POLICY FOR THE PROVISION
AND MANAGEMENT OF CLEANING SERVICES
15 January 2015
1
List of Contents
Foreword
Executive Summary
SECTION 1 – Introduction and Background
Strategic Context
Aims
Scope
Key Principles
Equality Screening
SECTION 2 – Developments since 2005 Strategy
Impact and Implementation of the Cleanliness Matters Strategy
Other Departmental Initiatives
Recent Developments
NHS Initiatives
Regional Healthcare Hygiene and Cleanliness Audit Tool
SECTION 3 – The Way Forward
Finance and General Management
Audit Approach
Elements to be Assessed
Training
Design and Other Issues
Multi Disciplinary Working
Colour coding Hospital Cleaning Equipment
Sharing Best Practice
Association of Healthcare Cleaning Professionals
SECTION 4 – Appendices
Appendix 1 – Reference List
Appendix 2 – EQIA Screening Template
Appendix 3 – GLOSSARY
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Alternative Formats
Consideration will be given to any request to make this document available, in
alternative formats - Braille, audio, large print, computer disk or as a PDF document.
The Department will consider requests to produce this document in other languages. If
the document is required in these or other formats please contact Investment
Directorate:
Phone:
028 9052 3246
Text Phone: 028 9052 7668
Fax:
028 9052 2500
Email:
investment.directorate@dhsspsni.gov.uk
Post:
Investment Directorate
DHSSPS
Room D1.4 Castle Buildings
Belfast BT4 3SQ
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Policy for the Provision and Management of Cleaning Services
Foreword
This policy sets out Policy for the Provision and Management of Cleaning Services in
the Health and Social Care Sector.
The policy is a reinforcement and clarification of previous policy and entails adopting a
risk based approach using National guidelines prepared by the National Patient Safety
Agency and a Publicly Available Specification (PAS 5748) issued in 2011 by the British
Standards Institution and sponsored by the Department of Health. This reflects
discussions with cleaning service providers which suggests that, whilst it is important
that Trusts locally produce a cleaning frequency schedule, a single regional version is
inappropriate since it cannot meet every organisation’s needs. The precise allocation of
resources, and the actual frequency of cleaning, will therefore vary according to locally
determined need. The logistics of this are an operational matter for each Trust, but the
expectation is that HSC Managers will carry out annual risk assessments and that these
will then receive approval at Board level as part of an annual self assessment exercise.
This complements and strengthens the main themes of the policy: provision of rigorous
programme of auditing to monitor standards of cleanliness; and, corporate governance
systems and procedures, to ensure that clear accountability and management
arrangements flow down from HSC Trust Boards.
I am aware that PAS 5748 is currently being updated and Departmental officials have
been part of the consultation process. Once this has been updated, it will be reviewed
and promulgated to HSC bodies in due course.
I would like to acknowledge the contributions made by, and also to thank, the interested
groups and individuals who have helped to inform and shape this Policy. It has
benefited greatly from the outcomes of the public consultation and I know that there will
continue to be ongoing engagement with key stakeholders as the Action Plan is rolled
out.
Jim Wells MLA
Minister of Health, Social Services & Public Safety
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Policy for the Provision and Management of Cleaning Services
Executive Summary
This policy sets out the Department’s commitment to maintaining and
improving environmental cleanliness in Northern Ireland (NI).
It has been developed with the aim that best management practice, staff
training and continued monitoring of performance will lead to services
being maintained and improved in a challenging financial climate.
The detail of the policy is presented in the three sections which follow this
executive summary.
Section 1 – Introduction and Background. This section sets out the
aims, objectives and scope of the policy. It also sets out the key principles
which should apply to cleaning services.
Section 2 – Developments since the launch of Cleanliness Matters
Strategy in October 2005. This outlines events and progress since 2005
and indicates how these are shaping the proposed strategic direction.
Section 3 – The Way Forward.
This section sets out the areas for
attention over the coming years.
Section 4 – Appendices.
4
Section One
Introduction and Background
5
Introduction
1.1
Cleanliness is an integral part of healthcare services both in terms of safe
treatment and quality of the environment. While there have been continuing
issues with healthcare associated Infections (HCAIs), recent statistics
demonstrate significant reductions in the rates of MRSA and Clostridium difficile
infections. It is important to maintain the focus on cleanliness in this context.
1.2
The thrust of this policy is: maintaining the momentum of the previous strategy;
good management practice, and developing staff. However, the policy also
reinforces work carried out by a Regional Hospital Hygiene and Cleanliness
Group which developed a new set of standards and a self assessment audit tool
for use by the HSC Trusts.
1.3
This document is primarily aimed at cleaning in hospitals, but the principles are
also relevant to the provision of cleaning services to patients and clients in other
health service facilities such as, mental health and community facilities. The
policy should be considered in any context where people using the health service
receive cleaning services.
Strategic Context
1.4
Providing a clean, safe environment for healthcare is a key priority for Trusts,
and is a core standard in “Standards for better health” (see Appendix 1 for link).
Other publications such as “Towards cleaner hospitals and lower rates of
infection” (see Appendix 1 for link) and “A Matron’s Charter: An action Plan for
Cleaner Hospitals” (see Appendix 1 for link) have further emphasised this, and
also recognise the role cleaning has in ensuring that the risk to patients from
healthcare associated infections is reduced to a minimum.
6
1.5
In the NHS, the Clean Hospitals Programme (in 2000) led to a series of initiatives
which aimed to improve the patient environment and standards of infection
prevention and control. Given increasing public awareness and concern about
healthcare associated infection (HCAI), cleanliness gained recognition as being
a key element in the provision of safe and high quality care, as opposed to a
support service.
1.6
In Northern Ireland, the requirement to market test support services was
abolished in 2001 and there was gradual movement back to in-house provision
of services. HSC bodies wished to promote the advantages of integrating
domestic services into care teams.
1.7
In response to GB initiatives, in October 2005 the DHSSPS issued “Cleanliness
Matters - A Regional Strategy for Improving the Standard of Environmental
Cleanliness in HSS Trusts 2005-08” (see Appendix 1 for link). The Strategy was
developed with a multi-disciplinary Environmental Cleanliness Consultative
Reference Group, which was largely drawn from Health & Social Services (HSS)
Trusts.
1.8
The Strategy was accompanied by the “Cleanliness Matters Toolkit -Practical
Guidance for Assessment of Standards of Environmental Cleanliness in HSS
Trusts” (The Toolkit), and an Environmental Cleanliness Controls Assurance
Standard (see Appendix 1 for link). These two documents reflected the main
themes of the Strategy: a rigorous programme of auditing to monitor standards of
cleanliness; and, corporate governance systems and procedures to ensure that
clear accountability and management arrangements flow down from Trusts’
Boards.
1.9
Hospital cleanliness continues to receive a high level of interest from the public;
the media and politicians alike. Improving and sustaining levels of
7
environmental cleanliness in hospitals is important if the Health & Social Care
sector is to retain public confidence, make a significant impact on reducing
HCAIs and improve the overall quality of care and patient experience.
1.10 The Regulation and Quality Improvement Authority (RQIA) undertook a
programme of unannounced hygiene inspections in hospitals, following the
launch on 23 January 2008 of a package of new initiatives aimed at tackling
HCAIs.
1.11 Significant reductions in MRSA and Clostridium difficile infections were
highlighted, and examples of real improvement were provided in the RQIA
reports. However, the RQIA reports also recorded areas of poor performance in
some Trusts.
1.12 In November 2009, further work was undertaken to drive up hygiene and
cleanliness standards in hospitals and other healthcare facilities. This was in
response to the publication of several reports of unannounced inspections by
RQIA which showed significant non-compliance and highlighted the need for
improvement.
1.13 The Regulation & Quality Improvement Authority (RQIA) conducted an
independent review which was commissioned by the Minister for Health, Social
Services and Public Safety, following the serious outbreak and tragic deaths of
babies from Pseudomonas. The final report was published on 31 May 2012 (see
Appendix 1 for link)
1.14 The Interim report of the RQIA Independent Review of incidents of
Pseudomonas aeruginosa infection in neonatal units in NI, was published on 31
March 2012. The report highlighted learning for all organisations involved and
made 15 recommendations for action to the Minister for Health, Social Services
and Public Safety. One of the recommendations related to cleaning of sinks and
8
taps. New standard guidance was developed for NI and issued on 31 May 2012
(see Appendix 1 for link).
1.15 During the second stage of this review, the governance arrangements and the
effectiveness of communications in relation to the pseudomonas incidents were
reviewed.
Aims
1.16 The aims of the policy are as follows:

To ensure high quality cleaning services are provided in a manner which
meets all current best practice, regulations and legislation.

To ensure that best use is made of available resources.

To ensure staff receive training in order to help them perform as effectively
as possible and to encourage personal development.

To modify the audit arrangements introduced by the Strategy and Toolkit in
2005.

To ensure that managers adopt the standards and tool developed by the
Regional Hospital Hygiene and Cleanliness Group.

To ensure that Trusts’ Boards continue to monitor the quality of provision of
cleaning.

Environmental cleanliness is a multi-disciplinary responsibility requiring
Professionals from all disciplines to work together to achieve the highest
standards of cleaning, hygiene, infection prevention / control and auditing.
The logistics of this are an optional matter for each Trust.
Scope
1.17 This policy applies to all staff. It applies particularly to all staff involved in the
provision of services which improve environmental cleanliness, hygiene, infection
9
prevention / control and auditing or with responsibility for providing a clean and
safe environment for patients and visitors.
Key Principles
1.18 This document sets out the Department’s policy for the future development and
delivery of cleaning services. The principles underpinning the development of
this policy include:
Quality
1.18.1 Trusts must continue to monitor cleanliness through implementation of
appropriate audit and reporting procedures. Audit procedures should be
reviewed and take account of local circumstances and the Regional
Healthcare Hygiene and Cleanliness Tool (see Appendix 1 for link).
Standards of environmental cleanliness should be maintained and
improved in accordance with the goals and objectives set out in “Quality
2020 – A 10-Year Strategy to protect and improve quality in health and
social care in Northern Ireland” (see Appendix 1 for link).
1.18.2 Trusts must deliver cleaning services to the standards set out in the
Regional Hospital Hygiene and Cleanliness Standards and supporting
standards (see Appendix 1 for link).
Training
1.18.3 It is recognised that all staff associated with cleaning services must be
competent and appropriately trained to a standard commensurate with
their role and duties. An example of appropriate training for supervisors
and basic grade cleaning staff is the Cleaning Professional Skills Suite
(CPSS) of the British Institute of Cleaning Sciences (BICSc).
Efficiency
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1.18.4 Compliance with agreed standards of cleanliness, hygiene and auditing is
an operational matter for each Trust. Trust Managers should implement
best professional management practice and review cleaning frequencies,
work schedules and budgets; this includes reviewing what is cleaned, how
it is cleaned, how often it is cleaned and assessing risk.
1.18.5 Trusts must carry out an annual self-assessment of the management of
cleaning services including a review of cleaning plans, resources and
audit scores.
Multi Disciplinary Working
1.18.6 Trust staff from different disciplines must work together to ensure the best
possible standards of environmental cleanliness and hygiene.
Governance and Accountability
1.18.7 Trusts should ensure that arrangements recommended in Cleanliness
Matters, the Regional Healthcare Hygiene and Cleanliness Standards and
the DHSSPS Environmental Cleanliness Controls Assurance Standard
are maintained. These arrangements include:
 Definitions of roles, responsibilities and accountability.
 Reporting to Trusts’ Management Boards on performance.
 Creation of a multi-disciplinary group within each Trust which is
charged with taking forward the local environmental cleanliness
strategy.
1.18.8 The leading role of Ward Managers / Ward Sisters / Charge Nurses
should be recognised, and authority over cleaning services at ward level
should be delegated to an appropriate person within each facility who
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should have the capacity to raise any cleanliness issues with the Cleaning
Manager, and responsibility for appropriate escalation / risk management.
Patient, Visitor and Staff Participation
1.18.9 Patients, visitors and staff must be involved in the planning, delivery and
audit of cleaning services and Trusts must engage with patients, visitors
and staff, and use regular surveys on the services provided.
Equality Screening
1.19 Section 75 of the NI Act 1998 requires all public bodies in carrying out their
functions relating to NI to have due regard to the need to promote equality of
opportunity between:

Persons of different religious belief, political opinion, racial group, age,
marital status or sexual orientation;

Men and women generally;

Persons with a disability and persons without; and

Persons with dependants and persons without.
1.20 In addition, without prejudice to the above, public bodies must also in carrying
out their functions relating to NI, have regard to the desirability to promote good
relations between persons of different religious beliefs, political opinion or racial
group.
1.21 DHSSPS has carried out an initial screening of this policy and determined that a
full Equality Impact Assessment is not required. A summary of the screening is
contained in Appendix 2. If you consider that this decision is not correct please
let us know why. Please provide details of any action(s) you need including any
supporting evidence that you may have.
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Section Two
Developments since the issue of the
Cleanliness Matters Strategy in October
2005
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Impact and Implementation of the Cleanliness Matters Strategy
2.0
Cleanliness Matters and the associated controls assurance standard imposed
significant new requirements; a rigorous audit regime and corporate governance
procedures. Despite initial concerns by Trusts about the workload implications,
the benefits were soon recognised. For example:

Accountability requirements brought cleanliness to the attention of Trusts’
Boards and highlighted risk and funding issues.

