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Cleaning Operational Plan=
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Amendments
Date Page(s) Comments Approved by

August 2010 15 Updated in line with revised national Valerie Howell

guidance Linda Fairhead

November Title changes Health and Safety

2012 Committee

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Compiled by: William Britton, Hotel Services Manager

In consultation with: Linda Fairhead Consultant Nurse, Infection Prevention and Control

Ratified by: Health and Safety Committee

Date: November 2012

Target Audience: All staff

Impact Assessment Carried
out By: William Britton
Date of Next Review: August 2015
Contact name for comments: William Britton, Hotel Services Manager

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Contents

1. Introduction 3
2. Broad principles used to develop the cleaning plan 3

3. Objectives of the cleaning plan 3

4. Goals 4
5. Infection Prevention and Control 4
6. Patient Environment Action Team (PEAT) 5
7. National standards of cleanliness for the NHS: the process 6
8. National standards of cleanliness principles and objectives 6
9. National standards of cleanliness eight key objectives 7
10. Matrons charter 9
11. Revised contract for cleaning/national specifications for cleanliness 10
12. Identifying risk 10
13. Elements 11
14. Operational statements 11
15. Audit 11
16. External audit results 12
17. The audit process flow chart 13
18. SWOT analysis 14
19. Operational cleaning manual 14
20. Conclusion 14
21. Other associated documents 15

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1. Introduction
The cleanliness of any hospital environment is important for infection prevention and control and
patient well being. Cleaning staff play an important role in quality improvement, in the confidence
the public has in hospitals, and in reducing infection related risks.

The purpose of developing a plan for cleaning is to provide focus for this important initiative and
this was first issued in 2003.

It was necessary to develop a plan to reflect the publication of the Matrons charter and the revised
Healthcare cleaning manual, published in 2009. The Revised Healthcare Cleaning Manual has a
complementary relationship with other cleaning-related publications: The National Specifications
for Cleanliness in the NHS, published by the National Patient Safety Agency (NPSA), and Revised
Guidance on Contracting for Cleaning, published by Department of Health (DH).

The revised National specifications for cleanliness recognises that, whilst many improvements in
the standards of cleanliness have been made over recent years within in the NHS, there is still
much work to be done. All too often, cleaning contracts (in-house or out-sourced) are driven by
price, with insufficient focus and weighting being placed on quality. This new document clearly sets
out the minimum cleaning frequencies in order for hospitals to achieve the national specifications.

2. The broad principles that have been used to develop the cleaning plan are:

• The understanding of the performance issues of the housekeeping services department.

• The development of specific objectives to enable housekeeping services to meet the national
standards for cleanliness in the NHS.

• The development of a performance management framework to ensure implementation.

• The development of a monitoring process by which the trust can monitor progress.

3. Objectives of the cleaning plan

• To ensure that Housekeeping Services can over a period of time meet and maintain the
requirements of National standards for cleanliness in the NHS.

• To respond to the challenges set by a more informed and involved public, with high
expectations of cleanliness in hospitals.

• To assist the trust in creating the right environment for patients through cultural change by
providing a new focus for staff through effective leadership.

• To ensure that housekeeping services secures and retains the manpower required to meet the
demands of the future.

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4. Goals

• To be recognised throughout the trust for providing a quality customer focused service.

• To enhance the reputation of the trust, both locally and nationally.

• To maintain and develop a well trained, flexible and motivated workforce capable of delivering
excellent services.

5. Infection Prevention and Control

Attention to cleanliness plays an important part in creating a culture that allows everyone, in a
healthcare facility to focus on infection control.

Maintaining high standards of hygiene is key in preventing the spread of infection including
Clostridium difficle spores and to a lesser extent Methicillin Resistant Staphylococcus aureus
(MRSA). Both survive well in the environment meaning that enhanced environmental cleaning and
decontamination are vital components in reducing rates of infection.

Cleanliness is also essential for the comfort and dignity of the patient. Patients and the public rate
a clean hospital, as one of the top five they wish to see in today’s NHS. (DOH 2008 Clean, Safe,
Care)

Therefore the dialogue between the Infection Control Team and the Head of Hotel Services and
Facilities is paramount in maintaining a clean, safe environment. This link is undertaken by:

• Head of Facilities and Hotel Services being members of the Control of Infection
Committee.

• The Infection Control Nurses attend monthly Matrons Cleanliness Meeting.

• Infection Control Environmental audits are feedback to Housekeeping.

• Daily communication with Housekeeping for Wards requiring enhanced cleaning.

