Linen and Laundry Management

Guidelines for the
Management of Linen
and Laundry

EAST CHESHIRE NHS TRUST

Guidelines for the Management of Linen & Laundry

Policy Title:

Executive
Summary:

The aim of this policy is to ensure effective linen and laundry
management to prevent cross infections between patients and
also to protect the staff that transport and handle used laundry.
Supersedes: V1.0
Description of
Amendment(s):
Minor wording to section 9.0 Special Articles
This policy will impact on:

Clinical practices, administrative practices, employees, visitors and patients

Financial Implications:

n/a

Policy Area: Trust Wide Document
Reference:

Version Number: 2.0 Effective Date: October 2010
Issued By: Director of Finance Review Date: October 2013
Author: Contracts Services
Facilitator
Impact
Assessment Date:
Ongoing

APPROVAL RECORD

Committees / Group Date
Consultation: Infection Prevention & Control December 2010

Approved by Director: Director of Finance December 2010
Received for information: Interim Associate Director of
Facilities
December 2010

East Cheshire NHS Trust
December 2010 V2
1



CONTENTS

Page

3 1.0 Introduction

3 2.0 Aim of this Policy

3 3.0 Scope

3 4.0 Organisational Responsibilities

4 5.0 Segregation of Laundry

4 6.0 Storage of Clean Linen

4 7.0 Used Linen within the Hospital Environment

5 8.0 Infected Linen within the Hospital Environment

5 9.0 Special Articles

5 10.0 Training

6 11.0 Performance Management

Appendix 1 References

Appendix 2 Procedure for the Storage of Linen Out of Hours

Appendix 3 Sunlight Colour Coding Bagging Policy

Appendix 4 Instruction Sheet Special Items

Appendix 5 Equality & Human Rights Screening Tool

December 2010 V2
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1.0 INTRODUCTION

It has been shown that used linen, within healthcare settings, in particular,
can harbour large numbers of potentially pathogenic microorganisms.
Therefore, it is important that the appropriate precautions are taken to ensure
contamination to/from linen does not occur as this might then lead to
transmission of microorganisms to people or to the environment potentially
causing infection. Such important precautions apply to all stages of linen
management: storage, handling, bagging, transporting, and laundering.

The provision and management of laundry and linen services is an important
function to enable sustainable delivery of patient care. By complying with this
policy staff will facilitate the continued delivery of these services, minimising
risks to health & safety, complying with infection control requirements and
ensuring best value for the Trust.

2.0 AIM OF THE POLICY

The aim of the policy is to outline how linen and laundry should be handled
and transported around the Trust and ensures Health & Safety and Infection
Control Guidelines are followed.

3.0 SCOPE OF THIS POLICY

3.1 To promote guidance for health care workers on the correct hygiene
measures for the laundering of linen
3.2 Highlight the risks of infection associated with handling dirty laundry, as
well as keeping clean laundry free from the risk of recontamination
3.3 Identify appropriate prevention measures to reduce the risk and protect
patients, staff and the wider community
3.4 Provide staff with a broad outline of what to do, and whom to contact for
more detailed advise in relation to the management of linen and laundry

4.0 ORGANISATIONAL RESPONSIBILITIES

4.1 Chief Executive
Has ultimate responsibility for the implementation and monitoring of
the policies in use at the Trust. This responsibility may be delegated
to an appropriate colleague
4.2 Director of Finance
Has Trust Board responsibility for all aspects of laundry and linen
management
4.3 The Associate Director of Facilities is responsible for implementing the
Guidelines for the Management of Laundry & Linen.
4.4 The Head of Facilities (Soft FM) is responsible for monitoring the
laundry and linen contract and ensuring that Trust staff are adequately
trained
4.5 Divisional and Associate Director Managers are responsible for
ensuring that staff are committed to implementing the Guidelines for
the Management of Laundry and Linen

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4.6 All staff must ensure they have read and understood the policy, and
incorporate the guidance on the management of linen and laundry into
their clinical practice.

5.0 SEGREGATION OF LAUNDRY

Category Definition
Used Items soiled by use or fouled by excretions or
secretions

Infected Linen from patients known or suspected to have an
Infection this includes gastro-intestinal infection (i.e.
clostridium difficile, Norovirus, patients with active
diarrhoea; pulmonary tuberculosis; MRSA
colonisation or confirmed; Hepatitis A; and other
notifiable diseases) For further advice please
contact IPCT

Heat-Labile Fabrics damaged by the normal heat disinfection
process and likely to be damaged at thermal
disinfection temperatures i.e. curtains and personal
items

6.0 STORAGE OF CLEAN LINEN

Clean linen should always be stored in a clean, designated area, preferably a
purpose built cupboard, off the floor to prevent contamination with dust and/or
aerosols. If a linen trolley is used for the storage of linen it should be
enclosed.

Ideally, linen should not be decanted onto different trolleys, or stored in
corridors when delivered, as this may result in contamination.