Audit processes clarified the respective responsibilities of nursing; estates
and domestic services; facilitated cross-disciplinary working, and made it
clear that cleanliness was not just a domestic services issue.

The scoring process brought about a sharper focus on performance and
associated issues, including estate condition.

Trusts have reported that including estates conditions in the scoring process
has been helpful in the speedier identification and rectification of estates
issues.
Other Departmental Initiatives
2.1
It is now accepted by Trusts that regular auditing is an essential element of
maintaining and improving standards of cleanliness. Similarly, the governance
aspects reflected in Cleanliness Matters and the Controls Assurance Standard
are now embedded in the culture of health and social care bodies.
2.2
After the launch of Cleanliness Matters, the Department commissioned an
independent assessment of environmental cleanliness which was carried out by
KPMG in early 2006. This produced mixed results. One of the difficulties was
that the basis of assessment was (and still) is, public perception of an element,
as opposed to how well it has been cleaned. Consequently, in older hospitals,
poor scores frequently reflected the age and condition of the estate as opposed
to poor cleaning performance. It was also recognised that the design of older
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buildings may make cleaning more difficult. A follow up audit by KPMG in late
2007 revealed a significant improvement, suggesting that Cleanliness Matters
was having a positive impact.
2.3
The Ward Sisters’ Charter which was launched in October 2006, encouraged
Ward Managers to take responsibility for ensuring that high standards of
cleanliness are maintained. This was consistent with the principle in Cleanliness
Matters, that cleanliness is everyone’s responsibility, not just the responsibility of
the cleaners.
2.4
After the restoration of devolved government in 2007, healthcare associated
infection (HCAI) became a major issue in healthcare and attracted continued
media and MLA attention. While cleaning performance was generally not subject
to criticism, the perceived association between HCAI and cleaning ensured that
cleanliness standards remained a key issue. The Department produced HCAI
action plans in 2006 and 2010 which acknowledged the role of environmental
cleanliness but did not introduce significant new requirements on domestic
services departments or change any of the principles or elements of Cleanliness
Matters.
2.5
In particular, there was intensive media coverage of the outbreak of the
Clostridium difficile (C diff) infection that occurred in Northern Health and Social
Care Trust (NHSCT) hospitals between June 2007 and August 2008. The RQIA
carried out an independent review of the outbreak, and in their final report, two
of the recommendations (Rec. 7 and 14) are of relevance to this policy:

Recommendation 7 -Consideration should be given to undertaking a
baseline review of cleaning arrangements against current standards and
methodologies.
15

Recommendation 14 -Trusts should review their ward environments to
ensure that there is no impediment to safe, cleaner, tidier patient areas.
The Public Inquiry, which was launched in 2009, was asked to establish how
many deaths occurred in the Northern Health and Social Care Trust hospitals
during the outbreak, for which C difficile was the underlying cause of death, or
was a condition contributing to death. It was also asked to report on the
experiences of patients and others who were affected directly by the outbreak.
2.6
The final report of the Public Inquiry into the Outbreak of Clostridium difficile in
Northern Trust Hospitals, published in March 2011 (see Appendix 1 for link),
made twelve main recommendations to help prevent and manage outbreaks.
Environmental cleanliness has a strong part to play in contributing to the
reduction of healthcare associated infections.
2.7
The outbreak of Pseudomonas in the Neonatal Unit at the Royal Jubilee
Maternity Hospital in early 2012 also brought hygiene and cleanliness into
sharper focus. Pseudomonas is a micro-organism that is found in many natural
environments, including soil and water. There are many different types and
strains of Pseudomonas and specialist tests are required to distinguish these.
Pseudomonas can be found in sinks, taps and water systems and is difficult to
eradicate completely and permanently.
2.8
The Interim report of the Independent Review of incidents of Pseudomonas
aeruginosa infection in neonatal units in Northern Ireland was published in March
2012. One recommendation related to cleaning of sinks and taps, and new
standard guidance was developed for NI. Further guidance in response to
recommendations from the Troop Review, was issued on 31 May 2012 following
the publication of the final report.
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2.9
Guidance was developed to produce a new set of standards and audit tool for
use in augmented care settings. This was piloted in Trusts in the late summer of
2012.
Recent Developments
2.10 A Neonatal Infection Prevention and Control Audit Tool (from the Regional
Infection Prevention and Control Audit Tools for Augmented Care Settings in
Northern Ireland) has been launched (See Appendix 1 for link). This tool is
applicable to all Neonatal Intensive care and special care baby units, and is
based on existing documents from the DHSSPS; DH England; the British
Association of Perinatal Medicine and a range of recognised research sources.
The tool contains seven sections, each of which aims to consolidate existing
guidance in order to improve and maintain a high standard in the quality and
delivery of care and practice in neonatal care, to assist in the prevention and
control of healthcare associated infections.
2.11 The introduction of unannounced hygiene and cleanliness inspections by RQIA
was part of a package of measures to combat HCAI, which was announced in
January 2008. In November 2009, publication of the third tranche of these
reports generated intense media coverage and an Assembly debate. This led to
the formation of the Regional Healthcare Hygiene and Cleanliness Reference
Group, comprising representation from a wide range of stakeholders, which was
charged with developing new hygiene and cleanliness standards and an
accompanying audit tool. This audit tool has been implemented regionally, and
has had a significant impact on the audit strand of the strategy. It is also being
used for routine cleanliness audits.
2.12 In 2008, the Department commissioned specialist support services consultants FM Specific -, to review cleaning services in a sample of acute hospitals. The
two main objectives were:
17

To compare the resources currently employed in acute hospitals, with the
estimated resources needed to meet the input standards (cleaning
frequencies) recommended for the NHS.

