperatures recommended in paragraph 3.2 should inactivate HIV but there is some uncertainty as to minimal temperatures required to inactivate hepatitis B virus. However, the heat inactivation at these temperatures, combined with the considerable dilution factor stage, should render the linen safe to handle on completion of the wash cycle.

4.5

Where central disinfection areas exist it is not expected that the arrangements will automatically be dispensed with but, if necessary, they will continue because of the financial and practical implications of making the alteration. However, where laundries are also producing linen and laundry for other than hospital purposes i.e. commercial contracts which may include food industry or related work, it may be a contractual requirement that a barrier operation is provided to effectively separate unprocessed work from clean work. In this situation, a central disinfection area or barrier room for infected work may be desirable.

4.6

Where a known infection occurs in a small unit all used and patients’ personal clothing must be disinfected in accordance with the preceding guidance and advice from the control of infection officer.

5.

DISINFECTION OF “HEAT-LABILE” LINEN

5.1

The purchase of fabrics which will not withstand the temperatures set out in paragraph 3.2 should be avoided where possible.

5.2

Heat-labile materials, for example, patients’ clothing articles manufactured from knitted polyester, need to be washed at low temperatures (40°C - 104°F) to avoid damage. The temperature in tumble driers, if used, must be limited to 60°C and calendars should be avoided wherever possible.

5.3

Disinfection with chemicals at low temperatures is possible with hypochlorite but the performance of hypochlorite is often restricted by the presence of soiling, detergents and alkalis in the wash. However, in clean conditions hypochlorite is active at a temperature below 60°C (140°F) in low concentrations and will not damage fabrics outside acceptable limits.

5.4

Disinfection of heat-labile materials, only if suitable, may be achieved by the addition of sodium hypochlorite to the penultimate rinse. This should be a medium or high dip rinse of at least five minutes duration and sufficient sodium hypochlorite must be added to achieve a concentration of 150 ppm available chlorine. Overriding of washing programmes must be avoided. Hypochlorite must not be used on fabrics treated for fire retardance. Other chemical processes may be used if approved by the Control of Infection Committee.

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IC/276/10 Linen Policy

6.

DESIGN FEATURES TO REDUCE CROSS-CONTAMINATION

6.1

The provision of a barrier between the section which receives the used or infected linen and the rest of the laundry is not considered necessary. It is recommended that infected linen should be washed in designated water extractors as set out in paragraph 4.1. Any vent pipe associated with such machines should be routed outside.

6.2

Effluent from the drains of such machines must be sealed (closed piped) from the machine to the manhole (preferable situated outside the laundry) to prevent cross- infection. If machines drain into an open sump or pit immediately below the machine drain valve, the sump or pit should be covered to reduce the risk of bacteria being spread by the aerosol effect when the water is pumped from the machine.

6.3

When laundering infected linen at launderettes or in on-premise laundries associated with small units the machine requirements set out in the preceding paragraphs are necessary.

6.4

There must be a physical barrier between clean and used or infected linen when carried on a vehicle at the same time. No bag of linen that is not securely fastened should be placed in a vehicle.

6.5

Trolleys for clean linen in transit should be covered with washable or disposable cover. Fully enclosed and sealed containers with a lockable door may be used in preference, in which case these covers are not required.

7.

PROTECTION OF LAUNDRY WORKERS

7.1

Staff in the sorting areas handling used unwashed linen should wear protective clothing e.g. waterproof aprons and gloves. Any exposed lesion should always be covered with a waterproof dressing. Although care needs to be given to proper protection at all times, the use of surgical face masks is not considered necessary. Hand washing and changing facilities must be provided in accordance with current legislation and clean overalls should be available to staff at each new shift or work period change.

7.2

Staff should be fully trained in all laundry operations. Guidelines setting out cleaning and operational procedures for plant, equipment and laundry buildings should be made available.

7.3

Detailed policy on the occupational health supervision of laundry staff should be determined locally in the light of guidance given in such documents as HN(82)33, HC(78)3 and on vaccination for NHS staff.

8.

BATCH CONTINUOUS WASHING MACHINES

8.1

All batch continuous washing machines must be fitted with the necessary controls and interlocks to ensure work being processed is not recontaminated during the rinsing stages of the wash process. To satisfy this requirement, rinse sections must be thermally disinfected before production commences each working day.

