DECONTAMINATION & SAFE HANDLING OF LINEN & LAUNDRY

SECTION: 18 INFECTION CONTROL POLICY/PROCEDURE: 18.26 NATURE AND SCOPE: SUBJECT: POLICY AND PROCEDURES TRUSTWIDE DECONTAMINATION & SAFE HANDLING OF LINEN & LAUNDRY This policy and procedure has been produced in line with the requirements of The Health and Safety at Work etc Act 1974 and the Management of Health and Safety at Work Regulations 1999 for identifying and controlling significant risks in the workplace by carrying out suitable and sufficient risk assessments in health and safety. DATE OF LATEST RATIFICATION: NOVEMBER 2017 RATIFIED BY: INFECTION CONTROL COMMITTEE IMPLEMENTATION DATE: NOVEMBER 2017 (REISSUED JULY 2018) REVIEW DATE: NOVEMBER 2020 ASSOCIATED TRUST POLICIES & PROCEDURES: All Trust Health and Safety and Welfare Policies and Procedures ISSUE 3 JULY 2018

1.0 Scope 2.0 Introduction ISSUE 3 JULY 2018 2 Decontamination & Safe Handling of Linen & Laundry 18.26 NOTTINGHAMSHIRE HEALTHCARE NHS FOUNDATION TRUST DECONTAMINATION AND SAFE HANDLING OF LINEN & LAUNDRY POLICY AND PROCEDURE 3.0 Policy/Procedure Principles 4.0 Definitions 5.0 Duties and Responsibilities 6.0 Implementation and Monitoring 7.0 Clean Linen 7.1 Clean Linen 7.3 Local Use 8.0 Used Soiled/Fouled Linen 9.0 Infectious Linen 9.7 Infested Laundry CONTENTS 10.0 Laundry which would Remain Hazardous following Normal Processing or for which Additional Precautions are Required 11.0 Condemned or Unfit Linen 12.0 Procedure for Water-Soluble Red Alginate Bags 13.0 Removal of Used Soiled/Fouled Linen 14.0 Manual Handling 15.0 Spillage from Used Soiled/Fouled Linen 16.0 Local Cleaning 17.0 Patient Clothing 18.0 Storage and Removal of Dirty/Soiled Linen 19.0 Safe Management of Linen in Transfer Vehicles (In-House) 20.0 Safe Management of Linen in Transfer Vehicles (Contracted) 21.0 Laundering of Linen (In House) 21.1 Environment 21.2 Validation and Maintenance of Equipment 22.0 Routine Cleaning/Disinfection of Equipment 23.0 Laundry Services Provider 24.0 Decanting Linen/Machine Loading 25.0 Wash Cycles 26.0 Heat Liable Linen 27.0 Testing Linen for Associated Infections/Micro-Organisms including Testing for Bacillus Bacteremia 28.0 Faulty Washing Machine/Tumble Dryer (Trust Owned)

29.0 Protection of Laundry Workers 30.0 Staff Uniforms 31.0 Bed Assemblies, Curtains and Soft Furnishings 31.1 Fire Retardation 32.0 Curtains 33.0 Duvets/Pillows/Mattresses 34.0 Mops 35.0 Performance Management (Contractors) 36.0 Colour Coding for Laundry Bags 37.0 Training 38.0 Target Audience 39.0 Review Date 40.0 Consultation 41.0 Relevant Trust Policies 42.0 Monitoring Compliance 43.0 Equality Impact Assessment 44.0 Legislation Compliance 45.0 Champion and Expert Writer 46.0 References/Source Documents Appendix 1 Appendix 2 Appendix 3 Validation of Maintenance of Equipment Checklist/Form Equality Impact Assessment Tool Record of Changes ISSUE 3 JULY 2018 3

1.0 SCOPE Decontamination & Safe Handling of Linen & Laundry 18.26 DECONTAMINATION AND SAFE HANDLING OF LINEN & LAUNDRY POLICY AND PROCEDURE 1.1 This policy covers all Trust owned, leased or informally occupied premises, these can be solely occupied or shared with other organisations. The aim of this policy is to highlight how laundry and linen items throughout the Trust should be handled to minimise the risk of cross infection. 2.0 INTRODUCTION 2.1 Nottinghamshire Healthcare NHS Foundation Trust recognises that with poor laundry and linen handling and segregation processes comes the risk of cross infection. It is important that as a Trust we recognise the need to reduce all health hazards and risks to patients, staff, visitors and all service users where reasonably possible. 2.2 This policy defines the responsibilities of all Trust staff on the importance of correct and safe management of linen procedures, from storage to handling, bagging, transporting and laundering. 2.3 It is important that everyone who comes into contact with laundry and linen is aware of the risks and also the appropriate precautions to take to prevent the transmission of microorganisms throughout all Nottinghamshire Healthcare properties. 2.4 This will ensure the Trust complies with HTM 01-04 Decontamination of linen for Health and Social Care - March 2016. 3.0 POLICY/PROCEDURE PRINCIPLES 3.1 The Trust and its contractors will adopt procedures to ensure essential quality requirements and best practice is monitored. 3.2 The policy should be read in conjunction with the appropriate local procedures. 3.3 The Trust recognises its legal obligation to take necessary measures to prevent the risk of cross contamination due to poor handling and management of linen. 4.0 DEFINITIONS Trust Premises - Applies to all buildings, sites, work areas and grounds owned by the Trust Landlord Hosted Premises - Applies to all buildings sites, work area and grounds where Trust staff occupy through a lease or informal basis. Linen - Articles or garments made from linen or a similar textile, such as cotton or man-made fibres. i.e. hoist slings Clean Linen - Items of linen that have been processed or are otherwise clean and have not yet been used. Flat Linen - Is inclusive but not limited to bed sheets, counterpanes, pillowcases and towels. Patients Linen - All patient related items, personal clothing, and specialist items of linen. Used Soiled & Fouled Linen - Any used linen that is soiled with blood or any other body fluid. ISSUE 3 JULY 2018 4