To assess the scope for improved efficiency, effectiveness and economy
within the current service delivery models.
2.13 The report concluded that:
 Additional resources would be needed to bring them up to the NHS
recommended frequencies.
 There was a need to carry out a fundamental re-calculation of cleaning hours
and budgets, and to develop cleaning plans in order to put service delivery
models on a sound base.
Since then, the NHS has shifted the emphasis away from recommended
frequencies, and moved towards cleaning frequencies based on local risk
assessment. Trusts should review their risk weighting; cleaning frequencies;
cleaning budgets and allocation of funding across the functional areas.
Attention to cleanliness is part of the holistic approach to maintaining quality of
safety and care. In light of ongoing competing budgetary priorities, the
Department continues to deliver significant investment in infrastructure and
Maintaining Existing Services (MES) through the management of its capital
programme.
NHS Initiatives
2.14 In June 2011, the British Standards Institution sponsored by the Department of
Health and the National Patient Safety Agency issued a Publicly Available
Specification “PAS 5748: 2011 – Specification for the planning, application and
measurement of cleanliness in hospitals” (see Appendix 1 for link). The Steering
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Group which contributed to the development of the specification included the
Association of Healthcare Cleaning Professionals, the British Institute of
Cleaning Science and the Infection Prevention Society.
2.15 The specification set out requirements for the provision of cleanliness. These
requirements include: responsibilities and accountabilities; risk assessment;
management of cleaning tasks; auditing and reporting. To a large extent, it
brought together existing good practice. The PAS builds on the experience and
content of “The national specifications for cleanliness in the NHS (HSC),” the
most recent version of which was published in April 2007.
2.16 The PAS is expected to be used in conjunction with The Revised Healthcare
Cleaning Manual (see Appendix 1 for link), published by the National Patient
Safety Agency in May 2009. It is also consistent with BS EN 13549:2001 (see
Appendix 1 for link), Cleaning Services – Basic requirements and
recommendations for quality measuring systems.
REGIONAL HEALTHCARE HYGIENE AND CLEANLINESS STANDARDS AND
TOOL
2.17 Work was carried out between 2009 and 2011 to develop:

Hygiene and cleanliness standards for hospitals which are clear and
evidence based.

A regional tool for use by the HSC and the RQIA to provide a consistent
measure. The purpose of the regional tool is to help to improve the
monitoring of the quality of the service provided against those standards.
19
Background
2.18 The RQIA undertook a programme of unannounced hygiene inspections in
hospitals following the launch on 23 January 2008 of a package of new initiatives
aimed at tackling Healthcare Associated Infections.
2.19 In November 2009, further work was undertaken to drive up hygiene and
cleanliness standards in hospitals and other healthcare facilities. This was in
response to the publication of several reports of unannounced inspections by
RQIA, which showed a great deal of non-compliance. These had been
publicised in the media in a very adverse manner, with many headlines such as
‘dirty hospitals’, which had the potential to damage public confidence.
2.20 The progress made until then by Trusts, was acknowledged in relation to
hygiene and cleanliness. Significant reductions in MRSA and Clostridium difficile
infections were highlighted and examples of real improvement were provided in
the RQIA reports. However, the RQIA reports also recorded areas of poor
performance in some Trusts, which undermined both public confidence in the
cleanliness of healthcare facilities and the morale of front-line staff working in
those facilities.
Development Work on New Standards and Tool
2.21 In 2010, a multi-disciplinary Regional Hospital Hygiene and Cleanliness Group,
led by the Director of Nursing, and comprising representatives of the HSC Board;
the Trusts and the Department, was set up to develop the new standards and
regional tool. The standards were to be clear, unambiguous and consistent
across the HSC. A regional tool was developed to replace the range of diverse
tools which had been used across the HSC and the RQIA, sometimes resulting
in different assessments for the same building.
20
2.22 In developing the revised standards and regional tool, the Group examined a
number of - hygiene and cleanliness documents which have evolved over a
number of years, and have been produced by a range of different individuals and
organisations. One key aim was to reduce the incidence of healthcare
associated infections through improved hygiene and cleanliness (in addition to
other measures in place to reduce HCAIs).
2.23 The revised standards were intended to assess the general cleanliness and state
of repair of healthcare facilities, as would be observed by patients, visitors and
members of the public. The standards provided a common set of overarching
hygiene and cleanliness standards for all hospitals and other healthcare facilities
in Northern Ireland.
2.24 All Trusts were asked to assure themselves, at Trust board level, that they were
compliant with the revised standards, and RQIA hygiene inspections would be
carried out on the basis of these standards.
2.25 An audit tool explicitly linked to these standards for healthcare hygiene and
cleanliness was developed for use by Trusts (for self-assessment) and by RQIA
(for inspection). This work was taken forward by RQIA in conjunction with Trusts
and DHSSPS. The audit tool was successfully piloted by RQIA in conjunction
with the Trusts prior to its adoption throughout HSC and the commencement of
any future RQIA hygiene inspection programme.
2.26 The Regional Healthcare Hygiene and Cleanliness Standards and Audit Tool
was approved by the Health Minister on 7 July 2011, and is now being used
during hygiene and cleanliness inspections by RQIA. The standards incorporate
the critical areas which were identified through a review of existing standards,
guidance and audit tools. They are used to assess healthcare hygiene; general
cleanliness and state of repair of healthcare facilities, and aspects of infection
21
prevention and control - not only from a professional perspective, but also as
would be observed, by patients, visitors and members of the public.
2.27 A great deal of work has already been carried out by Trusts to improve
compliance scores in RQIA inspections, and it is important that this improvement
is sustained in the future. Trusts already have audit processes in place for
environmental cleanliness based on the Cleanliness Matters Strategy. The
Regional Tool should be used to complement those procedures.
2.28 In using the common set of overarching hygiene and cleanliness standards, all
organisations should assure themselves at Board level, that they are compliant
with the standards. In seeking that assurance, the RQIA inspection reports are a
matter not only of great public interest, but can also highlight issues which could
indicate serious risks to public health. The RQIA reports will continue to be
subject to a high level of scrutiny.
22
Section Three
The Way Forward
23
The Way Forward
Introduction
3.0
The way forward has been considered under the following headings, which are
dealt with in turn:

Financial and General Management

Audit Approach

Training

Design and Other Issues

Multi Disciplinary Working

Colour Coding Hospital Cleaning Material and Equipment

Sharing Best Practice

Association of Healthcare Cleaning Professionals
Finance and General Management
3.1
It is essential that Trusts make best use of resources by adopting good
management practice for cleaning services.
3.2
The guideline NHS cleaning frequencies were the basis of an assessment of the
adequacy of cleaning resources in acute hospitals in the HSC commissioned by
DHSSPS in 2008 from FM Specific. In the NHS Specification these frequencies,
which were a minimum for each element to be cleaned and varied according to
the risk category of the area, are no longer regarded as the blueprint for the input
required. NHS policy now states that cleaning frequencies for each element to
be cleaned and each functional area should be determined locally based on risk.
3.3
A Publicly Available Specification (PAS 5748) (see Appendix 1 for link) was
issued in 2011 by the British Standards Institution and sponsored by the
Department of Health. PAS 5748 places a greater emphasis on a detailed risk
24
assessment methodology, which gives an equal weighting to the risks from both
healthcare associated infection and public confidence - for example, public
entrances might be very high risk from a public perception standpoint. It places
less emphasis on cleaning frequencies which were a strong feature of
Cleanliness Matters in 2005. The principles of risk management should be
applied by Trusts when reviewing how often elements and locations are cleaned.
3.4
FM Specific recommended development of cleaning plans based on a
fundamental review of the cleaning hours required. This should result in a
revised budget and allocation of resources. Given that budgets may not have
been fundamentally reviewed since compulsory competitive tendering, it is
important that there is a budget build-up process which reflects the way
healthcare is provided in the 21st century. This process will help to ensure that
resources are allocated in accordance with local risks and priorities.
3.5
PAS 5748 specifies requirements for:
 Governance of cleanliness services

Assessing the risk of a poor standard of cleanliness, both for infection and
damage to patient; public or staff confidence
 Providing cleaning tasks
 Measuring cleanliness on the basis of visual inspection – including setting
agreed performance levels
 Taking corrective action
 Conducting performance analysis and implementing improvement actions
 Providing a continuous service improvement plan
 Reporting cleanliness outcomes.
3.6
The specification also set out the basic management process for a fundamental
review- from identification of items to be cleaned through to cleaning
responsibilities, risk assessment, cleaning frequencies, method statements, and
25
work schedules. The FM Specific Cleaning Plan methodology includes much of
the above and trusts should go through the process of fundamentally reviewing
the service provided.
3.7
PAS 5748 should be regarded as good management practice for the HSC.
Managers should review their service in the context of the principles in this
document. The NHS Manual for Cleaning, which is to be revised by the
Association of Healthcare Cleaning Professionals, contains operational detail of
which managers should be aware. This policy will highlight areas to which
managers need to pay attention.
3.8
In 2007 the National Patient Safety Agency issued guidance on standards of
cleaning in hospitals. This guidance sets out the specifications for cleanliness in
the NHS. These have been designed to provide a simple, easy-to-apply
methodology within which hospitals in England can assess the effectiveness of
their cleaning services. The specifications apply chiefly to ‘traditional’ hospitals –
whether in the acute, mental health or primary care trust communities – but their
principles apply equally to other settings.
3.9
They describe a comparative framework within which hospitals and trusts in
England can set out details for providing cleaning services and assessing
‘technical’ cleanliness.
3.10 They give clear advice and guidance on:
 what is required;
 how trusts can demonstrate the way(s) in which cleaning services will meet
these requirements; and
 how to assess performance.
26
3.11 HSC Trusts should make use of both PAS 5748 2011 and NPSA 2007 and
develop a strategic cleaning plan which should enable identification of gaps
between best practice and current capacity, match available resources to a risk
based assessment and, demonstrate that sufficient resources have been
allocated to meet local need.
3.12 The Cleaning Reviews also revealed some potential for revenue savings from
investment in equipment. Examples included the use of ‘ride on’ mechanical
cleaners to clean corridors etc. Trusts should consider where modest
investment could produce revenue savings.
Audit Approach
3.13 The audit requirements were the most significant change introduced by
Cleanliness Matters. While Trusts now agree that a regular programme of self
assessed audit is essential to maintain standards, the mechanisms require finetuning.
3.14 In line with latest NHS policy, flexibility is permitted to take account of local
circumstances. Local circumstances and assessed risk may include giving more
attention to areas which are performing badly, or less attention to those which
are performing well. Strong local management and control procedures may
justify a reduction in audit frequencies. However, the following should be
regarded as good practice and policy reflecting audit frequencies.
Elements to be Assessed
3.15 The Regional Hygiene and Reference Group drafted a new set of cleanliness
and hygiene standards and an accompanying audit tool (the Regional Audit
Tool). The elements in the Regional Audit Tool are broadly similar but not
identical, to the 49 elements set out in Cleanliness Matters. The Cleanliness
Matters Toolkit is used to assess 49 defined elements to be cleaned and Trusts
27
take a view internally, as to which discipline is responsible for the element. In
contrast, the Regional Hospital Hygiene & Cleanliness Tool is used to assess a
number of hygiene issues as well as cleaning. Therefore, in taking forward audits
Trusts should:
o recognise that it is unlikely that all functional areas can be reviewed
annually. Trusts should aim to cover all very high risk and high risk areas.
o develop policies/procedures for managerial audits which include frequency
of reviews, sample sizes and team composition.
o have a policy/procedure for what the NHS Specification describes as Board
Assurance Visits. These were introduced locally in December 2009, when
Trust Chief Executives and / or senior officials were asked to walk the
wards at least every month to observe hygiene and cleanliness levels. This
is a less formal process than managerial audits.
Basis of Departmental Audit Assessment
3.16 Environmental cleanliness is a multi-disciplinary responsibility requiring
Professionals from all disciplines to work together to achieve the highest
standards of cleaning; hygiene; infection prevention / control and auditing.
3.17 The Regional Audit Tool is not focussed exclusively on the regular departmental
audits which were introduced by Cleanliness Matters and are still regarded as
best practice in the NHS. However, the cleanliness aspects of the Regional
Audit Tool will be complemented by the current departmental/technical audits
which are based on the Cleanliness Matters Toolkit 2005. Therefore, in broad
terms the departmental audit approach introduced by Cleanliness Matters is
retained with Departmental Audits as set out in Cleanliness Matters remaining
the basis of assurance for Controls Assurance purposes.
28
3.18 Responsibility for ensuring that the Departmental audit is undertaken rests with
the head of department being audited (e.g. ward manager /officer in charge) who
should preferably lead the audit or delegate the responsibility to a senior member
of staff .By leading the audit, the Head of department has key ownership in
ensuring that the necessary level of Environmental Cleanliness Standards are
achieved and maintained.
3.19 To highlight that otherwise good cleaning performance, may be thwarted by poor
estates condition, the basis of assessment should be capable of excluding
problems which reflect estate condition. However, whilst this disaggregation may
be useful to allow cleaning performance to be benchmarked across different
areas, the scores should not be disaggregated for the purposes of control
assurance and Estates scores should be retained to aid performance
management of that function.
3.20 Trusts have reported that including estate items has been helpful in the speedier
identification and rectification of estates issues. Therefore, the basis of
assessment should be able to mirror the NHS approach which is that “an
element shall be identified as clean if all parts of the element have the visual
appearance of being free of dirt and stains.” Dirt and stains are defined in some
detail.
3.21 As a consequence of removing estate condition issues, the acceptable level of
cleanliness in Departmental Audits which was set at 85% in Cleanliness Matters
is increased to 90% though Trusts may of course set higher internal standards.
Managerial audits
3.22 The purpose of managerial audits is to:

Validate the results of departmental audits.

