Linen Policy IC/276/10 - North Hampshire · PDF fileHospital linen that is potentially...

IC/276/10 Linen Policy

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BASINGSTOKE AND NORTH HAMPSHIRE NHS FOUNDATION TRUST

Linen Policy

IC/276/10 Owner Name Hazel Gray Job Title Senior Infection Control Nurse Final approval committee

Name Infection Control Committee

Date of meeting 5 March 2010 Authoriser Name Dr Nicki Hutchinson Job Title Director Infection Prevention and

Control 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 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.

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


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Implementation Plan Summary of changes New Policy Action needed and owner of action 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.


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Contents 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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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 • 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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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.

• It 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)


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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).


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12.0 Safe Management of Linen

12.1 Protection when handling used linen • 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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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

INFECTED & HEAVILY SOILED

LINEN ONLY

USED THEATRE

LINEN ONLY

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

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 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

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

LINEN SEGREGATION PROCEDURE


APPENDIX B

Basingstoke and North Hampshire NHS Foundation Trust Laundry operational procedures for the BNHFT 1st 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


EFM/Laundrydoms/Proc/2008

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

Storage and distribution of linen is operated by the Trusts EFM Laundry team

supported by the Porter team for site distribution

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

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

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



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.



Appendix 1

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



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



• 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



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. Additionally documentation must be sufficiently detailed and capable of manipulation to enable computer modeling and management forecasting to be undertaken by NHS clients.

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



Health Service Guidelines Hospital Laundry Arrangements for Used and Infected Linen Executive Summary 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.

HSG(95)18 Hospital Laundry Arrangements for Used and Infected Linen This replaces HC(87)30 which expired on 1 December 1992 21 April 1995



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



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



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.



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:-



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.



Circulars mentioned in this document HC(87)30 Hospital Laundry Arrangements for Used and Infected Linen HC(91)33 Decontamination of Equipment, Linen or Other Surfaces Contaminated

With Hepatitis B and/Or Human Immunodeficiency Viruses Memorandum on the Control of Viral Haemorraghic Fevers, HMSO 1986

HN(82)33 Occupational Health Services for NHS Staff HC(78)3 Control Of Tuberculosis in NHS Employees: Limitation of X-Ray

Examinations



APPENDIX A COLOUR CODING 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

Penalty SSG Proposed Escalation Procedure

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 and remedial actions agreed to rectify the stock shortage within 24 hours. If the shortage is not rectified with 24 hours the first stage of the escalation procedure will be implemented. If it is not rectified within the next 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.

Factory to monitor daily. No more than 3% shorts of each specification volume supplied per invoice period.

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



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 to monitor daily. No more than 2 late deliveries per invoice period. As long as delays are within Sunlight control.

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.



3. Soiled linen is collected from 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 action taken within a 24 hour period.

Factory to monitor daily. No more than 2 late collections per invoice period.

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


4. Provide evidence of the wash processes utilised within the factory. Including:-(i) Water usage (ii) Water retention (iii) Detergent dosing (iv) Acidity/alkalinity (v) PH (vi) Temperature – at least 72oC for 3 mins or 65 oC for 10 mins. (vii) Reflectance tests – average of 20 items

Tests to be completed on a 4 weekly basis minimum and results supplied to customer.

Variations from standards to trigger full investigation and start the escalation process

If any part of the laundering process that is key to ensuring UHL is not put at risk fails an alarm system sounds immediately in the factory. The machine will cease operating automatically and reparative action can be taken before the machine is put back into service again. At this point, Sunlight must notify the Trust immediately and in writing if a system/ operational failure will affect delivery to the Trust or if linen 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



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 50%.

Tests to be carried out every 6 months.


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 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.



6. Demonstrate a system that ensures:- (i) stained or contaminated items are diverted to rewash or special wash processes (ii) damaged items are diverted to repair or rag (iii) any Trust owned items that are not fit for purpose should be bagged separately and returned to the NHS client

Factory produce weekly record that details pieces processed and rewash percentage.