8.2

The apparatus used to thermally disinfect rinse sections of the batch continuous washing machine must be interlocked with the normal running control of the machine in order to prevent the machine being set to work before the thermal disinfection of the cool stages of the machine have been satisfactorily completed. The requirements are as follows:-

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IC/276/10 Linen Policy

i. All sections of the machines, following the high temperature sections, which do not reach a minimum temperature of 65°C (150°F), shall receive a thermal disinfection cycle. The disinfection cycle shall be considered satisfactory when the water temperature has been raised to 65°C (150°F) and held at this temperature for a period of not less than 10 minutes or at a temperature of 71°C (160°F) for a period of not less than 3 minutes. During the period of thermal disinfection of the rinse stages, it is essential that the machine cage/drum rotates to ensure that all surfaces are in contact with high temperature liquids. The disinfection process should be controlled by a timer.

ii. A timer shall be incorporated into the control system to override the necessity to proceed through the thermal disinfection of the cool stages of the machine if the machine is stopped for short periods during the day. This timer however shall be so interconnected that if the machine is shut down for a period of 3 hours or more the cool stage thermal disinfection cycle will proceed, and at the same time “lock out” the washing controls. The “lock out” shall include any mechanical devices, interlocked with the washing cycle or not, for feeding work into the machine.

iii. It is expected that the cool stage disinfection cycle will be initiated by a single button operation and that the cycling of any steam and/or water control valves necessary to raise the temperature of these stages to that required for thermal disinfection shall be automatic in operation. The incorporation of hand operated valves in this system is not acceptable.

8.3 Due to the growth of bacteria which may take place overnight, it will be necessary to run out all linen for the batch continuous washing machine at the end of the day to avoid reinfection. The adequacy of disinfection procedures must also be considered in the following ancillary areas:-

i. Tanks which are used to collect water for reuse within the batch continuous washer, from the extraction device or the conveyor leading from the washer to the extractor to the shuttle, shuttle platform and tumblers.

ii. If the installation of a heat exchanger in the recovered water system is envisaged, special consideration to thermal disinfection needs must be given.

iii. Machinery should be kept clean and free from algae.

iv. Attention to the cleaning and regular disinfection of all conveyor belting and surfaces used to transfer clean, processed work from the press/extraction device to tumblers is essential to avoid recontamination of the work.

v. Under no circumstances should infected linen be processed in batch continuous washing machines. These may suffer blockage at any stage, though the pre-wash section is the most likely. The pre-wash sections cannot be thermally disinfected as a routine. In the event of a blockage neither the pre-wash sections nor the wash sections would be safe to enter without exposing staff to an unacceptable level of risk. Until such blockages could be removed the machine could not be operated or any thermal disinfection routine undertaken. Washer extractor systems should be used for infected linen or foul linen where this has been categorised with infected linen following advice at local level from the local infection control committee.

EFM/Laundrydoms/Proc/2008

Circulars mentioned in this document

IC/276/10 Linen Policy

HC(87)30

Hospital Laundry Arrangements for Used and Infected Linen

HC(91)33

Decontamination of Equipment, Linen or Other Surfaces Contaminated

HN(82)33

With Hepatitis B and/Or Human Immunodeficiency Viruses Memorandum on the Control of Viral Haemorraghic Fevers, HMSO 1986 Occupational Health Services for NHS Staff

HC(78)3 Control Of Tuberculosis in NHS Employees: Limitation of X-Ray Examinations

EFM/Laundrydoms/Proc/2008

APPENDIX A

COLOUR CODING

IC/276/10 Linen Policy

1. All DMUs and Trusts are asked to work towards implementing the National Colour

Standard.