Infectious Linen - All linen from known or suspected infection and those isolated patients, patients with diarrhoea or items contaminated with bodily fluids from patients with blood-borne viruses. Condemned Linen - Rejected linen that is no longer fit for purpose i.e. torn or stained. Infested Linen - Laundry that is potentially infested with parasites (e.g. bed or body lice, scabies). Laundry Items - This term can relate to any items processed by the contracted laundry facility or used as a term of description for the building used to clean/process linen. 5.0 DUTIES AND RESPONSIBILITES 5.1 The Chief Executive Has overall responsibility for Health and Safety and shall ensure that this policy is implemented to ensure the Trust meets its obligations under the Health & Safety at Work Act 1974 and associated legislation. 5.2 The Director of Infection Prevention and Control (DIPC) The DIPC will have overall responsibility for IPC and will report directly to the Chief Executive and the Board quarterly and as required. The DIPC is an integral member of the Trust s clinical governance safety structure. The DIPC will chair the Trust Wide Infection Prevention and Control Committee. 5.3 Trust Wide Infection Prevention and Control Committee A Trust Wide Infection Prevention and Control Committee is a mandatory requirement. It is a key forum in providing assurance that the Trust has in place structures and arrangements to meet all statutory requirements for IPC. 5.4 The Infection Prevention and Control Teams Providing a management, consultative and advisory service to the Trust in order that the Trust ensures effective systems are in place for the monitoring, prevention and control of infection and ensure compliance with the Health and Social Care Act 2008 (Revised 2015). 5.5 Contractors Shall carry out linen services as per specification in any contract with Nottinghamshire Healthcare NHS Foundation Trust and shall adhere to the requirements of this policy. 5.6 Trust Staff For the purposes of this document, bank/agency staff and students/trainees/volunteers are considered to be Trust staff. All staff employed within Nottinghamshire Healthcare have duties and responsibilities in respect to the decontamination of linen, and must conduct their duties in accordance with the Trust Policy and procedures for the management and provision of linen decontamination. 5.7 Estates/Facilities Managers ISSUE 3 JULY 2018 5

A Manager will be identified as the Authorised Officer in respect of the Linen Contracts. The Manager will be responsible for monitoring the performance of the Linen Contractor to ensure that the contract specifications and standards are being met and that the Trust is receiving an efficient service. The Manager will develop the specification for Linen/Laundry services. The Manager will work in conjunction with the IPC team in the monitoring and auditing of Landlord procedures. 6.0 IMPLENTATION AND MONITORING 6.1 Each individual member of staff, volunteer or contracted worker within the Trust is responsible for complying with the standards set out in the document and reporting any breaches. The Trust Board and Chief Executive are informed by the Director of Infection Prevention (DIPC) to ensure that the correct systems are in place to effectively manage Infection prevention and control. 6.2 Laundry provided by Nottinghamshire Healthcare NHS Foundation Trust should be fit for purpose and this should include compliance with Department of Health Firecode HTM 05-03 Part C: Textiles and furnishings. All areas should ensure that they have adequate supply and access to linen incases of outbreak for example (either owned or rental). 6.3 The provision of clean linen is a fundamental requirement for patient care. Incorrect procedures for handling or processing linen can present an infection risk both to staff handling and laundering linen and to patients who subsequently use it. 6.4 It is the responsibility of the person handling the linen to ensure that it is segregated into the following categories: Clean Linen Used Soiled & Fouled Linen Infectious Linen Condemned Linen 7.0 CLEAN LINEN 7.1 Clean Linen: Ensure rotation of linen stock is utilized Clean linen should look visibly clean and should not be damaged or discoloured Once linen has been decontaminated, every effort must be made to maintain its quality and cleanliness Linen should be delivered to the clinical areas in clean covered containers. Clean linen should not be transported in containers used for used/soiled/fouled or infectious linen 7.2 All clean linen must be: Stored in a clean, closed cupboard (either a dedicated linen cupboard or dedicated, fully enclosed mobile linen trolley) Stored off the floor Stored with the linen cupboard/trolley doors closed to prevent airborne contamination ISSUE 3 JULY 2018 6

Stored in a clean, dust free environment Segregated from used/soiled/fouled or infectious linen Clean linen must not be stored in unsuitable areas e.g. the sluice, bathrooms, in bedspaces 7.3 Local Use Clean linen should not be decanted onto open trolleys unless for immediate use 8.0 USED SOILED/FOULED LINEN 8.1 This applies to all used linen, irrespective of state, but on occasions contaminated by body fluids or blood. 8.2 Used Soiled/Fouled linen should be placed directly into a white laundry bag. 8.3 Used Soiled/Fouled linen bags should not be filled to the point where they become heavy and difficult to lift 8.4 It is staff responsibility to ensure instruments, sharps and non-laundry items are not disposed of within linen bags. 8.5 Clothing belonging to the service users must be washed individually in accordance to local procedures. 9.0 INFECTIOUS LINEN 9.1 This includes patients known or suspected: MRSA, gram positives or gram negative infections Hepatitis A, B or C Tuberculosis (TB) Salmonella Norovirus Clostridium difficile Chickenpox Head or body lice, scabies Other notifiable diseases 9.2 Linen bags should not be filled to the point where they become heavy and difficult to lift. 9.3 Used soiled/fouled linen bags should be stored in appropriate containers designated for used laundry 9.4 Infectious linen should be placed directly into a red alginate bag which is secured, then placed into an outer bag ISSUE 3 JULY 2018 7

