Terminal Cleaning Co-ordination Policy Ratified by: Infection Control & Decontamination Assurance Group: 17

th May 2017

Review date: October 2021 Page 1 of 14

Terminal Cleaning Co-ordination Policy

Post holder responsible for Procedural Document

Judy Potter, Lead Nurse for Infection Prevention & Control

Author of Policy Judy Potter, Lead Nurse for Infection Prevention & Control

Division/ Department responsible for Procedural Document

Specialist Services, Infection Prevention & Control

Contact details x2690

Date of original policy June 2004

Impact Assessment performed Yes/No

Ratifying body and date ratified Infection Control & Decontamination Assurance Group: 17th May 2017

Review date (and frequency of further reviews)

October 2021 (every 5 years)

Expiry date April 2022

Date document becomes live 11 July 2017

Please specify standard/criterion numbers and tick other boxes as appropriate

Monitoring Information Strategic Directions – Key Milestones

Patient Experience Maintain Operational Service Delivery

Assurance Framework Integrated Community Pathways

Monitor/Finance/Performance Develop Acute services

CQC Fundamental Standards - Regulation: 8 Infection Control

Other (please specify):

Note: This document has been assessed for any equality, diversity or human rights implications

Controlled document This document has been created following the Royal Devon and Exeter NHS Foundation Trust Development, Ratification & Management of Procedural Documents Policy. It should not be altered in any way without the

express permission of the author or their representative.

Terminal Cleaning Co-ordination Policy Ratified by: Infection Control & Decontamination Assurance Group: 17th May 2017 Review date: October 2021 Page 2 of 14

Full History

Status: Final

Version Date Author (Title not name)

Reason

1.0 Jun 2004 Lead Nurse New guideline

2.0 Nov 2007 Lead Nurse Routine revision

3.0 Nov 2009 Lead Nurse Routine revision

4.0 Nov 2011 Lead Nurse Routine revision

5.0 Feb 2014 Lead Nurse Routine revision

6.0 Mar 2017 Lead Nurse Routine revision harmonised with community services requirements

Associated Trust Policies/ Procedural documents:

Hydrogen Peroxide Decontamination Protocol (Domestic Services) Source Isolation Policy & Procedures for Hospital Patients Decontamination Policy and Procedures

Key Words Outbreak clean, deep clean, specialist clean

In consultation with and date: Full membership of the Infection Control and Decontamination Assurance Group which includes representation from the executive team, divisional management teams (including community services), nursing and medical staff, therapists, facilities, operations support, estates and Public Health England’s Devon/Cornwall and Somerset Local Team: 17th May 2017. Policy Expert Panel (PEP): 15 June 2017

Contact for Review:

Lead Nurse, Infection Prevention & Control

Executive Lead Signature: (Only applicable for Strategies & Policies)

Medical Director

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CONTENTS

1. INTRODUCTION ................................................................................................ 4

2. PURPOSE .......................................................................................................... 4

3. DEFINITIONS ..................................................................................................... 4

4. DUTIES AND RESPONSIBILITIES OF STAFF .................................................. 4

5. MANAGEMENT .................................................................................................. 6

6. STAFF ................................................................................................................ 6

7. TIMESCALES FOR CLEANING ......................................................................... 6

8. EQUIPMENT AND DECONTAMINATION CHEMICALS .................................... 7

9. POST OUTBREAK CLEAN CHECK .................................................................. 7

10. ARCHIVING ARRANGEMENTS ........................................................................ 7

11. PROCESS FOR MONITORING COMPLIANCE WITH AND EFFECTIVENESS OF THE POLICY ................................................................................................ 7

12. REFERENCES ................................................................................................... 8

APPENDIX 1: CO-ORDINATORS CHECKLIST FOR TERMINAL WARD CLEAN ..... 9

APPENDIX 2: PROCEDURE FOR TERMINAL CLEANING OF WARD/BAY ........... 11

APPENDIX 3: COMMUNICATION PLAN .................................................................. 12

APPENDIX 4: EQUALITY IMPACT ASSESSMENT TOOL ...................................... 13

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1. INTRODUCTION

1.1 Stopping admissions into or transfers out of wards/units is a proven method of control during suspected or confirmed outbreaks of infection. Once the outbreak is at an end, the environment requires cleaning and disinfection to ensure that once new admissions resume they do not become infected through contact with a contaminated environment.