2. The following procedures should be adopted by ward and theatre staff:-

a. Used (Soiled and Foul) linen (Category 2.1.1) – containers should be coloured white or off-white.

b. Infected linen (Category 2.1.2) – containers should be coloured red or, at least, include red a prominent feature on a white or off-white background. Additionally the container should carry a bold legend on a prominent yellow label such as INFECTED LINEN. It should be noted that some red bags used for this purpose may not be colour-fast.

c. Heat-labile linen (Category 2.1.3) – containers should be coloured white with a prominent orange stripe.

d. The use of red for infected material should be regarded as mandatory and the use of blue or yellow for this type of laundry should be avoided

Schedule 2

Performance Standards - Key Performance Indicators

 

Description

Tolerance

Financial

SSG Proposed Escalation Procedure

 

Penalty

Actions to be undertaken by Contractor

     

1. Each delivery meets ordered requirements with no shortages, provided ordered requirements are no more than 120% of average daily order. If a shortage does occur, the customer must be informed by 10.00am on the day of delivery

Factory

0.1% credit of total invoice for every 1% above 3% tolerance

If at the end of the month Sunlight has failed to provide the service within the tolerance stated the General Manager will be notified. They will work with the Trust authorised officer to resolve the issue by the end of the following month. If Sunlight fail to rectify this by the end of the second month the Sunlight Regional / Business Development Director will be notified who will work with a Senior Trust Representative to resolve the issue. If the failure is not resolved by the end of the 3rd month the Commercial Director of Sunlight will be notified. At this point the Trust can issue a "PERFORMANCE NOTICE" in line with the PaSA Terms and conditions of the contract. If the failure is still not resolved by the end of the fourth month the Trust may issue a "REMEDY NOTICE" in line with the PaSA Terms and Conditions of the contract, giving Sunlight 30 days to

to

monitor

daily. No

more

than 3%

 

shorts of

each

and remedial actions agreed to rectify the stock shortage within

specificat

ion

24

hours. If the shortage is not

volume

rectified with 24 hours the first stage of the escalation procedure will be implemented. If

supplied

per

invoice

it is not rectified within the next

period.

24

hours the second stage of the

escalation procedure will be apply with a performance notice being issued if a further 24 hours passes without resolution.

EFM/Laundrydoms/Proc/2008

IC/276/10 Linen Policy

     

remedy the failure to the Trust's reasonable satisfaction. If at the end of the 30 days the failure is still not remedied, the Trust may serve written notice of "TERMINATION OF CONTRACT" in line with the PaSA Terms and Conditions of the contract.

2. Clean linen is delivered to designated location(s) during 2 hour delivery window which has been agreed with the NHS client. If the delivery will be outside of the delivery window, the customer must be informed prior to the earliest time within the agreed delivery window.

Factory

0.1% credit of total invoice for every delivery outside the 2 times delivery tolerance

If at the end of the month Sunlight has failed to provide the service within the tolerance stated the General Manager will be notified. They will work with the Trust authorised officer to resolve the issue by the end of the following month. If Sunlight fail to rectify this by the end of the second month the Sunlight Regional / Business Development Director will be notified who will work with a Senior Trust Representative to resolve the issue. If the failure is not resolved by the end of the 3rd month the Commercial Director of Sunlight will be notified. At this point the Trust can issue a "PERFORMANCE NOTICE" in line with the PaSA Terms and conditions of the contract. If the failure is still not resolved by the end of the fourth month the Trust may issue a "REMEDY NOTICE" in line with the PaSA Terms and Conditions of the contract, giving Sunlight 30 days to remedy the failure to the Trust's reasonable satisfaction. If at the end of the 30 days the failure is still not remedied, the Trust may serve written notice of "TERMINATION OF CONTRACT" in line with the PaSA Terms and Conditions of the contract.

to

monitor

daily. No

more

than 2

late

 

deliveries

per

 

invoice

period.

As long

as delays

are within

Sunlight

control.

EFM/Laundrydoms/Proc/2008

IC/276/10 Linen Policy

3.

Soiled linen is collected from

Factory

0.1% credit of

If at the end of the month Sunlight

designated location(s) during the 2 hour delivery window which has been agreed with the participating NHS client. If any on site logistics prevent this from being achieved this must be immediately communicated to the NHS client and remedial

to

total invoice for every collection outside of the 2 times collection tolerance

has failed to provide the service within the tolerance stated the General Manager will be notified. They will work with the Trust authorised officer to resolve the

monitor

daily. No

more

than 2

late

 

issue by the end of the following

collection

month. If Sunlight fail to rectify this

s

per

by the end of the second month the

 

invoice

Sunlight Regional / Business

action taken within a 24 hour period.

period.