Defective items supplied to customer to be replaced free of charge within 48 hours

If at the Trusts request Sunlight fail to provide proof of the weekly records in relation to 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.

7. Linen is finished in accordance with the agreed specifications. The tolerance level of 5% rejects will be applied to the amount of linen inspected.

Monthly check to take place to ensure specifications are being met. Factory to complete internal quality check of 100 items on a weekly basis and record results. Sunlight Representative to be in attendan

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

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



ce when audits take place (if available)

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.

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

Factory will polymark all NHS clients’ goods that are not labelled. Full audit trail utilising duplicate paperwork.




9. Provide management information on a monthly basis which shows: (i) monthly usage volumes (standard Sunlight reports) (ii) quality checks – at factory and site (iii) complaints (iv) van disinfection (v) customer’s own work – issues (vi) receipt of clinical waste (vii) delivery times/procedures

To be produced monthly and forwarded to NHS client within 10 days of month end.

If at the end of the month Sunlight has failed to provide the information within the tolerance stated the General Manager will be notified. They will work with the Trust 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.

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 complaints to be e-mailed to the helpdesk ([email protected]) and Commercial Manager ([email protected]) at the Leicester facility

If a response has not been received within 48 working hours of the 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 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.

10a Resolution of complaints to be within 7 days if possible.

as above

11. Verify disinfection of linen using microbiological testing including:- (i) Log kill of >5 on all washing machines when testing for Escherichia Coli and Enterococcus hirae. (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.

6 weekly microbiological testing to be completed.


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 Manager will be notified immediately. They will work with the 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.



12. Verify disinfection of delivery vans following unloading of dirty linen and before clean linen and report results to NHS client.

Daily check sheets to be completed by drivers. Van testing to be included in 6 weekly microbiological testing.


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 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 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.

13. All linen must comply to UHL agreed standards including fabric, reflectivity and fire retardency.

No change to specification without agreement 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



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 timely intervals to ensure that sufficient soiled linen is returned for processing.

Factory to monitor volumes returned.

2. No site logistics prevent the linen from being delivered or collected within the agreed delivery/collection window.

Factory to monitor and report in monthly review if any issues.

3. Linen supplied is used for the purpose it is provided. Any linen that has been abused and would not be fit for reuse will be charged to the NHS client at full replacement cost.

Monitored at factory level, 5% tolerance.

4. Any heavily soiled articles should be sluiced prior being returned to the factory for processing.

Monitored at factory level.

5. Cages provided should be for the use of transporting linen only.

Monitored on site.

6. No clinical waste should be returned to the factory. This is a severe health and safety risk.

Disposal of clinical waste will be charged.

7. Ensure that bagging procedure is adhered to.



Overarching Statements 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.



Schedule 3

Menu of Services

Basic Service

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



b) Trust owned linen (Wash and Return)

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



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 Theatre linen – NO HOLES or perforations are permissible. Neither are any foreign bodies, tape, plaster of Paris and visually lint free All other linen – a hole in an article greater than 2 cm in diameter

Creasing Material overlap. Definite fold ridges in an article. Wrinkling Defined as evidence of surface deformation. A wavy distortion

across an article not expected on an ironed finished Unacceptable dimensional distortion

Any shrinkage of the article which makes the article ineffective or unpractical for use

Odour Articles should not have any unpleasant residual odour Presentation Edges should be folded together and squarely, with no overlap Dampness All products must feel dry to the touch. Feel Articles which feel harsh, particularly towels, nappies etc are not

acceptable for use Stains relating to grease/oil/plastics

A dry cleaning process is required to effect removal of such stains for the articles to be acceptable for use. “Acceptability” will be the decision of the Authorised Officer for the linen article concerned. These items must then be wash to assure thermal disinfection


Schedule 5

STANDARDS OF FINISH

Linen Item Standard of Finish

Sheets and Counterpanes- Calender finish

Slight creasing allowed along any edges but must not exceed 15cm from the edge of the sheet. No creasing allowed in any other area. Holes are only permitted within 15cm from the edge but must exceed 2cm in diameter.