9.5 Please note imperial laundry requests red alginate bags to be placed into clear plastic bags or red cloth bags 9.6 Personal clothing that is soiled should be removed with care and placed into the appropriate bag 9.7 Infested Laundry Place into a red alginate bag which is then secured and placed in an outer bag Marking of laundry as infested is not required. 10.0 Laundry Which Would Remain Hazardous Following Normal Processing Or For Which Additional Precautions Are Required 10.1 Laundry thought to be contaminated with any of the following micro-organisms must be placed in the hazardous waste stream (yellow plastic bags) and incinerated and not sent to the laundry service. Advice should be requested from the Infection Prevention and Control Team and the Energy and Environmental Officers. Bacillus anthracis (Anthrax) Viral Hemorrhagic Fevers (i.e. Ebola) Rabies Bioterrorism agents e.g. Smallpox CJD were body fluids have leaked onto laundry items 11.0 CONDEMNED OR UNFIT LINEN 11.1 Linen deemed not fit for purpose (heavily stained, torn,) should be placed in the appropriate colour coded plastic bag as per service provider labelled as reject linen and returned according to local protocol. 11.2 Linen deemed not fit for purpose should not be placed in the same bag as other linen for processing. Ward staff are responsible for identifying unfit/condemned linen. 12.0 PROCEDURE FOR WATER-SOLUBLE RED ALGINATE BAGS 12.1 This procedure is to be used in all situations where linen is placed in red alginate bags: Place the linen inside the red alginate bag Do not overfill the water-soluble alginate bag Seal the alginate bag using the neck tie do not knot the bag Place the red alginate bag inside the outer linen bag. Imperial laundry requests red alginate bags places into clear plastic outer bags or red cloth bags. 12.2 Infection Prevention & Control policy must be adhered to when handling both clean and soiled linen. 13.0 REMOVAL OF USED SOILED/FOULED LINEN ISSUE 3 JULY 2018 8

All used linen must be handled with care and attention paid to the potential spread of infection through micro-organisms via dust and skin scales and bodily fluids. All dirty linen must be placed carefully and directly into the appropriate linen bag on removal from the bed or patient The used soiled/fouled linen skip should be at the bedside. Used soiled/fouled linen should not be carried to avoid contamination of uniforms/environments Used soiled/fouled linen must never be transported around the care environment unless within an appropriately colour coded linen bag Vigorous, enthusiastic bed stripping is microbiologically hazardous as large numbers of organisms (mainly skin flora) are dispersed. Care should be taken to minimise contamination of equipment and the near patient environment. When beds are changed open wounds/drains, for example, need to be temporarily covered during linen changes. Do not shake linen into the environment. Do not change linen whilst wounds are being dressed in the same area. Plastic aprons should be worn by all staff for all bed making in line with national colour coding and this includes beds where the patient has been discharged Plastic aprons must be changed between beds. Gloves must be worn when handling used linen Face protection/eye protection must be worn where there is significant contamination with blood and body fluids likely to cause a splash injury 14.0 MANUAL HANDLING 14.1 The use of linen, in its various forms, involves manual handling. For example, the use of roll containers and linen skips will be required for delivery, storage, retrieval and laundering activities. Bed and mattress movement will invariably be required in connection with bed linen. For manual handling activities that present a risk of injury, a suitable and sufficient risk assessment will be required. Examples of control measures will be in the appropriate selection and maintenance of any equipment, in the way items are stored, handled and transported and in the weights of laundry bags. Risk assessment documentation for inanimate load handling can be found in appendix 3 of the Manual Handling and Back Care Policy 16.09 14.2 In terms of checks on the physical condition of linen, this will be important for less apparent reasons such as if a sheet had to be used as part of an emergency fire evacuation procedure (lowering the patient to the floor onto a Ski Pad for example). Sheets would need to be capable of allowing this activity. Once a sheet has been used for an emergency fire evacuation it should be thereafter taken out of use. 15.0 SPILLAGE FROM USED SOILED/FOULED LINEN Gloves and apron must be worn ISSUE 3 JULY 2018 9

Re-bag linen into a red alginate bag and then place into an outer bag and tied securely (awareness to local procedure) Clean area with appropriate disinfectant if necessary If advice is required contact the Infection Prevention & Control team 16.0 LOCAL CLEANING 16.1 Manual soaking / washing of soiled items must never be carried out by staff. This is a contamination risk. 16.2 Solid contaminants should be disposed of in the appropriate clinical waste stream and linen bagged as per policy 17.0 PATIENT CLOTHING 17.1 When dealing with patients own soiled/fouled clothing i.e., covered in urine, vomit or faeces, linen should be placed in a water soluble red alginate bag and then in a patient property bag. The patient s bag of clothing should be handed to the patients relative or carer with clear instructions to put the red water soluble bag and contents in their domestic washing machine. Relatives/carers should be advised to set the washing machine at the temperature required to dissolve the bag (60 degrees) and that failure to do so could damage the machine. Staff may also consider disposing of heavily soiled patient clothing after discussion with the patient and their relative/ carer to gain their permission. This must be documented by staff. 17.2 Service users, who are responsible for laundering their own clothing / bedding, should have individual baskets for both clean and dirty laundry which are clearly marked. 17.3 The laundry baskets should be cleanable 17.4 Used soiled/fouled laundry should be transported to the laundry area in used laundry baskets and returned to the room in a clean basket 17.5 Used linen should not pile up in laundry areas 17.6 If necessary service users should use a locally agreed rota system 17.7 Personal clean laundry should not be left piled on work surfaces in the laundry, but returned to service user s bedroom 18.0 STORAGE AND REMOVAL OF DIRTY/SOILED LINEN 18.1 Laundry bags holding used soiled/fouled or infectious linen should not be left unsealed/tied for long periods i.e. longer than 24 hours 18.2 Soiled/fouled linen must be kept away from public areas 18.3 Storage areas must remain closed and kept secure from unauthorized persons 18.4 Used, soiled/fouled linen should not be stored outside due to the risk of contamination 19.0 SAFE MANGAGEMENT OF LINEN IN TRANSFER VEHICLES (IN-HOUSE) 19.1 All linen bags must be labelled with the hospital/ward/department area and dated. ISSUE 3 JULY 2018 10