Development Director will be notified who will work with a Senior Trust Representative to resolve the issue. If the failure is not resolved by the end of the 3rd month the Commercial Director of Sunlight will be notified. At this point the Trust can issue a "PERFORMANCE NOTICE" in line with the PaSA Terms and conditions of the contract. If the failure is still not resolved by the end of the fourth month the Trust may issue a "REMEDY NOTICE" in line with the PaSA Terms and Conditions of the contract, giving Sunlight 30 days to remedy the failure to the Trust's reasonable satisfaction. If at the end of the 30 days the failure is still not remedied, the Trust may serve written notice of "TERMINATION OF CONTRACT" in line with the PaSA Terms and Conditions of the contract.

4.

Provide evidence of the wash

Tests to

Variations from

If any part of the laundering process

processes utilised within the factory. Including:-(i) Water usage

be

standards to

that is key to ensuring UHL is not

complete

trigger full

put at risk fails an alarm system

d

on a 4

investigation

sounds immediately in the factory.

(ii)

Water retention Detergent dosing Acidity/alkalinity PH

weekly

and start the

The machine will cease operating

(iii)

basis

escalation

automatically and reparative action

(iv)

minimum

process

can be taken before the machine is

(v)

and

put back into service again. At this

(vi)

Temperature – at

results

point, Sunlight must notify the Trust

least 72oC for 3 mins or 65 oC

supplied

immediately and in writing if a

for 10 mins.

to

system/ operational failure will

(vii)

Reflectance tests –

customer

affect delivery to the Trust or if linen

average of 20 items

.

has already been delivered that has been compromised or affected before the detection of the system/production failure. If at the end of the 4 week period any issues have arisen Christeyns (External Company who complete Testing on all Parts of the Laundry operations) will rectify these immediately (where applicable) and will issue the General Manager with a written report on the results and any actions that need to be undertaken before the next set of tests are

EFM/Laundrydoms/Proc/2008

IC/276/10 Linen Policy

     

carried out. If the failure is not resolved by the end of the 4 week period the Commercial Director of Sunlight will be notified. At this point the Trust can issue a "PERFORMANCE NOTICE" in line with the PaSA Terms and conditions of the contract. If the failure is still not resolved by the end of the fourth month the Trust may issue a "REMEDY NOTICE" in line with the PaSA Terms and Conditions of the contract, giving Sunlight 30 days to remedy the failure to the Trust's reasonable satisfaction. If at the end of the 30 days the failure is still not remedied, the Trust may serve written notice of "TERMINATION OF CONTRACT" in line with the PaSA Terms and Conditions of the contract.

5. EMPA test pieces to be passed through the wash system every 6 months. Reflectance values protein 40% (manual washer), vegetable dye 48%, vegetable oil 50% and mineral oil

Tests to

Variations from standards to trigger full investigation

If at the end of the 6 months Sunlight has failed to provide the information within 4 weeks of the due date the General Manager will

be

carried

out every

6

and start the

be notified. They will work with the Trust authorised officer to resolve the issue by the end of the following month. If Sunlight fail to rectify this by the end of the second month the Sunlight Regional / Business Development Director will be notified who will work with a Senior Trust Representative to resolve the issue. If the failure is not resolved by the end of the 3rd month the Commercial Director of Sunlight will be notified. At this point the Trust can issue a "PERFORMANCE NOTICE" in line with the PaSA Terms and conditions of the contract. If the failure is still not resolved by the end of the fourth month the Trust may issue a "REMEDY NOTICE" in line with the PaSA Terms and Conditions of the contract, giving Sunlight 30 days to remedy the failure to the Trust's reasonable satisfaction. If at the end of the 30 days the failure is still not remedied, the Trust may serve written notice of "TERMINATION OF CONTRACT" in line with the PaSA Terms and Conditions of the contract.

months.

50%.

escalation process

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IC/276/10 Linen Policy

6.