7.0 USED LINEN WITHIN THE HOSPITAL ENVIRONMENT

The used linen must be placed into a white plastic bag; filled no more than
full and securely tied at the neck.

All used / dirty linen is to be stored in a secure external area for collection by
the laundry contractor.

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8.0 INFECTED LINEN WITHIN THE HOSPITAL ENVIRONMENT

The infected linen must be placed in a red dissolvo liner, tie when full and
placed in a red plastic bag with a label attached identifying the ward or
department.

Linen that has been taken into room where a patient has been barrier nursed
and then not used must be removed and sent to the laundry, this must not be
used for another patient.

All infected linen is to be stored in a secure external area for collection by the
laundry contractor.

9.0 SPECIAL ARTICLES

9.1 Patients Personal Laundry
Patients personal laundry should be given to relatives if possible, this
should be contained in an appropriate plastic bag. If the Linen is soiled
or from an Infected patient, staff should give the relatives appropriate
advice on how to handle the clothing. If they are sent to the Trusts
laundry service provider, they must be sent according to the agreed
protocol to ensure that they are returned
9.2 Curtains
Curtains must be placed in a plastic linen bag following local
procedures and labelled correctly. Disposable curtains, where in use,
should be disposed of as clinical waste
9.3 Mops
The Domestic Supervisor supplies fresh mop head to all wards or
departments. Mops are issued to each area of the hospital on an
exchange basis, replacing each areas quantity of soiled mops with
clean. The used mop heads are laundered on site and are laundered
to thermal disinfection standards. The mop heads are tumble dried
and then bagged up ready for distributing
9.4 Clean Room Gowns
Clean room gowns are provided as rental items to the HSDU
Department. The gowns are delivered sterile direct from the linen
supplier. Soiled gowns should be placed in green bags, tie when
full and securely tie at the neck. The green bags will be collected with
the normal soiled linen and will then be segregated by placing them in
a cage in a secure external area for collection by the laundry
contractor.
9.5 Special Items i.e. Glide & Lock Seat Cover, Slings etc.,
The item must be placed in a plastic linen bag following local
procedures and labelled correctly. The items must be sent
according to the agreed protocol to ensure that they returned

December 2010 V2
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11.0 TRAINING

11.1 All staff that deal with laundry (clean or used) must adhere to the
Trusts guidelines on linen and laundry
11.2 Clean laundry should be handled in such a way that contamination is
avoided including during transport and storage
11.3 Laundry bags should always be used when clearing away used linen
from bed areas. Staff must not hand carry loose used linen, or leave
them on the floor, in order to minimise environmental and personal
contamination
11.4 All staff must ensure that no extraneous items are disposed of with
used linen, such as dentures, spectacles, sharps, incontinence pads,
and tissues as they may harm, the laundry operators or cause
damage to machineries
11.5 The laundry bag should not be overfilled and should be securely
closed when full
11.6 Staff should wear aprons and gloves when handling linen from
infected patients or whenever handling linen contaminated with bodily
fluids
11.7 Staff should wash their hands after handling used linen, and after
removing gloves and aprons

12.0 PERFORMANCE MANAGEMENT

12.1 The Trust will monitor the contactor to ensure that the contractor is
demonstrating compliance to the contract specification and in
particular to HSG (95) 18
12.2 Facilities Department (Soft FM), Domestic Manager & Linen Manager
will ensure this policy is implemented efficiently and that the Infection
Prevention & Control Team is informed of any infection control non-
compliance incidents
12.3 Facilities Department (Soft FM) will monitor compliance to the policy
and multi disciplinary audits will be undertaken to ensure linen is
segregated appropriately

December 2010 V2
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Appendix 1

REFERENCE DOCUMENTS

NHS Executive (1995) HSG (95) 18 Hospital Laundry Arrangements for Used
and Infected Linen
Department of Health (2008) The Health & Social Care Act
Service Level Agreement with Sunlight Laundry for the laundry provision
East Cheshire NHS Trust Infection Prevention & Control (2009) Good
Practices

December 2010 V2
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Appendix 2

PROCEDURE FOR THE STORAGE OF LINEN OUT OF HOURS

Three linen cupboards have been purchased which will hold emergency supplies of
various pieces of linen; the purchasing of these cupboards will negate the need to
remove stock from the linen room.

The cupboards have been strategically placed on both the bottom and top streets for
the convenience of all the wards. The cupboards are sited as follows:-

Cupboard 1 - bottom street next to the Feastpoint vending machine
Cupboard 2 - top street next to lift number 5
Cupboard 3 - top street next to the vending machines o/s Orthopaedics

The service provider will monitor the cupboards daily, during the working week and
will top up stocks where necessary; cleaning of the cupboard is the responsibility of
the service provider.