19.2 NB. Loading and unloading linen is a manual handling activity and should therefore be appropriately assessed 19.3 Clean and used soiled/fouled or infectious linen should not be transported in the same vehicle unless they can be physically separated, i.e. in a separate, covered cage or trolley 19.4 Drivers should have access to hand washing facilities at pickup and delivery points and carry a personal alcohol based hand rub 19.5 Spill kits for managing body fluids spillages should be available in all linen transfer vehicles 19.6 All vehicles must have a documented cleaning schedule in place for both internal washing and production processes. The Trust or contractor as appropriate is responsible for the cleaning and disinfection of the container/vehicle in order to prevent contamination of clean linen 19.7 Vehicle interiors should have smooth, plain, impervious surfaces 19.8 Soiled and clean laundry articles must never be allowed to come into contact with each other at any time. In order to prevent such contact, soiled and clean articles shall not be carried on the same vehicle unless separated by a waterproof partition or barrier in addition to the bags in which the articles are contained 19.9 The majority of laundry consignments are not classified as dangerous for transport. 19.10 However, there may be occasions when soiled linen will need to be classed as dangerous for transport due to containing pathogens which pose a significant risk of spreading disease such as: Bacillus anthracis (Anthrax) Viral Hemorrhagic Fevers (i.e. Ebola) Rabies Bioterrorism agents e.g. Smallpox CJD were body fluids have leaked onto laundry items 19.11 This linen would be classed as healthcare waste will be disposed of by the Trust, not the laundry provider 20.0 SAFE MANAGEMENT OF LINEN IN TRANSFER VEHICLES (CONTRACTED) 20.1 The frequency of collections from the pick-up point to the laundry will be dependent on the volume of laundry and the agreed schedule between the Trust and laundry provider 20.2 All vehicles must have a documented cleaning schedule in place for both internal washing and production processes. The provider is responsible for the cleaning and disinfection of the container/vehicle in order to prevent contamination of clean linen 20.3 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 20.4 Each linen storage roll cage must be appropriately covered 20.5 Vehicle interiors should have smooth, plain, impervious surfaces 20.6 Soiled and clean articles must never be allowed to come into contact with each other at any time. In order to prevent such contact, soiled and clean articles shall not be carried on the same vehicle unless separated by a waterproof partition or barrier in addition to the bags in which the articles are contained ISSUE 3 JULY 2018 11

20.7 The provider must comply with all aspects of the Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2004 20.8 A staff member with a known skin infection or disease, advice would be taken from occupational health prior to handling linen 21.0 LAUNDERING OF LINEN (IN HOUSE) 21.1 Environment: 21.1.1 The laundry should be designed to minimise frequent movement between areas for storing/processing used soiled/fouled/infectious linen and clean linen. 21.1.2 Drainage and water systems should be designed to minimise the spread of infectious agents in aerosols. 21.1.3 Closed drainage systems should be used where possible and any open drains should be covered. 21.1.4 Walls and floors should be washable, sealed and the internal decoration must meet an acceptable standard. 21.1.5 In-house facilities should be designed so that workflow progresses from dirty to clean with no crossover to minimise the risk of recontamination. Staff laundering items in these settings should follow the guidelines set out in this document. 21.2 Validation and Maintenance of Equipment: 21.2.1 Before purchase and installation, washing machines should be approved by the infection prevention and control team (IPCT), estates and procurement. 21.2.2 All washing machines must be fitted with accurate heat sensors so that the disinfection stage of each wash can be monitored. 21.2.3 All washing machines must be checked at least 6-weekly to ensure compliance with thermal disinfection standards and fitness for purpose. This check must be recorded and logged. 21.2.4 Recorded and auditable logs of all repair, maintenance and equipment checks undertaken must be held by the clinic team. 21.2.5 Ensure that the laundry equipment is fit for purpose, following manufacturer instruction 21.2.6 Ensure that the laundry equipment is subject to periodic testing and maintenance such as annual PAT testing. 21.2.7 An industrial dryer should be used that is regularly maintained to dry all clothing and linen. A regular service and maintenance inspection schedule should be maintained. Prior to use filters must be checked and the removal of debris undertaken. 22.0 ROUTINE CLEANING/DISINFECTION OF EQUIPMENT 22.1 All washing machines must be regularly cleaned according to the manufacturer s instructions and be kept free from algae, biofilm and lime scale. ISSUE 3 JULY 2018 12