Demonstrate a system that

Factory

Defective items

If at the Trusts request Sunlight fail

ensures:-

produce

supplied to

to provide proof of the weekly

(i)

stained or

weekly

customer to be

records in relation to the tolerance

contaminated items are diverted to rewash or special wash processes

record

replaced free of

stated the General Manager will be

that

charge within

notified. They will work with the

details

48 hours

Trust authorised officer to resolve

(ii)

damaged items are

pieces

the issue by the end of the following

diverted to repair or rag

processe

month. If Sunlight fail to rectify this

(iii)

any Trust owned

d

and

by the end of the second month the Sunlight Regional / Business Development Director will be notified who will work with a Senior Trust Representative to resolve the issue. If the failure is not resolved by the end of the 3rd month the Commercial Director of Sunlight will be notified. At this point the Trust can issue a "PERFORMANCE NOTICE" in line with the PaSA Terms and conditions of the contract. If the failure is still not resolved by the end of the fourth month the Trust may issue a "REMEDY NOTICE" in line with the PaSA Terms and Conditions of the contract, giving Sunlight 30 days to remedy the failure to the Trust's reasonable satisfaction. If at the end of the 30 days the failure is still not remedied, the Trust may serve written notice of "TERMINATION OF CONTRACT" in line with the PaSA Terms and Conditions of the contract.

items that are not fit for purpose

rewash

percenta

should be bagged separately and returned to the NHS client

ge.

7.

Linen is finished in

Monthly

0.1% credit of total invoice for every 1% of rejects above the 5% tolerance identified by the

If at the end of the month Sunlight has failed to provide the service within the tolerance stated the General Manager will be notified. They will work with the Trust authorised officer to resolve the issue by the end of the following month. If Sunlight fail to rectify this by the end of the second month the

accordance with the agreed specifications. The tolerance level of 5% rejects will be applied

check to

take

place to

to the amount of linen inspected.

ensure

specificat

ions are

being

customer.

met.

Factory

Sunlight Regional / Business

to

Development Director will be notified who will work with a Senior Trust Representative to resolve the issue. If the failure is not resolved by the end of the 3rd month the Commercial Director of Sunlight will be notified. At this point the Trust

complete

internal

quality

check of

100

items on

a

weekly

can issue a "PERFORMANCE NOTICE" in line with the PaSA Terms and conditions of the contract. If the failure is still not resolved by the end of the fourth month the Trust may issue a "REMEDY NOTICE" in line with the PaSA Terms and Conditions of the

basis and

record

results.

Sunlight

Represe

ntative to

be in

attendan

contract, giving Sunlight 30 days to

EFM/Laundrydoms/Proc/2008

IC/276/10 Linen Policy

 

ce when

remedy the failure to the Trust's reasonable satisfaction. If at the end of the 30 days the failure is still not remedied, the Trust may serve written notice of "TERMINATION OF CONTRACT" in line with the PaSA Terms and Conditions of the contract.

audits

take

place (if

available)

8. Operate best practice to the security of NHS client owned items.

Factory

If at the end of the month Sunlight has failed to provide the service within the tolerance stated the General Manager will be notified. They will work with the Trust authorised officer to resolve the issue by the end of the following month. If Sunlight fail to rectify this by the end of the second month the Sunlight Regional / Business Development Director will be notified who will work with a Senior Trust Representative to resolve the issue. If the failure is not resolved

will

polymark

 

all NHS

clients’

goods

that are

not

labelled.

Full audit

trail

utilising

duplicate

paperwor

k.

by the end of the 3rd month the Commercial Director of Sunlight will be notified. At this point the Trust can issue a "PERFORMANCE NOTICE" in line with the PaSA Terms and conditions of the contract. If the failure is still not resolved by the end of the fourth month the Trust may issue a "REMEDY NOTICE" in line with the PaSA Terms and Conditions of the contract, giving Sunlight 30 days to remedy the failure to the Trust's reasonable satisfaction. If at the end of the 30 days the failure is still not remedied, the Trust may serve written notice of "TERMINATION OF CONTRACT" in line with the PaSA Terms and Conditions of the contract.

EFM/Laundrydoms/Proc/2008

IC/276/10 Linen Policy

9. Provide management

To be

If at the end of the month Sunlight

information on a monthly basis which shows:

produced

has failed to provide the information

monthly

within the tolerance stated the

(i)

monthly usage

and

General Manager will be notified.

volumes (standard Sunlight reports)

forwarde

They will work with the Trust

d

to NHS

authorised officer to resolve the issue within the 3 day timescale. If Sunlight fail to rectify this before the next due date for the report the Sunlight Regional / Business Development Director will be notified who will work with a Senior Trust Representative to resolve the issue. If the failure is not resolved by the end of the 3rd month the Commercial Director of Sunlight will be notified. At this point the Trust can issue a "PERFORMANCE NOTICE" in line with the PaSA Terms and conditions of the contract. If the failure is still not resolved by the end of the fourth month the Trust may issue a "REMEDY NOTICE" in line with the PaSA Terms and Conditions of the contract, giving Sunlight 30 days to remedy the failure to the Trust's reasonable satisfaction. If at the end of the 30 days the failure is still not remedied, the Trust may serve written notice of "TERMINATION OF CONTRACT" in line with the PaSA Terms and Conditions of the contract.