The Bed Manager is currently responsible for allowing access to the linen room for
emergency supplies; this responsibility will continue, however this stock will only be
used when stocks have been diminished from the new cupboards. Staff will
continue with the existing out of hours procedure of contacting the Bed Manager if
they require emergency supplies of linen.

Bed Management, Porters and the service provider will each have copies of the keys
for the three cupboards; spare copies will also be retained in the key cabinet.

December 2010 V2
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Appendix 3

SUNLIGHT COLOUR CODING BAGGING POLICY

R RE ED D B BA AG GS S
Inner Red dissolvable Bag
Outer - Red Sunlight Bags

W WH HI IT TE E B BA AG GS S
SOILED LINEN INFECTED LINEN ITEMS

G GR RE EE EN N P PL LA AS ST TI IC C B BA AG GS S
RE-USABLE DRAPES AND
GOWNS ONLY
NOT SCRUBS SUITS

B BL LU UE E P PL LA AS ST TI IC C B BA AG GS S

SCRUB SUITS, CURTAINS
CUSTOMERS OWN ITEMS
December 2010 V2
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Appendix 4

INSTRUCTION SHEET SPECIAL ARTICLES

Staff who require linen to be laundered and the linen is deemed as a special article
as documented in section 9.0 must follow the Trust Instruction Sheet. The Service
provider cannot guarantee that special articles will be returned if protocols have not
been followed

Special articles must be labelled with the Trust heat resistant label before they
can be sent to the service provider to be laundered. Labels are supplied and
affixed by the Facilities Department (Soft FM)

Special articles should be placed in a plastic linen bag following local procedures
and placed in the disposal room for collection

The Linen Room should be notified on either ext 1679 or by email
[email protected] that a special article is being sent to the
service provider. In order to keep an audit trail the Linen Room should be
supplied with a contact name and number, department and a brief description of
the special article

Special articles are laundered separately by the service provider and will normally
be returned within one week. Queries regarding unreturned items should be
directed to the Linen Department in the first instance.

Patients Personal Laundry is laundered with the agreement of the service
provider; any requests should be directed in the first instance to the Facilities
Department (Soft FM)

December 2010 V2
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Appendix 5 EQUALITY AND HUMAN RIGHTS POLICY SCREENING TOOL

Policy Title: Guidelines for the Management of Linen & Laundry Directorate: Finance
Name of person/s auditing / authoring policy: Teresa Hill
Policy Content:
For each of the following check whether the policy under consideration is sensitive to people of a
different age, ethnicity, gender, disability, religion or belief, and sexual orientation?
The checklist below will help you to identify any strengths and weaknesses of the policy and to
check whether it is compliant with equality legislation.
1. Check for DIRECT discrimination against any minority group of PATIENTS:
Response
Action
required
Resource
Implication
Question: Does the policy contain any statements
which may disadvantage people from the following
groups? Yes No Yes No Yes No
1.0 Age?
x
1.1 Gender (Male, Female and Transsexual)?
x
1.2 Learning Difficulties / Disability or Cognitive
Impairment?
x
1.3 Mental Health Need?
x
1.4 Sensory Impairment?
x
1.5 Physical Disability?
x
1.6 Race or Ethnicity?
x
1.7 Religious Belief?
x
1.8 Sexual Orientation?
x
2. Check for DIRECT discrimination against any minority group relating to EMPLOYEES:
Response
Action
required
Resource
Implication
which may disadvantage employees or potential
employees from any of the following groups? Yes No Yes No Yes No
2.0 Age?
x
x
Impairment?
x
x
x
x
x
2.7 Religious Belief?
x
x
TOTAL NUMBER OF ITEMS ANSWERED YES INDICATING DIRECT DISCRIMINATION =
3. Check for INDIRECT discrimination against any minority group of PATIENTS:
December 2010 V2
11



December 2010 V2
12
Response
Action
required
Resource
Implication
Question: Does the policy contain any conditions or
requirements which are applied equally to everyone, but
disadvantage particular people because they cannot
comply due to:
Yes No Yes No Yes No
3.0 Age?
x
x
Impairment?
x
x
x
x
x
3.7 Religious, Spiritual belief (including other belief)?
x
x
4. Check for INDIRECT discrimination against any minority group relating to EMPLOYEES:
Response
Action
required
Resource
Implication
which may disadvantage employees or potential
employees from any of the following groups? Yes No Yes No Yes No
4.0 Age?
x
x
Impairment?
x
x
x
x
x
4.7 Religious, Spiritual belief (including other belief)?
x
x
TOTAL NUMBER OF ITEMS ANSWERED YES INDICATING INDIRECT DISCRIMINATION = 0

Signatures of authors / auditors: Teresa Hill Date: 01.12.10

Equality and Human Rights Compliance / Percentage Calculation

Number of Yes answers for DIRECT discrimination.
0
Number of Yes for INDIRECT discrimination.
0
Total answers for POLICY CONTENTS discrimination.
0
Percentage content non compliant 0 (Divide a+b by 36 x 100)

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