Draw sheets- Calender finish

Slight creasing is allowed within 15cm of the hemmed edges. Slight creasing allowed towards both ends of the selvedge edges but no creasing allowed within the centre section of the selvedge. Holes or tears are permitted within 15cm from the hemmed edge but must not exceed 2cm in diameter or length.

Pillowcases- Calender finish

Creasing allowed around the opening end and the internal flaps. Slight creasing allowed near to seamed edges. No creasing allowed in any other area.

Blankets- Fully dried and folded

Slight creasing/wrinkling allowed in all areas of the article.

Towels- Fully dried and folded

Slight creasing/wrinkling allowed in all areas of the article.

Duvet covers- Fully dried and folded

Slight creasing is allowed near to the seamed edges and around the opening end of the duvet cover. No creasing allowed in any other area.

Scrub suits/Pyjamas Standard tunnel finish which will include minor creasing allowed around the collar and along seams and slight creasing and wrinkling under the armpits and crotch area. Slight wrinkling around tapes.

Uniforms/white coats Standard tunnel finish as above. The Offerer to be responsible for the replacement of buttons and other fastenings if damaged during the laundering process.

Trousers Standard tunnel finish as above. Patients’ gowns/nightwear

Standard tunnel finish as above.

Curtains (unlined)- Calender finish

All selvedges must be crease free. Only very light wrinkling allowed. Dimensional distortion should not exceed three inches and returned stacked in cages

Curtains (lined or for dry cleaning)

Crease free, lightly folded vertically only and returned on separate coat hangers


EFM/Laundry/Pro/2008

Appendix 2 SERVICE REQUIREMENTS

Sunlight Services Group will provide to the Authority a Linen Hire/Launder service in accordance with the Framework Agreement Service Specification and the following summary of

service;

1. The Basic Menu of Services as defined within the National Framework Specification.

http://nww.pasa.nhs.uk/outsourcing/shared/fmservices/laundry_specification.doc 2. Optional National Enhancements as defined within the National Framework Agreement;

Enhancement

Applied Details

Contract term (3 – 7 years) 5 1st April 2008 Transportation

Number of delivery points required 1 Frequency of Service

Number of drops / collections required per day 1 Number of business days service require 6 Saturday service Yes Sunday service No Bank holiday service (excluding Christmas & Boxing Day)

No

Packing

Pack to ward onsite / offsite No Finish / Presentation

Hand finish (where applicable) N/A Hand fold (where applicable) N/A On hangers (where applicable) N/A Additional Services

Soiled linen collection from ward No Repair service for Trust owned linen No Distribution of linen [WR & LH only] No Non-standard surgical barrier fabrics No Inspect, pack and fold theatre drapes No New stock purchase No



Appendix 3 Appendix 1

PaSA Prices for

Linen Hire Service

Item Description Price per Piece APRON £0.235 BLANKET - COT £0.255 BLANKET - CRIB £0.255 BLANKET-THERMO £0.285 BLNKT.CELL.BED £0.285 BOILERSUIT £0.600 CANVAS - WHITE £0.335 CLOTHS-OVEN £0.205 COATS-WHITE £0.320 COVERS-DUVET £0.335 CURTAIN £2.100 CURTAIN-LARGE £2.100 DRESS-NIGHT £0.265 DRESS-NIGHT £0.265 GOWNS-CHILDRENS £0.135 GOWNS-DRESSING £0.385 GOWNS-PATIENT £0.265 JACKETS-CHEFS £0.320 JACKETS-PYJAMA £0.265 MATS-BATH £0.255 MISCELLANEOUS £0.250 MISCELLANEOUS £0.250 MOPS £1.600 MOPS £1.600 NIGHTSHIRTS £0.265 PILLOWCASES-WHITE £0.175 PLASTIC BAG-RED £0.085 PLASTIC BAG-WHT £0.085 PLASTIC PURPLE £0.085 S/BOT COB L £0.265 S/BOT COB M £0.265 S/BOT COB S £0.265 S/BOT COB XL £0.265 S/BOT COB XXL £0.265 S/TOP COB L £0.265 S/TOP COB M £0.265 S/TOP COB S £0.265 S/TOP COB XL £0.265 S/TOP COB XXL £0.265