22.2 The rubber lining of the drum should be wiped clean at least weekly, paying attention to the folds of the lining to prevent build-up of soap scum and biofilm. 22.3 The detergent box should be removed and cleaned at least weekly to remove residual detergent and prevent biofilm. 22.4 Routine cleaning/disinfection of equipment is the responsibility of local clinical staff and this must be documented and records held locally for inspection. 22.5 Once a week run a 65 C wash for 10 minutes. 23.0 LAUNDRY SERVICES PROVIDER 23.1 Before production begins each day, the rinse sections of continuous tunnelled washers must be disinfected to ensure linen is not re-contaminated during the rinsing process. Either a thermal or chemical disinfection cycle can be used. The drums must rotate to come into contact with the disinfectant solution or high-temperature liquid. The purpose of linen reprocessing is to remove or kill microbial contamination. The linen wash process consists of 3 stages: washing, disinfection and dilution. These stages are required regardless of whether linen is used or infectious. The wash stages should ensure that all linen is visibly clean by removing contamination from the fabric. 23.2 Washing processes for used soiled/fouled or infectious linen should be carried out in a defined, functionally separate area from clean linen storage. 23.3 All processed linen should look visibly clean and should not be damaged or discoloured. 23.4 Processed linen that does not meet these criteria should be disposed of via the domestic waste stream and the department/ward of origin notified if required. 24.0 DECANTING LINEN/MACHINE LOADING 24.1 Linen hampers should be opened as close to the machine as possible and never emptied onto the floor as this presents an unnecessary risk of infection. Should used linen accidentally fall onto the floor, this area should be adequately decontaminated as soon as the linen has been removed. 24.2 All clear polythene bags should be disposed of as healthcare waste 24.3 If a water-soluble bag is present (as for infectious linen) this should not be opened but instead placed directly into the machine. The laundry staff should never open the inner water-soluble bags. Prior to using the alginate bags, all washing machines must be checked to ensure that they can withstand the use of these bags. 24.4 Machines must not be overloaded. Follow the manufacturer s instructions for maximum and minimum load weights 25.0 WASH CYCLES 25.1 Manual soaking/sluicing must never be carried out. 25.2 Ensure that the manufacturer s recommendations are followed including the quantity of detergent to be used. 25.3 The pre-wash / sluice cycle in the washing machine should be used after removing any solids. Many micro-organisms will be physically removed from the linen, by the detergent and water, ISSUE 3 JULY 2018 13

during the washing cycle. Washing at high temperatures, above the normal domestic 40 C wash, will allow the temperature of the water to disinfect the items. 25.4 All wash cycles should be completed. If the cycle is interrupted, the wash should be started from the beginning. The washing process should have a disinfection cycle in which the temperature in the load is either maintained at 60 C for at least ten minutes or 71 C for at least 3 minutes. With both of these options, mixing time must be added to ensure heat penetration and assured disinfection. For machines of conventional design and a low degree of loading, 4 minutes should be added to these times to allow for adequate mixing time. For machines with a heavy degree of loading, it is necessary to add up to 8 minutes. Heavily soiled/infected linen should also have a pre-wash cycle selected. Heat labile items should be washed at the highest temperature possible for the item. 25.5 If the item has been heavily soiled or is infected, it should be placed in a red, water-soluble bag and a pre-wash cycle selected. The wash load must not be over loaded. After the wash cycle, if bodily fluids remain on the laundry, the whole load should be washed again. 25.6 Fabric duvets should be able to withstand a 60 C wash cycle. However, staff should always ensure they follow the manufacturer specific decontamination instructions. 25.7 All items must enter a drying process within an industrial dryer. Laundry must not be washed and allowed to dry on the unit. At the end of all drying cycles, the machine must be allowed to cool down prior to the laundry being removed. Once the machine has cooled down, the laundry should be removed and stored in a clean area, above floor level. 25.8 All linen should be removed from machines at the end of the day and not left overnight. 26.0 HEAT LIABLE LINEN 26.1 Heat liable linen will be damaged (shrinkage/stretching) by temperatures above 40 C and therefore cannot be subjected to thermal disinfection. The majority of heat liable linen will be personal items/clothing belonging to a patient; in this case patients should have been offered the opportunity to take these belongings home to wash. It is unlikely that these items will present at the laundry facility. 27.0 TESTING LINEN FOR ASSOCIATED INFECTIONS/MICRO-ORGANISMS INCLUDING TESTING FOR BACILLUS BACTERAEMIA 27.1 All laundry providers shall ensure that they meet the standards from the guidance from the Department of Health, Code and Health Technical Memorandum 01.01 and EN14065 28.0 FAULTY WASHING MACHINE/TUMBLE DRYER (TRUST OWNED) 28.1 In the event of a washing machine or tumble dryer being faulty, the Estates Help Desk should be contacted and told that an urgent repair is required. Under no circumstances should any linen be taken to a local launderette, to be washed or taken home by a member of staff to be washed. Trust staff must not bring their own personal linen to Trust premises to be washed or dried. 29.0 PROTECTION OF LAUNDRY WORKERS 29.1 For staff members with a known skin infection or disease advice should be taken from occupational health prior to handling linen 29.2 Any exposed lesions on the body should always be covered with a waterproof dressing ISSUE 3 JULY 2018 14