(ii)

quality checks – at

client

factory and site

within 10

(iii)

complaints

days of

(iv)

van disinfection

month

(v)

customer’s own

end.

work – issues

(vi)

receipt of clinical

waste

(vii)

delivery

times/procedures

10. Demonstrate an appropriate complaints procedure that ensures that any complaints are responded to within 48 working hours to UHL representative on each site

All

If a response has not been received

complaint

within 48 working hours of the

s

to be e-

complaint being sent the General Manager will be notified. They will work with the Trust authorised officer to resolve the issue within the 7 day timescale (Where this is not practical a timescale will be agreed between both parties for the resolution of the issue) . If Sunlight fail to rectify this within the agreed timescale the Sunlight Regional / Business Development Director will be notified who will work with a Senior Trust Representative to resolve the issue (within an agreed timescale). If the failure is not resolved by the end of the 3rd

mailed to

the

helpdesk

 

(charnwo

od.servic

e@sunlig

ht.co.uk)

and

Commer

cial

Manager

(Johnny.

Wright@

sunlight.c

o.uk) at

the

month the Commercial Director of

Leicester

Sunlight will be notified. At this point

facility

the Trust can issue a "PERFORMANCE NOTICE" in line with the PaSA Terms and conditions of the contract. If the failure is still not resolved by the end of the fourth month the Trust

EFM/Laundrydoms/Proc/2008

IC/276/10 Linen Policy

     

may issue a "REMEDY NOTICE" in line with the PaSA Terms and Conditions of the contract, giving Sunlight 30 days to remedy the failure to the Trust's reasonable satisfaction. If at the end of the 30 days the failure is still not remedied, the Trust may serve written notice of "TERMINATION OF CONTRACT" in line with the PaSA Terms and Conditions of the contract.

10a

Resolutio

 

as above

n

of

complaint

s

to be

within 7

days if

possible.

11. Verify disinfection of linen using microbiological testing

6 weekly

Variations from standards to trigger full investigation

If at the end of the 6 week period Sunlight has failed on any of the key criteria highlighted via the microbiological testing the General

microbiol

including:-

ogical

(i)

Log kill of >5 on all

testing to

washing machines when testing

be

and start the

Manager will be notified

for Escherichia Coli and Enterococcus hirae.

complete

escalation

immediately. They will work with the

d.

process

microbiologists to ensure the issues are resolved by the end of the next testing period. If Sunlight fail to rectify this by the end of the next testing period the Sunlight Regional Director will be notified who will work with the General Manager and microbiologist to resolve the issue. If the failure is not resolved by the end of the 3rd period the Commercial Director of Sunlight will be notified. If the failure is still not resolved by the end of the fourth month the Trust may issue a "REMEDY NOTICE" in line with the PaSA Terms and Conditions of the contract, giving Sunlight 30 days to remedy the failure to the Trust's reasonable satisfaction. If at the end of the 30 days the failure is still not remedied, the Trust may serve written notice of "TERMINATION OF CONTRACT" in line with the PaSA Terms and Conditions of the contract.

(ii)

Bioburden of final

clean product for Coliforms,

Escherichia Coli, Enterococci, Staphylococous aureas, Bacillus cereus, Clostridium difficile achievement of <3 colony forming units per 100cm2 of linen tested.

(iii)

Employee’s hands

for Coliforms, Escherichia Coli,

Enterococci, Staphylococous aureas, Bacillus cereus, Clostridium difficile.

(iv)

Air settle plates

tested for environmental bacteria, yeasts and moulds.

(v)

Machine process

waters.

(vi)

Swabs of delivery

van interiors.

(vii)

Swabs of delivery

cages.