SCR/BOT CEIL LRG £0.265 SCR/BOT CEIL MED £0.265 SCR/BOT CEIL SML £0.265 SCR/BOT CEIL XLG £0.265 SCR/BOT CEIL XXL £0.265 SCRB MISTY BTM LGE £0.265 SCRB MISTY BTM MED £0.265 SCRB MISTY BTM SMLL £0.265 SCRB MISTY BTM XLG £0.265 SCRB MISTY BTM XXLG £0.265 SCRB MISTY TOP LRG £0.265 SCRB MISTY TOP MED £0.265 SCRB MISTY TOP SML £0.265 SCRB MISTY TOP XLGE £0.265 SCRB MISTY TOP XXLG £0.265 SHEET - CRIB £0.175 SHEET SLIDE £0.300 SHEETS-DRAW £0.255 SHEET-TOP WHITE £0.265 SS T L CEIL £0.265 SS T M CEIL £0.265 SS T S CEIL £0.265 SS T XL CEIL £0.265 SS T XXL CEIL £0.265 TENDERCARE/SPENCO £4.750 TOWEL-BATH STAFF £0.185 TOWELS-BATH £0.185 TOWELS-TEA £0.235 TROUSER-PYJAMA £0.265 TROUSERS-CHEFS £0.320 UNIFORMS £0.260 BAGS-WATER SOLUBLE £0.308 BLANKET - COT £0.255 BLANKET - CRIB £0.255 BLANKET-THERMO £0.285 BLNKT.CELL.BED £0.285 CANVAS - WHITE £0.335 COVERS-DUVET £0.335 COVERS-DUVET £0.335 CURTAIN-LARGE £2.100 CURTAIN-LARGE £2.100 DRESS-NIGHT £0.265 GOWNS-DRESSING £0.385 GOWNS-PATIENT £0.265 JACKETS-PYJAMA £0.265 MATS-BATH £0.255 MISCELLANEOUS £0.250 MOPS £1.600



NIGHTSHIRTS £0.265 PADS-INCO £0.300 PILLOWCASES-WHITE £0.175 PLASTIC BAG-RED £0.085 PLASTIC BAG-WHT £0.085 SHEETS-DRAW £0.255 SHEET-TOP WHITE £0.265 TOWELS-BATH £0.265 TROUSER-PYJAMA £0.265 BAGS-WATER SOLUBLE £0.308 BLANKET - COT £0.255 BLANKET - CRIB £0.255 BLANKET-THERMO £0.285 BLNKT.CELL.BED £0.285 CANVAS - WHITE £0.335 CURTAIN-LARGE £2.100 DRESS-NIGHT £0.265 GOWNS-DRESSING £0.385 GOWNS-PATIENT £0.265 JACKETS-PYJAMA £0.265 MATS-BATH £0.255 MOPS £1.600 NIGHTSHIRTS £0.265 OVEN CLOTH £0.205 PILLOWCASES-WHITE £0.175 PLASTIC BAG-RED £0.085 PLASTIC BAG-WHT £0.085 SHEET-COT 54X90 £0.175 SHEETS-DRAW £0.255 SHEET-TOP WHITE £0.265 TOWELS-BATH £0.265 TROUSER-PYJAMA £0.265 BLANKET - COT £0.255 BLANKET-THERMO £0.285 BLNKT.CELL.BED £0.285 COVERS-DUVET £0.335 GOWNS-CHILDRENS £0.135 GOWNS-PATIENT £0.265 JACKETS-PYJAMA £0.265 PILLOWCASES-WHITE £0.175 PLASTIC BAG-WHT £0.085 SHEETS-DRAW £0.255 SHEET-TOP WHITE £0.265 TOWELS-BATH £0.265



Laundry returns procedure BNHFT

Purpose This procedure offers a simple flow chart action for the return of faulty or substandard clean laundry provided by our contract service provider.

fig 1) Action flow chart: Supply of Pink bags Pink Polythene Bag (Size 15x29x39 inches 40 micron) order Roll of 50 from supplies.