29.3 Staff handling used or unwashed linen should wear appropriate personal protective clothing e.g. disposable, waterproof aprons and gloves. Gloves used for laundry should meet the same standards as gloves used for other caring activities. Hand decontamination facilities, including hand hygiene basin, liquid soap and disposable paper towels, hand decontamination solutions, e.g. alcoholic hand gel, along with a pedal-operated clinical and domestic waste bin should be available. 29.4 A hand hygiene poster should be on display at all times. The hand wash basin should be dedicated for hand hygiene only. 29.5 Food or drink must not be allowed in the laundry areas. 29.6 Ensure staff have had instruction and understanding with regards to linen and laundry processes 29.7 An appropriate area to launder linen should be available. There should be separate areas to store used soiled/fouled, infectious linen and clean linen. 29.8 Washed, dried and ironed linen should be removed and stored in a separate area. 29.9 An industrial washing machine with sluice and hot wash cycles is recommended. 29.10 Units that have domestic washing machines shall purchase, through procurement, an industrial washing machine when the domestic machine is being renewed. These should be professionally installed and maintained with precautions to prevent aerosol contamination. 29.11 Ensure staff records regarding instruction of laundry protocols are in place for inspection. 29.12 Ensure that the procedures for production, safe working, quality control, packing, dispatch and distribution systems are documented and adhered to in the light of statutory requirements and best practice 30.0 STAFF UNIFORMS 30.1 The clothing of staff providing personal care should be changed daily and the wash temperature should reach a minimum of 60 C for at least ten minutes. They should be tumble dried if possible and then pressed with a hot iron. 30.2 Staff clothing should be laundered separately from the family wash. 30.3 Heavily soiled uniforms should be washed separately if a uniform becomes very heavily contaminated with body fluids it is not advisable for the item to be washed at home by the member of staff. Instead it must be sent to the laundry contained in the appropriate coloured bag and labelled with the name of the individual, their ward and hospital. 30.4 After washing, (home laundry) uniforms should be protected from contamination from dust during storage. 31.0 BED ASSEMBLIES, CURTAINS AND SOFT FURNISHINGS 31.1 Fire Retardation: 31.1.1 All components of bed assemblies (duvet, duvet cover, pillow, pillow slips, sheets etc.), curtains and soft furnishings must be purchased through procurement, in compliance with NHS fire retardant fabric recommendations and in line with the Trust s fire policy. Note: this means that patients cannot bring their own bedding ISSUE 3 JULY 2018 15

and soft furnishings into wards. Technical advice can be sought from the Fire Team as needed. 31.1.2 When a fabric is designated as inherently fire retardant, permanently fire retardant, or durably fire retardant, the flame retardance will last for the life of the fabric. 31.1.3 For curtains or soft furnishings which cannot be purchased to these requirements, but that are suitable for chemical fire retardant application; the Trust Fire Team should be contacted for advice. In these instances, for such fabrics to conform to Fire code; a suitable fire retardant treatment must be carried out to ensure they meet the above standards 31.1.4 In the case of fabrics that are designated as having fire retardant properties, and that have been treated with chemicals; the flame retardant properties of the fabric will dissipate over time, particularly with repeated cleaning. The flame retardant properties of treated fabric will vary based on the number of times the fabric is laundered or dry-cleaned and the environmental conditions in the location in which the fabric is located 31.1.5 It is recommended that treated fabric be re-tested for fire retardant on an annual basis and re-treated by a qualified professional as required. 31.1.6 Fire code Fire safety in the NHS: HTM 05-03: Operational provisions Part C: Textiles and furnishings gives the following advice re: fire retardancy : The British Standard is a more rigorous standard in respect of durability; that is, the requirement for flame retardancy to be maintained after 50 washes for reusable products. This higher durability should be given due cognisance in the selection of suitable fabrics.. 31.1.7 Fire code Fire safety in the NHS: HTM 05-03: Operational provisions Part C: Textiles and furnishings also gives the following advice re: washing instructions in relation to fire retardancy: Wash materials: To minimise the risk of masking the FR properties by insoluble lime soaps, a synthetic, preferably non-ionic, detergent is recommended. BS EN ISO 15797 gives the appropriate industrial detergent formulation. 10.9 Sodium hypochlorite (chlorine) bleach should not be used as it will destroy the imparted FR properties. 10.10 Starch or other additives should not be used as they will mask the FR properties. 32.0 CURTAINS 32.1 Curtains shall be routinely changed when discharging or transferring a patient with a known infection such as Strep A or MRSA from the area or during outbreaks 32.2 Removal and changing of curtains results in aerosolisation of ingrained organisms which may be harmful to patients and contaminate the near patient environment. For this reason curtains should not be changed at key times e.g. during wound dressing changes etc. 32.3 Curtains require washing when visibly dirty, or at least every six months and this shall be known and documented by clinical team. 33.0 DUVETS/PILLOWS/MATTRESSES 33.1 All pillows used in clinical areas must have sealed, intact, impermeable covers. 33.2 Any pillow torn, split or stained must be discarded. ISSUE 3 JULY 2018 16

33.3 Duvets should be sealed, intact and impermeable. Decontamination & Safe Handling of Linen & Laundry 18.26 33.4 If a patient has a known infection such as Clostridium difficile, red sporicidal Clinell wipe or chlorlcean equivalent product to be used daily. 33.5 If the cover is damaged or punctured it must be condemned and disposed of as healthcare/clinical waste. 33.6 Wash the mattress using Clinell wipes and allow to air dry or hot soapy water and allow to air dry. 34.0 MOPS 34.1 Disposable mops are preferable for use whenever possible and should be considered in the first instance. 34.2 Mops must be placed in the appropriate coloured bag. 34.3 A dedicated washing machine must be used for the laundering of mops on trust premises. This machine must have a sluice facility and temperature indicator. 34.4 In the event of a machine failure another alternative may be used. This machine must be able to comply to high level thermal disinfection temperature levels.reaching 60 C 34.5 After every mop wash, the machine should be run on a full wash cycle without a load. 35.0 PERFORMANCE MANAGEMENT (CONTRACTORS) 35.1 The Trust will monitor the contactor to ensure that the contractor is demonstrating compliance to the contract specification. The Infection Prevention & Control Team is to be informed of any infection control noncompliance incidents. The Trust will conduct multi- disciplinary audits to ensure compliance. 36.0 COLOUR CODING FOR LAUNDRY BAGS 36.1 Ensure Staff Are Aware Of Local Procedures Regarding Different Laundry Providers A B CATERGORY DESCRIPTION SPECIAL NOTES COLOUR PICTURE All used (soiled/fouled Place into a white bag; this linen) for example now includes linen and nightwear, bed patient wear that is soiled Used (soiled Clear/white coverings, towels with blood, faeces, vomit and fouled Polythene sheets etc. and urine. Do not place linen) Bags soiled linen in clear bags NB Curtains must be if it s known as infected Infectious Linen bagged separately All used and soiled linen including patient wear from patients with known or suspected infections NB Curtains must be bagged separately linen Put in a red soluble (alginate) bag and tie, then put into an outer bag. The outer bag must be tied and attach tape round the neck of the bag which indicated Infected Linen as best practice Red Soluble Bag inside outer Bag ISSUE 3 JULY 2018 17