Take a more multi-disciplinary perspective of the patient environment.
29
3.23 Unlike the NHS Specification, Cleanliness Matters offered detailed guidance on
managerial audits.
While much of this guidance was sound, some
improvements were necessary:

The Cleanliness Matters Audit Tool (2005-2008) as updated and developed
by Trusts should continue to be used as the basis for departmental audits.
The more comprehensive Regional Healthcare Hygiene Audit Tool should be
used as a Managerial Audit Tool or, more frequently, as the departmental
audit tool if serious risks have been identified. This is consistent with the
existing managerial audit guidance which requires a multi-disciplinary audit
team.
Corrective Action
3.24 Corrective action is what should be done when shortfalls are revealed during
audits. Under existing guidance, there is a danger that departmental audits will
reveal problems but no remedial action will follow.
3.25 Corrective action may include:

Assigning responsibility for remedying each defect and ensuring that action
is taken within appropriate timescales.

Re-auditing the area or the element(s).

If there is no improvement, examining the reasons.

Reviewing work schedules.

Reporting problems to higher levels of management (escalation).

Increasing cleaning frequencies.

Training.
30
3.26 Trusts should draw up policies for the corrective actions to be taken following
shortfalls revealed during audits. These may vary according to risk category of
the area and element being audited.
Training
3.27 The Workforce Learning Strategy (see Appendix 1 for link) for Northern Ireland
Health and Social Care Services 2009-2014 aims to:

Equip staff with the skills and knowledge to work effectively.

Support staff in developing and realising their potential.

Promote a culture of lifetime learning.
3.28 It has been shown that investment in training may not only enable staff to carry
out their normal duties more effectively but also produce substantial benefits in
terms of self esteem and motivation.
3.29 Cleanliness Matters referred to the need for human resources strategies for both
cleaning staff and managers. All Trusts have now agreed that basic grade staff
and supervisors should have the opportunity to obtain a minimum level of
qualifications. The industry recognised standard qualification is the Cleaning
Professionals Skills Suite (CPSS), which is accredited by the British Institute of
Cleaning Science (BICS) (see Appendix 1 for link). This requires approximately
sixteen hours of training by in-house accredited staff. All Trusts now have a
BICSc accredited training centre.
3.30 Although BICS CPSS (see Appendix 1 for link) is a cost effective method of
providing training, given the numbers of staff to be trained, Trusts will have to
plan carefully to achieve this objective. While the financial outlay is modest,
cover for staff undergoing training may present a challenge.
31
3.31 Staff should have appropriate training in: basic cleaning techniques; customer
service; health and safety; control of substances hazardous to health (COSHH);
manual handling and infection prevention and control.
3.32 With regard to training of managers, many of the skills needed relate to general
management and can be taught in-house, with specialist cleaning skills and
cleaning science procured externally as necessary.
Design and Other Issues
3.33 Buildings designers, facilities planners and domestic services managers should
co-operate to ensure that new buildings take account of “cleanability.” This
includes considering accessibility of items to be cleaned; designing buildings to
minimise cleaning required and selection of materials which will be easy to clean.
Multi Disciplinary Working
3.34 In January 2010, DHSSPS issued “Changing the Culture 2010: Strategic action
plan for the prevention and control of healthcare-associated infections in
Northern Ireland” (see Appendix 1 for link). Whilst the focus of the document
was on HCAIs, it recognised that infection control and prevention was an integral
part of everyone’s responsibility. Environmental cleanliness has an important
role to play in inflection prevention and control and it is also everyone’s
responsibility. Therefore it is important that a multi disciplinary approach is
applied to the management of cleaning.
Colour Coding Hospital Cleaning Material and Equipment
3.35 Many sites in the HSC already have a colour coding scheme in place but there is
a lack of consistency with colours having different meanings on different sites.
Where it is not already in place, Trusts should standardise a common colour
coding scheme to reduce the risk of possible cross contamination.
32
3.36 The National Reporting and Learning Service (NRLS) developed a National
Colour Coding Scheme for cleaning materials, set out in this document. It was
designed to standardise, and streamline, existing schemes. Adopting the code
improves the safety of hospital cleaning, ensure consistency and provide clarity
for staff. A Safer Practice Notice is available and outlines the scheme (see
Appendix 1 for link).
Sharing Best Practice
3.37 There are many examples of best practice across the HSC and pilot exercises
are also in place to help develop new ways of working.
3.38 The Regional Support Services Steering Group is a forum through which patient
environment issues can be raised and best practice can be shared. It comprises
representatives from five HSC Trusts and DHSSPS representatives from Health
Estates Investment Group. It meets four times a year. However, the sharing of
best practice should be carried out continuously throughout the year via other
methods of communication and appropriate Trust meetings.
Association of Healthcare Cleaning Professionals
3.39 The establishment of a local branch of the Association of Healthcare Cleaning
Professionals (AHCP) in NI represents a very positive step. It helps to provide a
regional forum for the exchange, sharing and promotion of best practice. It also
allows members to set local issues in regional and national contexts. It is
important that Trust managers continue to support and encourage staff to attend
the regular meetings and sharing of good practice.
33
SECTION FOUR
APPENDICES
34
Appendix 1
Standards for Better Health,
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh
_4132991.pdf
Towards cleaner hospitals and lower rates of infection
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh
_4085861.pdf
A Matron’s Charter: An Action Plan for Cleaner Hospitals
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4
091506
Cleanliness Matters – A Regional Strategy for Improving the Standard
http://www.dhsspsni.gov.uk/cleanliness-matters-strategy-2005.pdf
Cleanliness Matters Toolkit – Practical Guidance for Assessment of Standards of
Environmental Cleanliness in HSS Trusts
http://www.dhsspsni.gov.uk/index/hss/governance/governance-controls.htm
Independent review of incidents of pseudomonas aeruginosa infections in neonatal units in
Northern Ireland – RQIA Final Report
http://www.rqia.org.uk/cms_resources/Pseudomonas%20Review%20Phase%20II%20Final%20Repo
rt.pdf
Guidance on cleaning sinks/basins and taps in clinical settings – including augmented care
settings/neonatal units
www.dhsspsni.gov.uk/sub-611-2012-policy-cleaning-services.doc
Regional Healthcare Hygiene and Cleanliness Tool - RQIA
http://www.rqia.org.uk/cms_resources/RHHC%20Audit%20Tool%20072011.pdf
Quality 2020 – A 10-Year Strategy to protect and improve quality in health and social care in
Northern Ireland
http://www.dhsspsni.gov.uk/quality2020.pdf
Regional Healthcare Hygiene and Cleanliness Standards - RQIA
http://www.rqia.org.uk/cms_resources/SUB%201137%202011%20%20Regional%20Healthcare%20
Hygiene%20and%20Cleanliness%20Standards%20-%20Jun%202011.pdf
The Public Inquiry into the Outbreak of Clostridium Difficile in the Northern Trust Hospitals
Northern Ireland
http://www.cdiffinquiry.org/inquiry-report.htm
A Neonatal Infection Prevention and Control Audit Tool
http://www.rqia.org.uk/cms_resources/Reg%20IPC%20Audit%20Tool_Sec%203_Neonatal_%20DHS
SPS.pdf
35
The Revised Healthcare Cleaning Manual
http://nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=61814&type=full&servicetype=Attach
ment
BS EN 13549:2001
http://shop.bsigroup.com/ProductDetail/?pid=000000000030012952
PAS 5748:2011 - Specification for the planning, application and measurement of cleanliness
services in hospitals
http://shop.bsigroup.com/en/ProductDetail/?pid=000000000030208877
Workforce Learning Strategy
http://www.dhsspsni.gov.uk/workforce-learning-strategy-apr-2009.pdf
British Institute of Cleaning Science,
http://www.bics.org.uk/
Cleaning Professionals Skill Suite
http://www.bics.org.uk/files/download/Cleaning-Professional-Skills-Suite-13.pdf
Changing the Culture 2010: Strategic action plan for the prevention and control of healthcare
associated infections in Northern Ireland
http://www.dhsspsni.gov.uk/changing_the_culture.pdf
National Colour Coding Scheme – Safer Practice Notice
http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=60086&
36
Appendix 2
SCREENING TEMPLATE
See Guidance Notes for further information on the ‘why’ ‘what’ ‘when’ and ‘who’ in relation to
screening. For background information on the relevant legislation and for help in answering the
questions on this template (follow the links). For further help contact Evaluation, Equality and Human
Rights Branch at ext. 20539
(1)
INFORMATION ABOUT THE POLICY/DECISION
1.1
Title of policy/decision
Policy for the Provision & Management of HSC Cleaning Services 2012-2016
1.2