Review of monthly KPI Review of KPI outcomes with Supplier and Laundry Management team. Resolve and communicate actions

Return to supplier Items returned to supplier at delivery/collection, in Pink bag marked with reject label

Record of items returned Laundry team to log on KPI daily sheet items rejected.

Return of reject item to linen room Place item in green plastic bag and place in returns bin in linen room.

Reject item identified Substandard product Torn / poor repair Dirty / stained

Poor folding or aesthetic look

Replace item for ward / user Laundry team to send replacement items if required.



Appendix 5 Business continuity plan contract supplier

THE SUNLIGHT SERVICE GROUP LTD, HEALTHCARE DIVISION

TECHNICAL ABILITY & CONTINGENCY

INTRODUCTION

We are able to ensure that there will always be sufficient stock in the system to provide correct levels at the point of use. This is as a result of the stock holding agreed with Sunlight’s suppliers, the significant investment that is made by Sunlight to ensure that the correct amount of stock is installed upon commencement of its contracts and the continuing investment in stock replenishment during the contract term. We would propose to leave at least 25% of the daily requirement of linen products in the linen room on site for the Trust to use as necessary. However, separate emergency cupboards can be provided at other locations within the Hospital as required. Sunlight has a bonded warehouse, consistently topped up to a level of £1,000,000, which provides enough linen to start up two 500 bedded hospitals. This arrangement is by firm contractual agreement with our partner provider Standard Textile who have planned production in anticipation of our requirements against our guarantees to purchase. During working hours Sunlight maintain a special request call out service which will respond within 3 hours for any urgent linen requirements. Out of hours we operate a call out procedure for emergencies with a maximum response time of three hours. In the event of major breakdown at our factory we are able to call on spare capacity at other factories within our division and sister divisions. Any events that would result in a possible disruption to the supply of service will be communicated at the earliest convenience to the Trust via the servicing factory. Our contingency arrangements will be fully operational within 24 hours.

Weekly Capacities Factory Throughput Spare Capacity Basildon 333,000 pieces 57,000 pieces Brixton 1,112,000 pieces 61,000 pieces Chesterfield 263,000 pieces 87,000 pieces Leicester 947,000 pieces 250,000 pieces Rubery 361,000 pieces 50,000 pieces Whitley 436,000 pieces 150,000 pieces Camberwell 160,000 pieces 100,000 pieces Shrewsbury 150,000 pieces 150,000 pieces

Chatham 277,000 pieces 28,000 pieces



MAJOR INCIDENT PROCEDURE

FACTORY DOWNTIME

Incidents causing loss of processing time and potential shortages of product to customers must be categorised so that the appropriate actions can be taken to minimise the effects. Incidents are categorised based upon the nature of the incident and an estimate of the amount time that it will take to resume processing at a normal speed. There are arrangements in place within Sunlight to provide production cover in the event of a breakdown. The following matrix should be used to decide what action is required: INCIDENT ESTIMATED

DOWNTIME ACTION MANAGEMENT

RESPONSIBILITY MONITORING CONTINGENCY

Machinery Fire < 4 hours Check on parts availability and assess impact

General Manager, Production Manager, Engineer

Hourly from first report

Plan to go to extended shifts if required

Machinery Fire > 4 hours Check on parts availability and assess impact




Linen Fire N/A Estimate loss and the effect on order fulfilment

General Manager Operations Director Main Board – if total loss

Every 2 hours Advise suppliers of incident and arrange for immediate delivery of contingency stocks. Other factories to support with processing, if necessary.