1.2 The type of cleaning and disinfection post outbreak is referred to as a terminal clean

and needs to be planned and coordinated to ensure that it is carried out effectively, in a timely fashion and with as little impact on the patients who remain on the ward as possible.

1.3 Failure to comply with this policy could result in disciplinary action.

2. PURPOSE 2.1 To provide a framework for efficient, effective terminal cleaning of a ward or unit following an outbreak of infection.

3. DEFINITIONS 3.1 Terminal clean – thorough cleaning and disinfection of an environment that could be a

potential source of infection

4. DUTIES AND RESPONSIBILITIES OF STAFF 4.1 Lead Nurse/Director for Infection Prevention Control and/or Infection Prevention and Control Nurse (IPCN) is responsible for:

Making the decision to undertake a terminal clean and reopen a ward/area once they have assessed that patients and staff in the affected area do not pose an infection risk to new admissions.

Identifying the type and extent of terminal clean that is required and communicating this to the ward staff, domestic services and site management team

Confirming the arrangements with the site management team for any required movement of patients in order to free up at least one bay to start the cleaning process

Endeavouring to give at least 24 hours’ notice to the ward and domestic services department that a clean is likely. This should allow time for adequate arrangements and staffing to be made available (refer section 5). It should be noted that in extreme circumstances less notice may be given.

4.2 Trust Lead Patient Flow and/or Site Practitioners is responsible for:

Liaising with the Infection Prevention Control Team (IPCT) and ward team about the terminal cleaning arrangements

Ensuring that admissions are not made to the ward prior to completion of the cleaning process, unless agreed with the Infection Prevention and Control Nurse.

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4.3 Senior Nurse and/or Ward Matron is responsible for:

ensuring that there are adequate nurse staffing levels on the ward throughout the terminal clean to ensure that, in addition to normal provision of patient care, that there are enough staff to transfer patients from bay to bay, make up cleaned beds, pack up patients personal items, restock supplies.

Identifying an experienced ward nurse to take on the role of terminal cleaning co-ordinator ideally this will be the ward matron or ward sister.

4.4 Terminal Cleaning Co-ordinator i.e. Matron, Sister, experienced staff nurse is

responsible for:

communicating progress as appropriate to the site management team and escalate any problems or difficulties in a timely manner to either the domestic services management team or the senior nurse.

liaising closely with the Domestic Supervisor and Infection Prevention and Control Team to :

o Identify the order in which the various parts of the ward will be cleaned.

o Ensure that patients are moved as early in the day as possible out of the area where cleaning will start.

o Identify when breaks are taken by domestic and nursing staff so that it is coordinated and the progress of the clean is not disrupted.

On completion of the clean, ensuring that the ward is checked and the checklist is signed off to confirm that the ward is cleaned and completed to their satisfaction. (See appendix 1)

4.5 Domestic Services Manager/Domestic Supervisor is responsible for:

Provision of a cleaning team of adequate size (refer section 6) and competence to complete the clean within the a reasonable time scale (refer section 7)

Provision of cleaning materials 4.6 Terminal cleaning team (including ward housekeeper and ward domestic assistant)

are responsible for:

Cleaning and disinfection of the environment, patient equipment, fixtures and fittings (except grilles) and the taking down and re-hanging of all curtains

4.7 Ward nursing staff are responsible for:

Keeping patients and their visitors informed about the process

Stripping and remaking beds

Packing up patient belongings into property bags to facilitate ease of transfer around the ward

Moving patients in and out of areas to be cleaned swiftly to minimise delays in the cleaning process

Working collaboratively with the terminal cleaning team

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4.8 Estates Services are responsible, where required by the IPCT, for:

cleaning grilles, vents

removing radiator covers

making good any damage to walls, fixtures and fittings.