EFM/Laundrydoms/Proc/2008

IC/276/10 Linen Policy

12.

Verify disinfection of delivery

Daily

Variations from standards to trigger full investigation and start the

If at the end of the 6 week period Sunlight has failed to provide the information required or failed to pass the microbiological testing the General Manager will be notified

vans following unloading of dirty linen and before clean linen and report results to NHS client.

check

sheets to

be

 

complete

d

by

escalation process

immediately. The General Manager will liaise with the Trust Authorised Officer to ensure this is resolved by the next test date. They will work with the microbiologists to ensure the issues are resolved by the end

drivers.

Van

 

testing to

be

included

in

6

of the next testing period. If Sunlight fail to rectify this by the end of the next testing period the Sunlight Regional Director and Senior Trust Representative will be notified who will work with the General Manager and microbiologist to resolve the issue. If the failure is not resolved by the end of the 3rd period the Commercial Director of Sunlight will be notified.At this point the Trust can issue a "PERFORMANCE NOTICE" in line with the PaSA Terms and conditions of the contract. If the failure is still not resolved by the end of the fourth month the Trust may issue a "REMEDY NOTICE" in line with the PaSA Terms and Conditions of the contract, giving Sunlight 30 days to remedy the failure to the Trust's reasonable satisfaction. If at the end of the 30 days the failure is still not remedied, the Trust may serve written notice of "TERMINATION OF CONTRACT" in line with the PaSA Terms and Conditions of the contract.

weekly

microbiol

ogical

testing.

13.

All linen must comply to UHL

No change to specificat ion without agreeme nt of UHL

 

If at the end of the month Sunlight has failed to provide the service within the tolerance stated the General Manager will be notified. They will work with the Trust authorised officer to resolve the issue by the end of the following month. If Sunlight fail to rectify this by the end of the second month the Sunlight Regional / Business Development Director will be notified who will work with a Senior Trust Representative to resolve the issue. If the failure is not resolved by the end of the 3rd month the Commercial Director of Sunlight will be notified. At this point the Trust can issue a "PERFORMANCE NOTICE" in line with the PaSA Terms and conditions of the

agreed standards including fabric, reflectivity and fire retardency.

EFM/Laundrydoms/Proc/2008

IC/276/10 Linen Policy

   

contract. If the failure is still not resolved by the end of the fourth month the Trust may issue a "REMEDY NOTICE" in line with the PaSA Terms and Conditions of the contract, giving Sunlight 30 days to remedy the failure to the Trust's reasonable satisfaction. If at the end of the 30 days the failure is still not remedied, the Trust may serve written notice of "TERMINATION OF CONTRACT" in line with the PaSA Terms and Conditions of the contract.

Actions to be undertaken by the Customer

   

1.

Soiled linen is collected at

Factory

 

timely intervals to ensure that sufficient soiled linen is returned

to

monitor

for processing.

volumes

returned.

2.

No site logistics prevent the

Factory

 

linen from being delivered or collected within the agreed delivery/collection window.

to

monitor

and

 

report in

monthly

review if

any

issues.

3.

Linen supplied is used for the

Monitore

 

purpose it is provided. Any linen

d

at

that has been abused and would not be fit for reuse will be charged to the NHS client at full replacement cost.

factory

level, 5%

tolerance

.

4.

Any heavily soiled articles

Monitore

 

should be sluiced prior being

d

at

returned to the factory for processing.

factory

level.

5.

Cages provided should be for

Monitore

 

the use of transporting linen only.

d

on site.

6.

No clinical waste should be

Disposal

 

returned to the factory. This is a

of clinical

severe health and safety risk.

waste will

be

charged.

7.

Ensure that bagging

   

procedure is adhered to.

EFM/Laundrydoms/Proc/2008

Overarching Statements

IC/276/10 Linen Policy

Financial penalties identified in the table will apply for failure of service standards within each invoice period.

Any Financial Penalties as a result of the Performance Notice being issued are in addition to any financial penalty as a result of a failure identified against any individual performance measure identified in the financial penalty column of the performance measurement table above.

If Sunlight fail to the extent that there are at least 3 Performance Notices active at any one

time, the Trust can issue a Remedy Notice ( for one or more of the Performance Notices), irrespective of whether the Performance Notice(s) has reached the end of its period or not. If by the end of the 30 day Remedy period there were still 3 or more active Performance Notices ( or 3 or more active Remedy Notices), then the Trust may issue a Notice of Termination of Contract in line with the PaSA Terms and Conditions of the Contract.