Main Washer Breakdown

All machines < 4 hours

Check on parts availability and assess impact. Place other factories on alert



Plan to go on extended shifts if required

Main Washer Breakdown

All machines > 4 hours

Extend shifts and advise other factories

General manager, Production Manager, Engineer


Other factories on standby



FACTORY DOWNTIME - CONTINUED INCIDENT ESTIMATED

DOWNTIME ACTION MANAGEMENT

RESPONSIBILITY MONITORING CONTINGENCY

Electricity Cut-Off

< 4 hours Alert other factories of incident and put them on standby

General Manager, Production Manager


Contact electricity supplier

Electricity Cut-Off

> 4 hours Generator on site within 10 hours. Alert other factories

General Manager, Production Manager, Engineers


Internal logistics to be arranged. Arrange for generator to be brought on site

Boiler Breakdown

< ½ hour Check on parts availability and assess impact


Constantly No action

Boiler Breakdown

> ½ hour Start spare boilers




Break in Water Supply

< ½ hour Alert other factories of incident and put them on standby


Constantly Plan to go to extended shifts if required

Break in Water Supply

> ½ hour Advise other factories that processing time is required. Tankers onsite within 2 hours

General manager, production Manager, Engineer


Contact Operations Director. Ask them to start arranging tanker deliveries

Break in Gas Supply

< ½ hour Switch to fuel oil


Break in Gas Supply

> ½ hour Switch to fuel oil


In all instances Operations Director to be made aware, in their absence Commercial Director.



DISASTER RECOVERY PLAN

Every factory within Sunlight has its own personalised Disaster Recovery Plan. This document details the following information that details the processes and actions to be taken in the event of part or total loss of a processing facility and includes:- Standard Disaster Recovery Contingency Plan

- Internal Contact Details

- Loss Adjuster Details - Holding Company Details - Key Personnel involved in management of disaster - Process to be followed if plant is part or totally inoperative - Arrangements to be made due to status of operation

Customer Details

Salvage Teams

- Key Personnel Details - Duties - Customer contact and any arrangements for transfer

Important telephone numbers for key Sunlight personnel

Directory for suppliers in relation to:-

- Buildings - Demolition - Electrics - Boilers - Pipework

Directory for essential services including:-

- Buildings - Plant - Generators - Cleaning - Water treatment - Compressors - Utilities - Repairs

Directory for fire alarms and sprinklers and security alarms Directory for sundry suppliers Directory for transport suppliers Directory for linen suppliers Pre-printed letters for:-

- Customers - Suppliers - Local Residents -

Note: In the event of a major outbreak which affects a geographical area it is assumed that the Disaster Recovery Plan would be invoked



MAJOR INFECTION PROCEDURE – INCLUDING BIRD FLU

Introduction An outbreak of infectious disease may affect Sunlight’s service in a number of ways:

1. Where infection is localised to a hospital or department and there is a requirement for the linen service to be adjusted to support the hospital whilst the outbreak is contained and eliminated. An example of this might be Norwark Like Virus, bacterial food poisoning or other communicable diseases confined geographically. It is unlikely that, with normal precautions, Sunlight staff will be directly affected through personal illness.

2. Where infection is widespread in the community and its effects are amplified within the hospital by virtue

of patient contact e.g. seasonal influenza or bird flu. It is likely that Sunlight staff will be affected by normal daily contact in the community as well as being exposed within the hospital. Additionally staff who must act in the role of carer are likely to be unavailable for work. It is possible in a major outbreak 25% of staff could be affected.

3. Where Sunlight is supplying hospitals with bed linen, towels etc an increase in volume requirement may

result due to the increased number of patients treated, but this may be balanced by a reduction in elective treatments. An increase in the processing of bed curtains may also result. An increase in the proportion of infected linen within the returned linen is to be anticipated.