Description of policy/decision
what is it trying to achieve? (aims/objectives)
how will this be achieved? (key elements)
what are the key constraints? (e.g. financial, legislative)
The aims of the strategy are as follows:

The provision of high quality cleaning services is important and it is vital that standards are met
and maintained. Cleaning services must be provided in a manner which meets all current best
practice, regulations and legislation.
To ensure that best use is made of available resources.
To ensure staff receive training in order to help them perform as effectively as possible and
encourage personal development.
To modify the audit arrangements introduced by Strategy and Toolkit in 2005.
To encourage managers to adopt best practice developed for the NHS contained in the
Specification for Cleanliness in Hospitals and the NHS Cleaning Manual.
To ensure that Trusts’ Boards continue to monitor the quality of provision of cleaning.





The aims will be achieved by ensuring that cleaning services are delivered in accordance with the
Regional Hospital Hygiene and Cleanliness Standards. This will be supported by a hierarchy of audits
using the Regional Hospital Hygiene and Cleanliness Audit Tool. This will also be supported by a
programme of announced and unannounced inspections by the Regional Quality & Improvement
Agency.
Key constraints are primarily financial as there are increasing pressures on a limited cleaning budget
as the demand for discharge cleans etc increases.
1.3
Main stakeholders affected
(E.g. staff, actual or potential service users, other public sector organisations, voluntary and
community groups, trade unions/professional organisations or private sector organisations)
The main stakeholders are patients, visitors and HSC staff.
1.4


Other policies/decisions with a bearing on this policy/decision
what are they?
who owns them?
Infection control procedures will need to work together with and in support of this strategy.
Infection control staff within each site should work
37closely with colleagues in cleaning services
to improve hygiene and cleanliness.
2)
SCREENING THE POLICY/DECISION
2.1
In terms of groupings under Section 75, what is the make up of those affected by the
policy/decision?
Group
Please provide details
Gender
Both genders are affected. It is widely accepted and Workforce
Monitoring would confirm that the majority of HSC staff in each of the
Trusts is female. It is also acknowledged that the majority of cleaning
staff is female. It is further accepted that women live longer than men
therefore this could impact on more women using HSC facilities.
However, the policy aims to improve cleaning services for all patients,
visitors and staff members regardless of gender.
All ages are affected. It is widely accepted that hospital admission
tends to increase with age. However, the policy aims to improve
environmental cleanliness for everyone who attends hospital.
All religions are affected. It is accepted that there is significant
differences in the religious backgrounds of patients, visitors and staff
in different Trusts throughout the region. However, the policy aims to
improve environmental cleanliness for everyone
People of all political opinions are affected. It is accepted that there is
likely to be significant differences in the political opinions of patients,
visitors and staff in different Trusts throughout the region. However,
the policy aims to improve environmental cleanliness for all patients,
visitors and staff regardless of political opinion.
There is no data available which suggests any obvious positive or
negative impact in terms of marital status, the policy aims to improve
environmental cleanliness for all patients, staff and visitors regardless
of marital status.
It is accepted that the majority of HSC staff in each of the Trusts is
female, it is further accepted that most carers are female. However,
the policy aims to improve environmental cleanliness for all patients,
visitors and staff members regardless of whether or not they have
dependents.
It is widely accepted that hospital admission tends to increase with
disability. However, the policy aims to improve environmental
cleanliness for all patients, visitors and staff members regardless of
whether or not they have any disability.
All ethnic backgrounds are affected. It is accepted that there is
significant differences in the ethnic backgrounds of patients, visitors
and staff in different Trusts throughout the region. However, the policy
aims to improve environmental cleanliness for all patients, visitors and
staff members regardless of ethnicity.
There is no data available which suggests any obvious positive or
negative difference between persons of different sexual orientation,
the policy aims to improve environmental cleanliness for all patients
and visitors regardless of sexual orientation.
Age
Religion
Political Opinion
Marital Status
Dependent Status
Disability
Ethnicity
Sexual Orientation
38
2.2
Is there any indication or evidence of higher or lower participation or uptake by
different groups?
Group
Yes/No/
Please provide details
Don’t
Know
Gender
No
Age
No
Religion
No
Political
No
Opinion
Marital
No
Status
Dependent
No
Status
Disability
No
Ethnicity
No
Sexual
No
Orientation
2.3
Is there any indication or evidence that different groups have different needs,
experiences, issues and priorities in relation to the policy/decision?
Group
Yes/No/
Please provide details
Don’t
Know
Gender
No
Age
No
Religion
No
Political
No
Opinion
Marital
No
Status
39
No
Dependent
Status
Disability
No
Ethnicity
No
Sexual
No
Orientation
2.4
Is it likely that the policy/decision will meet those needs?
Group
Yes/No/
Please briefly give details
Don’t
Know
Religion
N/A
Ethnicity
N/A
2.5
Is there an opportunity to better promote equality of opportunity or good relations by altering
the policy/decision or working with others in government or in the larger community?
Group
Suggestions
N/A
2.6
What changes to the policy/decision – if any – or what additional measures would you suggest
to ensure that it promotes good relations?
Group
Religion
Suggestions
N/A
Political Opinion
N/A
Ethnicity
N/A
40
2.7
Have previous consultations with relevant groups, organisations or individuals indicated that
particular policies create problems that are specific to them? Also, please detail information used to
answer any of the questions above (e.g. statistics; research reports; views of colleagues, service
users, or other stakeholders).
N/A
2.8
Please detail what data you will collect in the future in order to monitor the effect of the
policy/decision on any of the groups under Section 75?
The Department will review the policy in light of any data which provides
evidence of any adverse effect on any of the groups under Section 75.
41
(3)
SHOULD THE POLICY/DECISION BE SUBJECT TO EQUALITY IMPACT ASSESSMENT?
Equality impact assessment procedures are confined to those policies/decisions considered likely to
have significant/major implications for equality of opportunity.
If your screening has indicated that a policy/decision is likely to have an adverse
differential impact, how would you categorise it?
Please tick.
Significant/major impact
Low impact
X
Do you consider that this policy/decision needs to be subjected to a full equality
impact assessment?
Yes
No
X
Please give reasons for your decision.
There is no evidence that the guidance policy is likely to have a significant
impact on any categories within the nine groupings.
The purpose of the policy is to improve environmental cleanliness for all
HSC patients, visitors and staff, regardless of their circumstances and
background. The Department would expect HSC Trusts to consult locally
and equality screen each local decision.
42
(4)
DISABILITY DISCRIMINATION
4.1
Does the policy/decision in any way discourage disabled people from participating in public life
or does it fail to promote positive attitudes towards disabled people?
NO
4.2
Is there an opportunity to better promote positive attitudes towards disabled people or
encourage their participation in public life by making changes to the policy/decision or introducing
additional measures?
No changes required.
4.3
Please detail what data you will collect in the future in order to monitor the effect of the
policy/decision with reference to the disability duties?
None
43
(5) CONSIDERATION OF HUMAN RIGHTS
5.1
Does the policy/decision affect anyone’s Human Rights? [PLEASE COMPLETE THE TABLE
BELOW]
POSITIVE
IMPACT
ARTICLE
NEGATIVE NEUTRAL
IMPACT =
IMPACT
human right
interfered
with or
restricted
Article 2 – Right to life
Article 3 – Right to freedom from torture,
inhuman or degrading treatment or punishment
Article 4 – Right to freedom from slavery,
servitude & forced or compulsory labour
Article 5 – Right to liberty & security of person
X
X
Article 6 – Right to a fair & public trial within a
reasonable time
Article 7 – Right to freedom from retrospective
criminal law & no punishment without law.
Article 8 – Right to respect for private & family
life, home and correspondence.
Article 9 – Right to freedom of thought,
conscience & religion
Article 10 – Right to freedom of expression
X
Article 11 – Right to freedom of assembly &
association
X
Article 12 – Right to marry & found a family
Article 14 – Prohibition of discrimination in the
enjoyment of the convention rights
1st protocol Article 1 – Right to a peaceful
enjoyment of possessions & protection of
property
1st protocol Article 2 – Right of access to
education
X
X
X
X
X
X
X
X
X
X
If the effect you have identified is positive or neutral please move on to Question 5.3.
5.2
If you have identified a likely negative impact who is affected and how?
At this stage we would recommend that you consult with your line manager to determine whether to
seek legal advice and to refer to Human Rights Guidance to consider:
 whether there is a law which allows you to interfere with or restrict rights
 whether this interference or restriction is necessary and proportionate
44

What action would be required to reduce the level of interference or restriction in order to comply
with the Human Rights Act (1998)?
N/A
45
5.3
Outline any actions which could be taken to promote or raise awareness of human rights or to
ensure compliance with the legislation in relation to the policy/decision.
None
Policy/Decision Screened by: Conrad Kirkwood
Date: 21 February 2012
Please note that having completed the screening; you will need to ensure that:
the screening decision is shared with key stakeholders and other interested parties (e.g.
Trusts); and
that consultation takes place on the outcome of screening in line with Equality Commission
guidance.
Contact the Evaluation, Equality and Human Rights Branch at ext. 20539 for advice regarding the
above actions.
46
Appendix 3
GLOSSARY
BHSCT
Belfast Health & Social Care Trust
BICSc
British Institute of Cleaning Sciences
BSI
British Standards Institute
Cleaning Operatives Proficiency Certificate
DHSSPS
Department of Health, Social Services and Public Safety
EQIA
Equality Impact Assessment
GB
Great Britain
HCAI
Healthcare Associated Infection
HSC
Health and Social Care
HSCB
Health and Social Care Board
HSS
Health and Social Services
HSCT
Health and Social Care Trust
IPC
Infection Prevention & Control
NHSCT
Northern Health & Social Care Trust
NI
Northern Ireland
NPSA
National Patient Safety Agency
PHA
Public Health Agency
RQIA
Regulation and Quality Improvement Authority
SEHSCT
South Eastern Health & Social Care Trust
SHSCT
Southern Health & Social Care Trust
UK
United Kingdom
UN
United Nations
WHSCT
Western Health & Social Care Trust
47