A notice of Termination of Contract may also be issued at any time in line with the PaSA

Terms and Conditions of Contract.

EFM/Laundrydoms/Proc/2008

Basic Service

IC/276/10 Linen Policy

Schedule 3

Menu of Services

1. The service will include collecting soiled linen and delivering clean linen.

2. At the discretion of each Trust, items will be collected from and delivered to either:

a) a single drop/collection point per Trust or

b) up to 3 points within a single Trust inside a 3-mile radius.

3. Linen will be delivered/collected once per day

4. This service will include traveling the distances required to deliver to all Trusts you have selected within each region.

5. Delivery and collection will take place during business hours, and/or at night in the London region

6. The Service will be carried out 5 days per week, Monday through Friday. However Linen Hire and Total Linen Management stock levels provided must be sufficient for each day of the week (weekend volume)

7. The frequency of Linen delivery for Total Linen Management service will be carried out as necessary to maintain the agreed-upon linen stock levels

8. The service will include use of rolling cages

9. Clean linen will be packed in bulk, except for Total Linen Management, where pack to ward is part of the service

10. Packed to bulk linen will include a plastic cover

11. For Linen hire and Total Linen Management services, management of agreed-upon stock levels will be included

12. Trust owned linen will be laundered and return to each Trust within 72 hours

13. The service will exclude bank holidays

14. Trusts will use the supplier’s standard colour coding for soiled linen bags

15. The items will include the 46 categories listed in the Offer Schedule for each region

16. The product items will be either:

a) Standard supplier product range (Linen Hire or Total Linen Management Services) or

EFM/Laundrydoms/Proc/2008

b) Trust owned linen (Wash and Return)

IC/276/10 Linen Policy

17. The service will include automated folding as applicable

18. Clean line will have the supplier’s finish as appropriate to the linen article (e.g. calendared finish for sheets, etc)

19. For Trust-owned items, linen repair services are excluded, but for Line Hire and Total Line Management, they are included

Service variations and enhancements to Basic Service

Transportation

Adjustment for each additional delivery point over and above those included in the basic service

Frequency of Service

Each additional drop/collection required per day

Discount for each business day deducted from the 5 day per week service included in the basic service

Saturday service

Sunday service

Bank holiday service, excluding Christmas and Boxing Day

Discount for extending Trust-owned linen turnaround time to two weeks from 72 hours

Discount for extending Trust-owned linen turnaround time to 1 week from 72 hours

Turnaround time of 48 hours for Trust-owned linen

Turnaround time of 24 hours for Trust-owned linen

Packing

Pack to ward onsite

Pack to ward offsite

Fabric Type (Applicable items within flat work)

100% Cotton (if not supplier standard)

80% Polyester 20% Cotton (if not supplier standard)

70% Polyester 30% Cotton (if not supplier standard)

Finish/Presentation

Hand finish

Hand fold

On hangers (when applicable)

Additional Services (Applicable to basic service)

Repair service for Trust owned linen

Distribution of linen

Soiled linen collection from ward

EFM/Laundrydoms/Proc/2008

IC/276/10 Linen Policy

Schedule 4

KEY FINISH DEFINITIONS

Standard of Finish

Definition

Condition of receipt

The actual state of an item on return from the Offerer to the Trust

Staining

A noticeable variation in colour caused by residue soiling

Major stain

A fresh stain that is clearly visible and greater than 2cm in

diameter in any area of the article.

Minor stain

A

stain of less intensity but still fairly visible to the naked eye and

greater than 4cm in diameter.

Permanent Stain

A

stain which is embedded on to the weave of the material and

which has been washed twice through the normal wash process. Likely types of staining will be mildew, iron or rust, concrete or

floor marking and medical products.

Transfer these products to

the rewash process. Products which are stained with a medical consumable will need to be discussed with the Trust.

Unacceptable stain

Any stain which falls in the definition of a major or minor stain or any stain on theatre linen

Repair

An alteration to an article which returns it to a serviceable

condition

Repair free

An article which may have been repaired but requires no further

 

repair

Hole