5. MANAGEMENT 5.1 Outbreak cleaning requires a multi-disciplinary approach and therefore planning will be undertaken by the following staff:

Domestic Services Manager (or deputy)

Patient Flow Lead

Infection Prevention and Control Nurse

Senior Nurse/Matron

Community Facilities Manager (or assistant)

6. STAFF 6.1 The number of staff required to complete a regular template ward (see below*) terminal clean in one day, using the procedure outlined at Appendix 2, is:

6 Domestic Services staff (to include incumbent Ward Housekeeper and Domestic Assistant)

1 Domestic Supervisor (to stay for duration of clean if availability allows)

Normal staffing levels as per ward establishment 6.2 On larger wards, additional Domestic Services staff and unregistered nurses may be required. 6.3 Community staff levels supplied by regular work force with additional resources where available. 7. TIMESCALES FOR CLEANING 7.1 There are a number of variables which will ultimately affect the time that is taken to complete an outbreak clean of an infected ward; not least the number of patients still accommodated on the ward and their dependency in terms of transfer between bed spaces or side rooms as the clean is undertaken. 7.2 However, it is recognised that time scales need to be identified to ensure that colleagues can plan for the ward re-opening: 7.3 Therefore, approximate times are:

Regular template wards (4 x 6 bedded bays and 4 side rooms)* = 10 hours

Modular wards e.g. Kenn / Bovey / Bolham / Dyball / Tavy= 12 hours

Clyst / Creedy / Durbin ward – 16 hours

This may vary in Community hospitals as each ward and resources differ

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7.4 On template wards on the Wonford site where there are fewer beds than a standard template ward, then it is anticipated that the outbreak clean will be completed in a shorter time frame than that stated.

7.5 Additional time (usually 3 hours) will be required if there is a requirement to decontaminate using hydrogen peroxide vapour.

8. EQUIPMENT AND DECONTAMINATION CHEMICALS 8.1 All relevant cleaning equipment and chemical solutions will be provided by Domestic

Services. 8.2 Usually, cleaning and disinfection will be undertaken using a 1000ppm solution of NaDCC

(e.g. Chlor-Clean) or equivalent chlorine producing disinfectant. However, the product used will depend on the type of outbreak and will be advised by the Infection Prevention and Control Team.

8.3 In some circumstances there may be a requirement to use hydrogen peroxide vapour

(HPV) for decontamination but this will only be used upon instruction from the Director of Infection Prevention and Control or their deputy. Thorough cleaning using neutral detergent must be completed prior to use of HPV.

8.4 The use of HPV must be used in accordance with the Hydrogen Peroxide

Decontamination Protocol and the required permit to work completed before use.

9. POST OUTBREAK CLEAN CHECK 9.1 The ward will be checked and signed off by the co-ordinator (or delegated to Ward Housekeeper). Site Practitioners must be informed by the co-ordinator as soon as possible that the ward is ready to be re-opened. 9.2 When HPV is required, the checklist will be completed after cleaning but prior to use of

HPV.

10. ARCHIVING ARRANGEMENTS The original of this policy will remain with the Lead Nurse for Infection Prevention and Control. An electronic copy will be maintained on the Trust Intranet P – Policies (Trust- wide) – T – Terminal Cleaning Co-ordination Policy. Archived electronic copies will be stored on the Trust's “archived policies” shared drive, and will be held indefinitely. A paper copy (where one exists) will be retained for 10 years.

11. PROCESS FOR MONITORING COMPLIANCE WITH AND EFFECTIVENESS OF THE POLICY

11.1 In order to monitor compliance with this policy, the auditable standards will be monitored

as follows:

No Minimum Requirements Evidenced by

1. The terminal clean will be completed effectively and within the anticipated timescale

Real-time monitoring performed with monitoring checklist.

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11.2 Frequency This will be undertaken every time a terminal clean has been undertaken.

11.3 Undertaken by

A member of staff not involved in cleaning i.e. the coordinator, housekeeper, site practitioner, depending on the time of day the clean is completed.

11.4 Dissemination of Results

N/A 11.5 Recommendations/ Action Plans

N/A

11.6 Any barriers to implementation will be risk-assessed and added to the risk register. 11.7 Any changes in practice needed will be highlighted to Trust staff via the Governance Managers’ cascade system.