General

1. Sunlight will be advised of a major outbreak by the Trust Infection Control Team. This must be within 24 hours of the outbreak in order that staff at factory level can be issued with the relevant protective equipment as deemed necessary and arrangements can be made for any on site staff.

2. The Sunlight General Manager will act as the local liaison with the Trust. The Operations Director will

also be advised and kept up to date with progress.

3. The Production Manager will replace the General Manager should the latter become ill or otherwise unavailable. However this deputisation should be used in an emergency only.

4. When based at hospitals, Sunlight staff should avoid contact with other hospital staff to the greatest

extent possible commensurate with their duties. Management

1. In the event of a major outbreak affecting a significant geographical area and hence a number of Sunlight sites, the Managing Director will convene a Sunlight Crisis Team to oversee service provision and use the network of services.

2. Sunlight is unique in having extensive contingency not only within the healthcare division, but the sister

divisions of linen and workwear who could assist with both personnel deployment and factory processing capacity in the event of a major outbreak such as bird flu or seasonal influenza. In such cases Sunlight would convene a high level meeting consisting of Main Board members and Managing Directors of all 3 divisions to discuss the operational profile of the business.

3. A Key Contact to interact between both the Trust and Sunlight will be established and confirmed to the

Trust. In the first instance it is assumed that this will be the General Manager of the processing factory with the back up of the Operations Director.

4. It is the responsibility of this Key Contact Manager to fully understand the impact and depth of the major

outbreak that is being managed in order that sufficient resources are available to support the NHS and the necessary arrangements can be made once it is understood the nature of the outbreak.



5. In the event of a major outbreak the necessary arrangements in relation to linen usage within the Trust must be understood by the Key Contact in order that the correct volumes can be supplied.

6. The Trust and Sunlight will liaise to understand how the linen returned from the infected areas is to be

collected and processed. In the case of a Trust wide breakout then all linen must be bagged as infected and will be subjected to washing procedures as outlined in HSG 95 (18). When an outbreak is isolated to certain wards or departments, only linen utilised within these areas should be bagged as infected in order that specialist processing is actioned.

Workload

1. Factories will expect to experience an increase in workload with reduced staff numbers. Overtime working and the employment of temporary staff may need to be actioned.

2. Sunlight has unique arrangements within its organisation to source staffing from outside the UK, in

excess of 2,000 personnel are available for immediate employment. It is anticipated that these staff will be established and trained for work within a 5 day period.

3. Transfer of staff from other Sunlight factories will be arranged to ensure that service to the NHS is

maintained. 4. At laundry sites, temporary staff should be preferentially placed in work areas dealing with “clean”

product. Experienced Sunlight staff should be redeployed to the “dirty” area.

5. At laundry sites, management should pay particular attention to segregation of work and should minimise staff movement between “dirty” and “clean” area.

Staff and Work Practices

1. Staff who are infected by a contagious disease, or who suspect they may be infected, should not attend work. The site should be alerted by telephone. Staff should not return to work for an appropriate period after cessation of the symptoms as advised by a General Practitioner.

2. Personal hygiene will be more than normally important. Frequent and thorough hand washing is

essential. Alcohol hand disinfectant (95% ethanol) is already made available and hand drying should be by paper towels. Roller and textile towels should be removed from toilet and wash areas (including offices) and replaced by paper. Regular microbiological testing is completed within factory operations. The on site staff will be closely managed by the Contract Manager in order to ensure all preventative actions necessary are taken.

3. Segregation protocols must be adhered to on all sites. Unnecessary movement of staff and equipment

between areas must be avoided. Necessary movements must take account of cross infection risks and minimise these.

4. The General Manager must ensure that all trolleys, boxes, laundry cages etc are thoroughly washed and

dried in accordance with company procedures.

5. Laundry transport staff currently ensure that vehicles are disinfected internally after each trip.

6. At the onset of the outbreak the General Manager should check stock of all disposable, PPE, cleaning materials, plastic bags, detergents, disinfectants etc and increase stock appropriately. The security of such stock should be assured to prevent pilferage. Current stocks held for such items are approximately 2 months supply at factory level and 6 months supply with suppliers.