• Active participation in Deep Clean Programme.

• Attendance at ad hoc meetings as required to discuss Housekeeping and Facilities

issues.

• Infection Control Nurses link with Housekeeping regarding outbreak management.

• Infection control advice regarding cleaning products and cleaning regimes.

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6. Patient Environment Action Team (PEAT)

In February 2008, following the annual deep clean, the trust set up its own Patient Environment
Action Group.

MEMBERSHIP:

• Associate Director for Facilities and Estates

• Chief Nurse
• Head of Facilities Support Services
• Assistant Hotel Services Manager
• Estates Manager
• Catering Manager
• Infection Control representative
• Matrons
• Patient representative

The terms of reference are:

• To develop strategies that supports the modernisation and continual improvement of the
patient environment.
• To meet on a quarterly basis and be responsible for submitting reports to the Executive and or
Trust Board.
• To gather evidence in line with Standards for Better Health.
• To monitor and evaluate the reports and action plans from the mini PEAG inspections
produced by the inspection group.
• To action PEAG recommendations in a timely and cost-effective manner
• To act as the decision-making group for all aspects of the maintenance of a pleasant patient
environment, incorporating patient views and involvement whenever possible.
• To maintain an overview of the impact of matrons and patients through a variety of forms of
feedback (PALS, complaints and commendations, patient surveys).
• To prioritise the actions required and make prioritised recommendations for funding from the
allocated PEAT budget.
• To take ownership of the national standards of cleanliness for ASPH NHS Trust.
• To develop strategic and operational plans for cleaning.

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7. National standards of cleanliness for the NHS: the process

Involvement Activity Outputs

Trust board, Trust

Patient Environment Action plans
Housekeeping services,
nursing, and estates Action Group (PEAG)

Hotel Services, Matrons Develop the

Trust PEAG
and Infection Control Strategic cleaning plan
Committee

Communication Develop the

Operational cleaning
plan
Implementation

Hotel Services group Audits (internal)

Trust PEAG, Estates

Audits (external) Board report

External audit team

8. National standards of cleanliness principles and objectives

The outcome-based cleanliness standards have been developed using current best practice within
the NHS. The outcome based standards offer:

• Patient and customer focus;

• Clarity for housekeeping staff and service providers

• An effective aid to management

• Consistency with infection control standards and requirements.

• Clear outcome statements, which can be used as benchmarks and output indicators.

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Patient and customer focus

Everyone, who enters a hospital, whether as a patient, visitor or member of staff, is a customer of the
cleaning service. The standards have to focus clearly on their expectations.

Patients are asked to give their views on hospital cleanliness, and are asked directly about their
satisfaction with the patient environment via local patient satisfaction surveys. These results form part
of a performance measure in the performance assessment framework.

Clarity for housekeeping services staff

The clarity of cleanliness standards is of paramount importance. It is essential that the Housekeeping
staff have a clear understanding of the Standards and task requirements to ensure they are working
towards and assessing the same cleanliness outcomes. The standards are to be realistic and
achievable and the housekeeping staff must be able to carry out their jobs safely and in a controlled
environment.

9. National standards of cleanliness: eight key objectives

The national standards of cleanliness now have eight key objectives, (previously five), covering the
following areas:

Taking cleanliness seriously

To ensure that high standards of comfort and cleanliness are the norm across
the whole country, by:

Setting clear local standards and policies, and keeping cleanliness high on the agenda.

Identifying a board member to take personal responsibility for monitoring
hospital cleanliness.

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 Chief Operating Officer
The Board nominee for
ASPH NHS Trust

The accountability for all aspects of cleanliness lies with the chief executive and the trust board.

Listening to patients

To ensure that patients receive care in an environment that is clean, safe and
welcoming, through:

• Promoting strong, visible nursing leadership with clear authority at ward level, and acting on
patient feedback.

Infection control

To ensure that the risk of healthcare associated infection is minimised through:

• Developing, implementing and monitoring infection control policies; and learning from
experience.

Education and development

To ensure those staffs responsible for cleanliness have the ability and support to do a good job,
through:

• Induction training;

• On-the-job support;

• Customer service training;

• Supervisory, managerial and leadership development training (where

appropriate), and certificated competence of operatives.

Monitoring and performance

To make sure those standards of comfort and cleanliness stay high, and that any slippage is
recognised and corrected, through:

This policy will be monitored by the PEAT Group and the Trust Infection Control Committee by
reviewing the Trust’s performance in cleanliness audits internal and externally.

• Setting targets that measure performance over a range of factors; establishing management
systems that support continuous improvement; and involving ward managers and matrons in
maintaining standards.

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Recruitment and retention

Recruitment and retention of the workforce is essential to the long term stability of the standards
and will be achieved through:

• A streamlined and timely recruitment process;

• Robust sickness management policies;

• Regular reviews of changes and developments to ensure efficient workforce planning;

• Specific plans to enhance staff retention.

Resources
The appropriate levels of resource are essential in delivering and maintaining the standards. Key
to this will be:

• best value reviews and benchmarking, to ensure effective and efficient methods are being
used, and that sufficient staff are always available; and that

• adequate and modern equipment is used to ensure the best achievable service.

Documentation

Comprehensive documentation should be available to ensure that operational and strategic needs
are met in terms of the standards and will be achieved through:

• Developing an up to date cleaning manual that gives written guidance on how to complete
each task;

• Comprehensive risk assessments undertaken to ensure working methods and staff are as safe
as possible;

• Staff rota systems to ensure appropriately trained staff are available and deployed as
necessary;

• Policies that involve cleaning service providers in future developments or changes.

10. The Matrons Charter

The charter sets out ten broad principles for delivering cleaner hospitals. It is aimed at all staff in
the NHS, whatever their role, and should be shared with patients and visitors, to involve them in
plans for improvement and to gather their feedback. The public look to nurses and midwives to
make sure that the patient environment is clean and safe. Their leadership is essential but they
cannot succeed alone. Matrons have worked with clinical and non-clinical colleagues to set out ten
key commitments that will apply to everyone, whatever their role might be. These commitments will
be delivered differently in different places but the underlying ethos remains the same. They are as
follows:

• Sufficient resources will be dedicated to keeping hospitals clean: keeping the NHS clean is
everybody’s responsibility.

• The patient environment will be well-maintained, clean and safe.

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• Matrons will establish a cleanliness culture across their units.

• Cleaning staff will be recognised for the important work they do. Matrons will make sure they
feel part of the ward team.

• Specific roles and responsibilities for cleaning will be clear.

• Cleaning routines will be clear, agreed and well-publicised.

• Patients will have a part to play in monitoring and reporting on standards of cleanliness.

• All staff working in healthcare will receive education in infection control.

• Nurses and infection control teams will be involved in drawing up cleaning contracts, and
matrons will have authority and power to withhold payment.

• Sufficient resources will be dedicated to keeping hospitals clean.

ASPH NHS Trust needs to continuously review their current practice against these commitments.
The Patients Environmental Group will support the matrons’ charter, lead the Trust with this
initiative, and advise them of the necessary steps required to develop services to meet the spirit of
the charter.

11. Revised Healthcare Cleaning Manual issued in 2009 and supported by the National
Cleaning Specification for Cleanliness

This document is supplemented by the Revised Contract for cleaning document issued to trusts in
December 2004. This document takes the first step in meeting the undertaking of Towards cleaner
hospitals & lower rates of infection.

• A best practice guide on evaluating & awarding contracts so that quality is considered
alongside price.

• Revised national specifications for cleanliness (formerly the national standards of cleanliness)
which set out clearly the standards which hospitals should provide as a minimum.

• To clearly identify cleaning responsibilities within the Trusts staff groups and that there is a
clear, written and well publicised cleaning responsibility framework.

• The recommended minimum cleaning frequencies which need to be followed to achieve

national specifications and determine cleaning responsibilities.

• Clear specific cleaning schedules available to the public and all staff supplemented by method
statements. The Healthcare cleaning manual issued in 2009 has been produced and will be
updated regularly to reflect changes in cleaning technologies and practices.

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12. Identifying risk

The areas that are to be cleaned in the hospital are broken down into functional areas. Maintaining
the required standard of cleanliness is more important in some functional areas than others.

In line with the revised contract for cleaning/national specifications for cleanliness, the functional
areas will be grouped into four levels of cleaning intensity, based on the risks associated with
inadequate cleaning in that functional area:

1. Very high risk. Consistently high levels of cleanliness must be maintained. Very high risk areas
may include theatres, critical care areas and other departments where invasive procedures are
performed. Over a period of a month, all rooms within these areas should be audited at least
once.

2. High risk. Outcomes should be maintained by regular and frequent cleaning with ‘spot’
cleaning in between. High risk areas may include general wards, public thoroughfares and
public toilets. Over a period of one month all rooms within these areas should be audited at
least once.

3. Significant risk. In these areas high levels of cleanliness are required for both hygiene and
aesthetic reasons. Outcomes should be maintained by regular and frequent cleaning with ‘spot’
cleaning in between. Significant risk areas may include out-patient area. Over a period of one
month all rooms within these areas should be audited at least once.

4. Low risk. In these areas high levels of cleanliness are required for aesthetic and to a lesser
extent hygiene reasons. Outcomes should be maintained by regular and frequent cleaning with
‘spot’ cleaning in between. Low risk areas may include administrative areas, non-sterile supply
areas, record storage and archives. Over a period of twelve months all rooms within these
areas should be audited at least twice.

13. Elements

The items to be cleaned are broken down into 49 elements as defined in the national standards of
cleanliness.

14. Operational statements

In order to meet the national standards of cleanliness and as part of this operational cleaning plan,
cleaning frequencies will be developed, which will detail how often these tasks should be
undertaken.

Work schedules to form part of the Service Level Agreements will be developed for each area,
which will detail the daily duties, weekly duties and periodic tasks.

15. Audit
The completion of an internal audit is a fundamental prerequisite of implementing the national
standards of cleanliness. The baseline audit provides a detailed report on the current standard of
cleanliness within the hospital.

The principles of the audit are:

1. The audit clearly identifies anything that impacts on the capability to clean.

2. The audit clearly identifies tidiness issues that impact on the capability to clean.
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3. The audit identifies any areas/items/elements that are not within the remit of the cleaning team.

4. The audit clearly identifies the distance between current cleanliness levels and the standard
levels of cleanliness.

5. The audit is an integral part of the strategic cleaning plan.

6. The audit clearly highlights the gap between current levels of cleanliness and the standards
laid down in the national standards of cleanliness for the NHS.

7. All issues/items identified as part of the audit generate exception reports.*

*A report giving detail of failures or defects that require immediate inspection as they impact on the
capability to clean. These reports are escalated to the relevant professional lead and where
appropriate the Patient Environment Action Team.

The audit process

An audit process has been implemented in line with the recommendations in the national
specifications for cleanliness. Two levels of audit are undertaken:

• Technical. These take the form of regular monthly audits which form a continuous and
inseparable part of the day-to-day management and supervision of the cleaning services.
Technical audits are undertaken by the housekeeper. The frequency of these audits is in
accordance with the relevant risk category as detailed in Section 12: Identifying risk.

• Managerial. These are planned audits that should verify cleaning outcomes of technical audits
and identify any areas for improvement. The audit team should consist of housekeeping
management, matrons with responsibility for cleaning, infection control, estates. These audits
are undertaken at least yearly.

An annual programme for cleanliness audits on the ASPH will be developed to ensure that each
area receives regular audits. Obviously, higher risk areas receive a higher proportion of audits to
ensure that the high standards of cleanliness required are achieved. The audits are evidence
based and if an element is not acceptable the auditor is required to make a comment as to why it is
not acceptable and indicate the corrective action needed. A timescale for corrective action is
recorded on the audit form and forwarded to the necessary personnel for action.

When the audit has been completed the score is produced and sent to the ward and/or
Housekeeper or to allow the ward staff or duty supervisor to take action to rectify the problem
areas highlighted. The following staff will be included in some/all stages of the auditing processes:

1. Housekeeping manager

2. Infection Control Team

3. Estates manager/officer

4. Nursing staff (matron/senior nurse)

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16. Results of the external audits for ASPH NHS trust

In order to comply with the national specifications for cleanliness targets, audits are carried out
daily and weekly on a selection of wards and departments within the various risk categories. Using
the national standards. Members of the Housekeeping team, Matrons and Patient Panel
representatives carry out the audits.

The above scores are averaged over 12 months and forwarded to NHS estates as a requirement
of the Estates Returns and Information Collection (ERIC).

Annual audits will continue to be undertaken against the revised Contract for cleaning.

17. Audit process flow chart

Audit Exception report to

(initial procedure) board nominee and
relevant department

Exception and Very high risk area

remedial work (monthly internal)
reported on audit
comment sheet

High risk area

(monthly internal)

Low risk areas

(bi-annual internal)

Whole hospital
(annual external)

Achieved score sent

Board report Board to NPSA
sign-off score

The strategy includes:

A current situational analysis against the national standards of cleanliness for the NHS
(baseline assessment).

Identification of the gap between the two.

A top line action plan for closing the gap.

Operational cleaning plan.
The strategy details short term, medium term and long term objectives.

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18. SWOT Analysis

STRENGTHS WEAKNESSES

• Defined standards of cleanliness • Critical mass – no reserve on staffing

• Clear expectations of the service • Cost improvements/financial constraints

• Loyal staff/well trained • Unplanned growth and developments

• Flexible workforce

OPPORTUNITIES THREATS

• Further flexible working – develop the • Non compliance to the national standards
role of the hotel services assistant at of cleanliness
ward level
• Implementation of a HSA service not
• Develop an operational cleaning funded.
manual that staff can use as a
reference manual. • Cost improvements/financial constraints

• Develop service level agreements for

all service users

• Improvements to training and

recognition of staff value.

19. Operational cleaning manual

The clarity of cleanliness standards is of paramount importance. It is essential that the staff have a
clear understanding of the standards and task requirements to ensure they are working towards and
assessing the same cleanliness outcomes. The standards are to be realistic and achievable and the
Housekeeping staff must be able to carry out their jobs safely and in a controlled environment. In
order to ensure that staff fully understand the national standards.

20. Conclusion

The implementation of the national standards of cleanliness initiative has been an opportunity to
encourage improvement in and measurement of cleaning standards through a multi disciplinary
staff group. Whilst significant progress has been made, there is still much to do.

This document has clarified reporting lines and gives housekeeping a higher profile within the
Trust. The Hotel Services Group, Infection Control Committee and PEAG are tasked with driving
this initiative forward and to shape the future pattern of services. The direction is consistent with
the plans for rolling out further improvements to all housekeeping services in the future.

The publication of The matrons charter and Revised national specifications for cleanliness during
the latter part of 2004 has given us more targets to achieve. This direction is consistent with the
plans for developing and re-modelling ward housekeeping services in the future.

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The ongoing use of an audit tool has focused attention on performance and quality and has been
seen as a positive move forward. There are measurable improvements in service standards and
an increased awareness among all staff of the standards to be achieved.

This Plan will be subject to annual review and update through the trust PEAG.

21. Other associated documents

Ashford & St. Peters NHS Trust documents:

Control of Infection Policies
Occupational Health Department Policies
Health and Safety Policy
Risk Management Policy
Cleaning Responsibilities Definitions Manual
Strategic Cleaning Policy

Monitoring

This Plan will be subject to annual review and update through the trust PEAG.

Dissemination and implementation

The policy has been written by the Hotel Services Team, agreed by the Patients Environmental
Action Group (PEAG) and the Infection Control Committee and ratified by the Non Clinical Risk
Committee.

The policy will be available on Trustnet and as a hard copy at ward level for ease of use.

Equality impact assessment

A baseline equality impact assessment has been carried out (see Appendix 1). This has
concluded that no further assessment is required.

Archiving
Responsibility for archiving trust-wide policies lies with the Quality Department, where all paper
copies will be stored, and electronic folders have been set up to hold master copies.

Requests for retrieval of documents can be made to the Quality Department.

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Yes/No Comments

1. Does the policy/guidance affect one group For each category describe
less or more favourably than another on the how you have involved
basis of: stakeholders including service
users and employees
Operational Cleaning Policy

Race and Ethnic origin (include gypsies and

travellers) (consider communication, access to
information on services and employment, and No
ease of access to services and employment)

Disability (consider communication issues,

access to employment and services, whether
individual care needs are being met and No
whether the policy promotes the involvement of
disabled people)

Gender (consider care needs and employment

issues, identify and remove or justify terms
which are gender specific) No

Culture (consider dietary requirements and No

individual care needs)

Religion or belief (include dress, individual care No

needs and spiritual needs for consideration)

Sexual orientation including lesbian, gay and No

bisexual people (consider whether the
policy/service promotes a culture of openness
and takes account of individual needs
Age (consider any barriers to accessing No
services or employment, identify and remove
or justify terms which could be ageist)
2. Is there any evidence that some groups are No
affected differently?
3. If you have identified potential No
discrimination, for example, less than equal
access, are any exceptions valid, legal
and/or justifiable, for example a genuine
occupational qualification?
4. Is the impact of the policy/guidance likely to No
be negative?
5. If so can the impact be avoided? N/A
6. What alternatives are there to achieving the N/A

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 Yes/No Comments
policy/guidance without the impact?
7. Can we reduce the impact by taking N/A
different action?
If you have identified a potential discriminatory impact of this policy, please refer it to the appropriate Action
Group, together with any suggestions as to the action required to avoid/reduce this impact.

For advice in respect of answering the above questions, please contact Maria Crosbie, HR Manager, on
extension 2552.
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