12. REFERENCES N/A

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APPENDIX 1: CO-ORDINATORS CHECKLIST FOR TERMINAL WARD CLEAN CO-ORDINATORS CHECKLIST FOR TERMINAL WARD CLEAN Ward Name ……………………………………………………………………… Date of Clean ………………………………………… Signature of co-ordinator ………………………………… (To be signed after clean to confirm that area is cleaned and completed to their satisfaction)

TASK TO BE COMPLETED TICK WHEN COMPLETED

1. Contact General Service to provide a yellow clinical waste bin and separate skip for all soiled linen and curtains. These will be delivered to the ward being cleaned

2. Wear the appropriate personal protective equipment (PPE).

3. Strip beds of linen, place in red water-soluble bag and then in a red laundry bag. Leave at the appropriate collection point.

4. Remove all curtains. Remove all hooks and place in a bowl of chlorinated water. Place curtains in a red water- soluble bag and then in a red laundry bag. Leave at the appropriate collection point

5. Remove all crockery, cutlery, water jugs and glasses and cups to the catering trolley for return or to the ward pantry for washing (if applicable)

6. Dispose of flowers and place vases in the sluice for cleaning.

7. Dispose of throwaway items i.e. serviettes, tissues and disposable locker bags and sponge ear covers only of Patient line & hospital radio headsets.

8. Remove surface hand towels, gloves and aprons only from dispensers

9. Remove and dispose of all large items of litter etc from the floor

10. Tie all clinical and domestic waste bags and place for disposal.

11. Move all furniture to the centre of the room and invert all chairs and tables

12. High dust the environment, especially curtain tracks, high window ledges, walls above hand height, ceiling corners and light fittings

13. Damp dust the periphery of the room/area, especially notice boards, lamps, pipework, radiators, and light sockets. Walls only require washing if visibly contaminated.

14. Particular attention is to be paid to cleaning objects that are frequently handled e.g. door handles, bath rails etc.

15. Wipe clean non-washable furniture

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TASK TO BE COMPLETED TICK WHEN COMPLETED

16. Clean the mattresses and all parts of the bed.

17. Clean all medical equipment e.g. drip stands, PAT slides, hoists, commodes etc.. Steam cleaning can be used for equipment that is difficult to clean

18. All sanitary ware to be thoroughly cleaned

19. All Patient Line equipment is to be wiped over

Hard Floors:

20. Static mop all hard floors to remove any dust and debris.

21. Damp mop Floors

Soft Floors:

22. Vacuum floor to remove any dust or debris

23. Steam clean carpeted floors

24. Re-hang fresh clean curtains

25. Move all furniture back to its original place

This form is to be returned to Domestic Services where it will be retained for performance monitoring / reporting purposes Thank you

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APPENDIX 2: PROCEDURE FOR TERMINAL CLEANING OF WARD/Bay 1. Where possible, decant patients into an empty bay or dayroom.

2. Dispose of any disposable patient care items as clinical waste e.g. wipes, pads, tissues, oxygen masks and tubing etc.

3. Strip the bed linen and place in appropriate bag for laundering. 4. Dispose of any remaining debris/rubbish into a clinical waste bag. 5. Remove curtains and place in appropriate bag for laundering. 6. Clean the environment thoroughly using a combined detergent and disinfectant

solution ( e.g. Chlorclean 1000ppm) and disposable cloths and mop heads. Rinse any metal objects with water to remove chlorine residues. Stream cleaners may only be used for difficult to clean equipment.

7. Dust walls and clean all visible splash marks 8. Clean curtain rails, overhead light and ‘Patientline’ equipment. 9. Clean patient equipment that cannot be removed, (e.g. suction/oxygen points,

monitors) 10. Clean mattresses, bed frames & wheels. Wipe chlorine residues off mattresses

with a clean cloth dampened with clean water. 11. Clean hand washing sinks and any en-suite facilities 12. Clean bed tables, chairs & lockers. This includes inside, underside and all wheels 13. Clean all other surfaces 14. Wet mop vinyl flooring. 15. Hang clean curtains. 16. Move patients to vacate other bays and siderooms immediately to allow the next

area to be cleaned as above. 17. Ensure all communal areas are also cleaned thoroughly e.g. bathrooms, shower

rooms and toilet areas. Ensure main ward thoroughfare has been thoroughly cleaned. 18. Clean all patient handrails and door handles. 19. Ensure dirty utility room and sluice are cleaned thoroughly. Thoroughly clean all

parts of each commode (seat, lid, arms, backrest, legs and underside). Dispose of opened boxes of pulp products and contact Procurement Dept. for replacements.