7. All uniforms (including those worn by engineers etc) must be laundered daily and not taken home. PPE

should be of a disposable type wherever possible and placed in Clinical Waste.

8. Vaccination (if available) and antiviral drugs will be provided in accordance with local Trust policy.



9. The following procedures will be actioned if any of the following contaminated linen is returned to the factory for processing:-

Anthrax Standard precautions. Wash formula will include 100ppm Sodium Hypochloride beach at pH 10.2 to 10.8 for a minimum of 8 minutes at a temperature of 71oC. Smallpox The driver and all staff in the sorting area must wear protective gloves and a N95 mask. All linen must be returned in red bags to be processed as “infected linen”. Wash formula will include 100ppm Sodium Hypochloride beach at pH 10.2 to 10.8 for a minimum of 8 minutes at a temperature of 71oC. Arrange for microbiologist to visit site and make necessary tests to ensure that the virus is not transferred to the laundry. Plague Standard precautions. Wash formula will include 100ppm Sodium Hypochloride beach at pH 10.2 to 10.8 for a minimum of 8 minutes at a temperature of 71oC. Botulism Standard precautions. Wash formula will include 100ppm Sodium Hypochloride beach at pH 10.2 to 10.8 for a minimum of 8 minutes at a temperature of 71oC. Tularemia Standard precautions. Wash formula will include 100ppm Sodium Hypochloride beach at pH 10.2 to 10.8 for a minimum of 8 minutes at a temperature of 71oC. Nerve Agents No linen or clothing exposed to nerve agents should be returned to the laundry for processing.

Common Areas

1. Work surfaces must be cleaned before and after every shift. Disposable cloths must be used. 2. Commonly touched surfaces such as door handles should be disinfected frequently by Sunlight staff.

3. The General manager (or deputy) must make daily check to ensure that cleaning protocols are adhered

to by sub-contract staff. Disposable mops should be used.

4. Rest areas must be cleaned thoroughly by cleaning staff and surfaces wiped by Sunlight staff before each break.

5. All cups, plates and cutlery must be washed in a dishwasher. If no dishwasher is available disposable

items must be obtained.

6. Drying of crockery etc should be disposable kitchen towel, if required to be done.

7. Wherever possible, individuals should limit handling to their own property.

8. Non-essential items such as magazines should be removed from rest rooms.

9. The use of equipment that creates excessive air movement such as fans, vacuum cleaners and hand dryers should be avoided where possible.



Training

1. At the onset of an outbreak the General Manager should instruct staff in the requirements of this policy. Additionally, staff should be reminded of all standard precautions outlined elsewhere on the QMS.

2. On recruiting temporary staff, the General Manager should ensure that they are fully trained in this policy

and the reasons for it. Linen Sunlight always has a contingency stock to the value of £1,000,000 which would be sufficient to install 2 x 500 bedded hospitals. Our suppliers also have further bonded stocks in the United Kingdom that can be called upon, this totals in excess of £2,000,000. The linen and workwear divisions have similar arrangements with their suppliers in relation to linen supply. If the total stocks of healthcare linen specifications were exhausted then this could be substituted with the hotel and workwear products that are very similar. Contacts & Escalation Procedure Servicing Factory: Coventry Postal Address: London Road Whitley

Coventry CV3 4AR Phone Number: 02476 504 383 Fax: 02476 504 359 E-mail: [email protected] Admin/Credit Control: Denise Amos Phone Number: 02476 504 383 Direction of Escalation Service Solutions Manager: TBC Email: Phone Number: General Manager: Andrea Warrington Email: [email protected] Phone Number: 07967 623841 Key Account Manager: Lindsay Ward Email: [email protected] Phone Number: 07971 608016 Service Director: Peter Bennett Email: [email protected] Phone Number: 07966 212788 Operations Director: Ralph Farmer Email: [email protected] Phone Number: 07967 623532

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