C Infested Linen All used and soiled linen including patient wear from patients with known or suspected infections. Put in a red soluble (alginate) bag and tie, then put into an outer bag. The outer bag must be tied. Red Soluble Bag inside outer Bag D Rejected clean linen (unused) Any clean linen which is found to be unusable (i.e. torn, stained, etc. not fit for purpose) All rejected linen must be placed in the appropriate coloured bag (check local procedure for different linen providers) As per service provider E Return to Sender Items Items owned by the Trust, Hospital, Ward or patient. All items must be labelled, any items not sent labelled may not be returned. If you have any Return to Sender items that are infected follow instruction B. As per service provider 37.0 TRAINING 37.1 Managers must ensure that all staff that handle linen or responsible for the laundry of any lined will be aware of the requirements of this policy. 37.2 All staff will undertake their infection prevention and control training as identified by the Trust as essential training. 37.3 Where any specialist training is identified and required then this will be undertaken by the relevant specialist 38.0 TARGET AUDIENCE 38.1 The target audience is all employees who come into contact and work with linen and laundry. 39.0 REVIEW DATE 39.1 The Policy will be reviewed every 3 years or in light of legislation or organisational changes. 40.0 CONSULTATION Trust Leadership Council Trust Infection Control Committee Disability Equality Steering Group 41.0 RELEVANT TRUST POLICIES Infection Prevention and Control 18.05 Manual Handling and Back Care 16.09 Fire Safety 16.03 Waste Management 16.08 42.0 MONITORING COMPLIANCE 42.1 Each Executive Director / Chief Operating Executive will monitor the implementation of this policy and procedure in all areas within their control. ISSUE 3 JULY 2018 18

42.2 The Trust Infection Control Committee will monitor compliance and effectiveness of this policy on a regular basis. 42.3 Process for Monitoring Compliance and Effectiveness: The Infection Prevention and Control team will undertake planned audits and inspections across the Trust and report back to the Divisional and Trust Committee meetings All local areas will monitor their compliance Where relevant Odyssey will be used to collect and present audit findings 43.0 EQUALITY IMPACT ASSESSMENT 43.1 This policy and procedure has been assessed using the Equality Impact Assessment Screening Tool. The assessment concluded that the policy and procedure would have no adverse impact on, or result in the positive discrimination of, any of the diverse groups detailed. These include the strands of disability, ethnicity, gender, gender identity, age, sexual orientation, religion / belief, social inclusion and community cohesion 44.0 LEGISLATION COMPLIANCE Health and Social Care Act 2008 Health and Safety at Work etc. Act 1974 Control of Substances Hazardous to Health Manual Handling Operations Regulations Regulatory Reform (Fire Safety) Order HTM 01-04 Decontamination of linen for Health and Social Care 45.0 CHAMPION AND EXPERT WRITER 45.1 The Champion of this policy and procedure is Julie Attfield Executive Director of Nursing and the Expert Writer is Annie Clarke, Physical Healthcare and Infection Prevention and Control Lead, Fiona Hind, Infection Prevention and Control Practitioner, David Smith, Estates Officer and Ian Freegard, Trust Health and Safety Manager. 46.0 REFERENCES / SOURCE DOCUMENTS Care Quality Commission Regulation 12 Safe care and treatment HTM 01-04 Decontamination of linen for Health and Social Care ISSUE 3 JULY 2018 19

VALIDATION AND MAINTENANCE OF EQUIPMENT: APPENDIX 1 Action required Equipment approved by procurement prior to purchase Date evidenced and comments Date evidenced and comments Date evidenced and comments Date evidenced and comments Date evidenced and comments Date evidenced and comments Equipment fitted with accurate heat sensors to ensure the disinfection stage of each wash is monitored. 6 weekly check that is compliant with thermal disinfection standards and fitness for purpose. This is recorded and logged. Recorded and auditable logs of all repair, maintenance and equipment checks for washer An industrial dryer should be used that is regularly maintained to dry all clothing and linen. A regular service and maintenance inspection schedule should be maintained. Annual PAT testing recorded for washer and dryer Prior to every use filters must be checked and the removal of debris undertaken. Routine cleaning/disinfection of equipment: Action required All washing machines must be regularly cleaned according to the manufacturer s instructions and be kept free from algae, biofilm and limescale. Date evidenced and comments Date evidenced and comments Date evidenced and comments Date evidenced and comments Date evidenced and comments Date evidenced and comments The rubber lining of the drum should be wiped clean at least weekly, paying attention to the folds of the lining to prevent buildup of soap scum and biofilm. The detergent box should be removed and cleaned at least weekly to remove residual detergent and prevent biofilm. Weekly run a 65 C wash for 10 minutes and record this. ISSUE 3 JULY 2018 20

Wash Cycles Ensure that the manufacturers recommendations are followed regarding the quantity of detergent to be used. The pre-wash / sluice cycle in the washing machine should be used after removing any solids All wash cycles should be completed. The washing process should have a disinfection cycle in which the temperature in the load is either maintained at 60 C for at least ten minutes or 71 C for at least 3 minutes. With both of these options, mixing time must be added to ensure heat penetration and assured disinfection Fire safety in the NHS: HTM 05-03 Requirements: Linen washed no more than 50 washes before replacement to ensure Flame retardancy Sodium hypochlorite (chlorine) bleach not used not be used as it will destroy the imparted FR properties Starch or other additives should not be used as they will mask the fire retardancy properties Curtains Documented Curtain changes that is when visibly dirty, or at least every six months. Linen Linen stored in separate, clean designated area. Clean linen must not be stored in unsuitable areas i.e. sluice, bathrooms in bed spaces Adequate supply of linen which complies with Department of Health Firecode HTM 05-03 Part C: Textiles and furnishings evidenced Used/soiled/fouled or infectious linen clearly identified and segregated into colour coded bags according to policy. ISSUE 3 JULY 2018 21

Condemned or Unfit Line which is deemed as not fit for purpose (heavily stained or torn) placed in appropriate colour coded plastic bag and labelled as reject linen and disposed of according to policy and local protocol. Patients clothing stored in individual basket or wipeable container before and after washing. ISSUE 3 JULY 2018 22

APPENDIX 2 EQUALITY IMPACT ASSESSMENT (EIA) SCREENING TOOL Name of policy/procedure/strategy/plan/function etc being assessed: DECONTAMINATION AND SAFE HANDLING OF LINEN & LAUNDRY POLICY AND PROCEDURE Brief description of policy/procedure/strategy/plan/ function etc and reason for EIA: Names and designations of EIA group members: List of key groups/organisations consulted This policy seek to ensure the Trust complies with HTM 01-04 Decontamination of linen for Health and Social Care - March 2016 whilst defining the responsibilities of all Trust staff on the importance of correct and safe management of Linen procedures, from storage to handling, bagging, transporting and laundering. Annie Clarke Physical Healthcare and Infection Prevention and Control Lead Ian Freegard Trust Health and Safety Manager David Smith Facilities Monitoring Manager Trust Health and Safety, Facilities Department, Infection Prevention and Control team Data, Intelligence and Evidence used to conduct the screening exercise HTM 01-04 Decontamination of linen for Health and Social Care Infection Prevention and Control policies and The Health and Social Care Act 2008 (revised 2015) ISSUE 2 APRIL 2018 23

Equality Strand Race Gender Incl. Transgender Disability Incl. Mental Health and LD Does the proposed policy/procedure/ strategy/ plan/ function etc have a positive or negative (adverse) impact on people from these key equality groups? Please describe No impact identified. This policy complied with the health and Social Care Act 2008 (revised 2015) and HTM 01-04 Decontamination of linen for Health and Social Care. This policy is equally applicable to all No impact identified. This policy complied with the health and Social Care Act 2008 (revised 2015) and HTM 01-04 Decontamination of linen for Health and Social Care. This policy is equally applicable to all No impact identified. This policy complied with the health and Social Care Act 2008 (revised 2015) and HTM 01-04 Decontamination of linen for Health and Social Care. This policy is equally applicable to all Are there any changes which could be made to the proposals which would minimise any adverse impact identified? What changes can be made to the proposals to ensure that a positive impact is achieved? Please describe No, this is legislative compliance. No, this is legislative compliance. No, this is legislative compliance. Religion/Belief No impact identified. This No, this is legislative policy complied with the health compliance. and Social Care Act 2008 (revised 2015) and HTM 01-04 Decontamination of linen for Health and Social Care. This ISSUE 2 APRIL 2018 24 Have any mitigating circumstances been identified? Please describe Areas for Review/Actions Taken (with timescales and name of responsible officer) Not applicable. Author to Review in 3 years Not applicable. Not applicable. Not applicable. As above As above As above

policy is equally applicable to all Sexual Orientation No impact identified. This No, this is legislative Not applicable. As above policy complied with the health and Social Care Act 2008 (revised 2015) and HTM 01-04 Decontamination of linen for Health and Social Care. This policy is equally applicable to all compliance. Age No impact identified. This No, this is legislative Not applicable. As above policy complied with the health and Social Care Act 2008 (revised 2015) and HTM 01-04 Decontamination of linen for Health and Social Care. This policy is equally applicable to all compliance. Social Inclusion* 1 Not applicable. Not applicable. Not applicable. As above Community Not applicable. Not applicable. Not applicable. As above Cohesion* 2 Human Rights * 3 Not applicable. Not applicable. Not applicable. As above * 1 for Social Inclusion please consider any issues which contribute to or act as barriers, resulting in people being excluded from society e.g. homelessness, unemployment, poor educational outcomes, health inequalities, poverty etc * 2 Community Cohesion essentially means ensuring that people from different groups and communities interact with each other and do not exclusively live parallel lives. Actions which you may consider, where appropriate, could include ensuring that people with disabilities and non-disabled people interact, or that people from different areas of the City or County have the chance to meet, discuss issues and are given the opportunity to learn from and understand each other. * 3 The Human Rights Act 1998 prevents discrimination in the enjoyment of a set of fundamental human rights including: The right to a fair trial, Freedom of thought, conscience and Religion, Freedom of expression, Freedom of assembly and association and the right to education ISSUE 2 APRIL 2018 25