20. Ward to open once cleaning is complete and surfaces are dry. Red = nursing responsibility

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APPENDIX 3: COMMUNICATION PLAN

The following action plan will be enacted once the document has gone live.

Staff groups that need to have knowledge of the strategy/policy

Ward nursing staff Site Practitioners Domestic Services Staff Ward Housekeepers Senior Nurses On call managers

The key changes if a revised policy/strategy

Minor change to recognise community hospital ward requirements

The key objectives To provide a framework for efficient, effective terminal cleaning of a ward or unit following an outbreak of infection.

How new staff will be made aware of the policy and manager action

Ward staff will be made aware of the policy as and when an outbreak is recognised Domestic staff, site practitioners, on call senior nurses and managers will be informed as part of local induction to that role.

Specific Issues to be raised with staff The importance of checking the adequacy of the terminal cleaning process prior to reopening the ward/bay to new admissions

Training available to staff Support available from Domestic Services Supervisors and Managers and the Infection Prevention and Control Team

Any other requirements N/A

Issues following Equality Impact Assessment (if any)

No negative impacts.

Location of hard / electronic copy of the document etc.

Hard copy retained in Site Management Office and Infection Prevention and Control Team (IPCT) offices. Electronic copy available on intranet and on IPCT shard drive.

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APPENDIX 4: EQUALITY IMPACT ASSESSMENT TOOL

Name of document Terminal Clean Co-ordination Policy

Division/Directorate and service area Trust wide

Name, job title and contact details of

person completing the assessment Judy Potter, Lead Nurse/Director Infection Prevention and Control

Date completed: 29/03/2017

The purpose of this tool is to: identify the equality issues related to a policy, procedure or strategy summarise the work done during the development of the document to reduce

negative impacts or to maximise benefit highlight unresolved issues with the policy/procedure/strategy which cannot be

removed but which will be monitored, and set out how this will be done.

1. What is the main purpose of this document?

To provide a framework for efficient, effective terminal cleaning of a ward or unit post outbreak.

2. Who does it mainly affect?

Carers ☐ Staff ☐ Patients X Other (please specify)

3. Who might the policy have a ‘differential’ effect on, considering the “protected

characteristics” below? (By differential we mean, for example that a policy may have a noticeably more positive or negative impact on a particular group e.g. it may be more beneficial for women than for men)

4. Apart from those with protected characteristics, which other groups in society might

this document be particularly relevant to… (e.g. those affected by homelessness, bariatric patients, end of life patients, those with carers etc.)?

Protected characteristic Relevant Not relevant

Age ☐ X

Disability ☐ X

Sex - including: Transgender,

and Pregnancy / Maternity ☐ X

Race ☐ X

Religion / belief ☐ X

Sexual orientation – including:

Marriage / Civil Partnership ☐ X

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N/A

5. Do you think the document meets our human rights obligations? ☐

A quick guide to human rights:

Fairness – how have you made sure it treat everyone justly?

Respect – how have you made sure it respects everyone as a person?

Equality – how does it give everyone an equal chance to get whatever it is offering?

Dignity – have you made sure it treats everyone with dignity?

Autonomy – Does it enable people to make decisions for themselves?

6. Looking back at questions 3, 4 and 5, can you summarise what has been done

during the production of this document and your consultation process to support our equality / human rights / inclusion commitments?

N/A

7. If you have noted any ‘missed opportunities’, or perhaps noted that there remains some concern about a potentially negative impact please note this below and how this will be monitored/addressed.

“Protected characteristic”: N/A

Issue:

How is this going to be

monitored/ addressed in

the future:

Group that will be

responsible for ensuring

this carried out: