Linen Policy 0310

IC/276/10 Linen Policy
BASINGSTOKE AND NORTH HAMPSHIRE NHS FOUNDATION TRUST
Linen Policy
IC/276/10
Owner
Final approval
committee
Authoriser
Name
Job Title
Name
Hazel Gray
Senior Infection Control Nurse
Infection Control Committee
Date of meeting
Name
Job Title
5 March 2010
Dr Nicki Hutchinson
Director Infection Prevention and
Control
Signature
Review date
Audience
Standards
Date of authorisation
(maximum 3 years from date
of authorisation)
(tick all that apply)
Standards for Better Health
NHSLA
05/03/2010
2013
Trust staff
NHS
General public
C4a
Reviewed in accordance with The Health and Social Care Act 2008:
Code of Practice for health and adult social care on the prevention and
control of infections and related guidance published 16 December 2009
Summary
This linen policy outlines how linen should be handled and transported around the
Trust and ensures Health and Safety and Infection Control Guideline are followed.
Implementation Plan
Summary of changes
New Policy
Action needed and owner of action
All staff that uses the linen service must adhere to the Trust policy.
All staff must ensure that all linen is segregated and sent back to trust linen supplier in the
correct linen bags depending on the condition of the linen, i.e. infected/fouled linen must be
placed in red alginate bag before being placed in red plastic bag.
Contents
1.0
2.0
3.0
3.1
3.2
4.0
5.0
6.0
6.1
6.2
6.3
6.4
6.5
6.6
7.0
7.1
7.2
8.0
9.0
10.0
10.1
10.2
10.3
10.4
11.0
12.0
12.1
12.2
12.3
12.4
13.0
13.1
13.2
14.0
14.1
14.2
15.0
15.1
15.2
Introduction
Aim of the Policy
Organisational Role and Responsibilities
All staff
Managers
Performance Management
Training
General Linen
Rental Items/Issues
Clean Linen Delivery
Linen Stocks/Issue Levels
Soiled Linen Collections
Infected/Foul Linen
Linen contaminated with chemotherapy waste
Curtains
Curtain Changes
Soiled Curtain Collection
Pillows
Mops
Garments/Workwear/Boiler suits
Chefs Wear
Scrub Suits
Theatre Drapes & Gowns
Rejects
Bags
Safe Management of Linen
Protection when handling used linen
When and how to dispose of used linen
Preparation and staff protection
Procedures
How to dispose of soiled/foul/infected linen
Procedures
Linen Transportation
Procedures
Advice for relatives on taking laundry home to launder
Preparation
Procedures
References
Appendix A: Linen Segregation Procedure
Appendix B: Laundry Service Procedures
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1.0 Introduction
It has been shown that used linen, within healthcare settings, in particular, can harbour large
numbers of potentially pathogenic microorganisms. Therefore, it is important that the
appropriate precautions are taken to ensure contamination to/from linen does not occur as
this might then lead to transmission of microorganisms to people or to the environment
potentially causing infection. Such important precautions apply to all stages of linen
management: storage, handling, bagging, transporting, and laundering.
The provision and management of Linen Services is an important function to enable
sustainable delivery of patient care. By complying with this policy staff will facilitate the
continued delivery of these services, minimising risks to health & safety, complying with
infection control requirements and ensuring best value for the Trust.
2.0 Aim of the Policy
The Aim of the policy is to outline how linen should be handled to minimise the risk of cross
infection.
3.0 Organisational Role and Responsibilities
3.1 All staff
Have a responsibility to safely manage linen that they use whilst delivering care
Have the responsibility to report any exposure incidents that occur related to
contaminated linen and to take appropriate measures to avoid these in the first
instance
Have a responsibility to undertake training on relevant aspects of the
management of linen
Have a responsibility to display available posters clearly demonstrating the
actions to be taken to manage linen safely
3.2 Managers
Have the responsibility to ensure local risk assessments are carried out where
necessary, and ensure appropriate personal protective equipment (PPE) is
available to staff. They should also ensure immunisation programmes are offered
appropriately and any incidents that occur are reviewed and subsequent actions
taken where appropriate
Have the responsibility to ensure staff are aware of training sessions and facilitate
their attendance
Responsibility for the operational management of the linen services policy is that
of Estates and Facilities Domestic & linen Service and the Trusts chosen
provider Service Group
4.0 Performance Management
The General Manager Facilities and Domestic & linen Manager will ensure this
policy is implemented efficiently and that the ICT is informed of any infection
control non-compliance incidents
To monitor compliance to the policy spot checks will be undertaken by the ICT at
ward level on an ad hoc basis to ensure linen is segregated appropriately and any
discrepancies will be fed back to the ward managers
The ICT will provide advice and support on safe handling of infected linen
5.0 Training
Segregation of linen will be part of mandatory training for all staff who handle or
deal with linen throughout the Trust.
6.0 General Linen

6.1 Rental Items / Issues
All stock and Issue figures will be amended on a continuous basis responding to
changes in operational requirements e.g. outbreak situations
6.2 Clean Linen Delivery
Linen will be packed into linen roll cages the day prior to issue, identified and
stored in the A level linen room outer area.
Portering & designated linen staff will move the roll cages from the A level linen
room to a general area within each floor / departmental area each morning.
Linen services staff will top up each ward / departments linen store directly, with
the identified linen issue quantities in line with the identified delivery frequencies.
Linen services staff will return all empty linen cages to the linen room for use the
following day. (To comply with infection control requirements, linen cages
are to be used for clean linen only. They are not to be used for soiled linen,
rubbish or to move any other items)
6.3 Linen Stock/Issue Levels
Linen stock and issue levels will be constantly reviewed based on continuing
usage patterns within each ward I department, and amended by either increasing
or decreasing the quantities. Agreed ward/department quantity lists will be
maintained and serviced with variation to quantity being communicated as
instructed.
Ward / Departmental staff may request additional quantities I items of linen in
response to local ad hoc requirements, by speaking to linen services staff when
they are topping up the linen stocks or by contacting the linen room on ext 5043.
6.4 Soiled Linen Collections
Soiled linen is to be placed in the supplied white plastic linen bags for each
category of linen. The soiled linen bag colour scheme is attached as appendix A.
Portering or designated Linen Staff will collect soiled linen on a regular basis via
dedicated linen wheeled bins, from all ward / departmental areas.
All soiled linen collected should be taken to the soiled linen area, within the A
Level linen room and deposited in the trust linen supplier provided cages, in the
appropriate areas as identified. All soiled linen from all areas of the hospital
should be in the soiled linen area before 3am each morning to ensure that the
maximum linen is available for trust linen supplier to collect each day. (To
comply with infection control requirements all soiled linen is to be stored
within the A Level linen room soiled linen area only, no other areas of the
hospital are to be used as collection points for soiled linen)
Trust linen supplier will collect all soiled linen from the A Level linen room early
morning Monday to Friday. Additional arrangements will be made to allow for the
removal of soiled linen on Bank Holidays.
6.5 Infected/Fouled Linen
All Infected/fouled linen is to be placed in a red soluble bag (alginate), which
should then be placed within a red plastic bag (as per the soiled linen bag colour
scheme)
Collections of infected linen in red bags should follow the same procedure as for
soiled linen.
6.6 Linen contaminated with chemotherapy waste
If spillage has penetrated the bed linen place it in a yellow bag and dispose of as
cytotoxic waste. Hospital linen that is potentially contaminated with cytotoxic
drugs should never be returned to the hospital laundry. The mattress should then
be cleaned using warm soapy water. Once dried the bed may be remade with
4
clean linen. If the mattress is affected seek further guidance from health and
safety advisors.
7.0 Curtains and window Blinds
All curtains and window blinds supplied conform to all relevant regulations on fire
retardancy and fabric performance. The ICT should be informed of any change
and consulted on specifications
7.1 Curtain Changes
To ensure compliance with infection control procedures, curtains across all areas
with be changed by linen services staff on a rotating 3 month schedule.
To ensure that the above detailed scheduled changes take place, ad hoc
changes due to infection will be undertaken by the designated staff who
undertake deep cleaning of areas.
Standard curtain panels are available in the linen room for ad hoc changes.
These can be accessed by contacting the linen room on ext 5043 between 8am &
5pm Monday to Friday, outside of these hours curtains will be available in the
linen room for collection by EFM Portering staff via bleep 1201.
7.2 Soiled Curtain Collection
All soiled/infected curtains are to be placed within a red alginate bag and then a
red plastic bag
Paperwork is not required to accompany curtains sent for laundering.
Collections of curtains in red bags should follow the same procedure as for soiled
I fouled linen detailed above.
8.0 Pillows
All pillows used MUST have a protective cover on it that can be wiped down
Any pillow cover that becomes torn should be placed in a clear plastic bag (NOT
a trust linen supplier bag) and placed in the sluice area for collection by the linen
room staff.
Any pillow that becomes contaminated or stained and which cannot be wiped
clean must be double bagged at the ward area and the word condemned written
on the bag. This should then be placed in the sluice area for collection by the
linen room staff.
Pillows MUST NOT be disposed off at ward area by nursing staff.
9.0 Mops
Single undyed Kentucky string mops will be issued as standard rental items to
each area in quantities as required.
Mops will be issued to each area of the hospital on an exchange basis, replacing
each areas quantity of soiled mops with clean.
Linen Services staff will deliver the exchange quantity of mops to each agreed
area daily Mon to Fri with double quantities issued at weekends.
Soiled Mops should be individually bagged in the supplied clear plastic bags.
These bags should then be placed in the supplied mop container / bag identified
with the area name.
Portering staff on a daily basis should collect the identified container I bag
containing the soiled bagged mops and transport to the identified area within the
linen room.
Linen services staff will count each bagged mop for each area and reissue clean
mops to replace these in each area.
All soiled mops will then be collected by trust linen supplier for laundering to
thermal disinfection standards.
It is the responsibility of the cleaning staff in each area to ensure that all soiled
mops are returned to the linen room for laundering. (Under no circumstances
should soiled mops be placed in domestic or clinical waste bags)
5
10.0 Garments I Work wear/Boiler suits

Garments I work wear requiring industrial laundering with be issued as rental
items to each individual staff member on an exchange basis.
Staff should take their soiled garments I work wear to the A Level linen room
between 8AM and 5PM Mon to Fri, where linen services staff will exchange each
item for a clean replacement.
10.1 Chefs Wear
Chefs Wear requiring industrial laundering will be issued as rental items to each
individual staff member on an clean issue and dirty exchange basis.
Staff deposit their soiled Chefs wear into the designated linen bins located in the
Catering departments changing areas for cleaning by the designated service
provider.
10.2 Scrub Suits
Pool issue scrub suits will be issued to all areas requiring these items in the
range of sizes required as per the procedure for general linen detailed above.
Soiled scrub suits should only be placed in white (or red alginate followed by red
plastic bag if heavily soiled or if infected) bags as per the procedure for general
linen items detailed in above. (Under no circumstances should scrub suits be
placed in green bags)
10.3 Theatre Drapes & Gowns
Microfibre theatre drapes and gowns will be provided as rental items to theatres
as required.
All drapes and gowns will be supplied sterile direct from trust linen supplier.
Containers containing sterile drapes and gowns will be delivered by trust linen
supplier to the A level linen room. Linen service staff will sort each container into
the correct area.
Portering staff will distribute each container of sterile drapes to each area
identified.
Theatre staff are responsible for ordering replacement stock of theatre drapes
and gowns to their agreed stock levels direct from trust linen supplier. Contact
information is as issued to each department and is also available by contacting
the A Level linen room on ext 5043.
Soiled drapes and gowns should be placed in green bags only. These green bags
should be placed in the trust linen supplier cages used for delivery, and stored in
a suitable area to await collection. (Under no circumstances should theatre
drapes and gowns be placed in any other colour than green bags)
Portering staff will collect all cages of drapes and gowns, which are, bagged in
green bags, along with all delivery boxes. All cages and boxes are to be taken to
the A Level linen room soiled linen area and placed in the appropriate identified
location, to await collection.
10.4 Rejects
Reject Bags will be issued to all areas
Any items that are unsuitable for use (stained / holed etc.) should be placed in the
reject bag. (Under no circumstances should rejected items be placed in any
soiled linen bags)
11.0 Bags
Plastic soiled linen bags are supplied via trust linen supplier.
Additional supplies of all soiled linen bags can be obtained by contacting the linen
room on 5043.
To comply with manual handling requirements, and also to ensure undue strain is
not placed on the plastic bags, do not over fill the bags (as a guide fill to 2/3s full
to allow for tying the bag opening).
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12.0 Safe Management of Linen

12.1 Protection when handling used linen
A disposable plastic apron should always be worn when handling used linen (and
disposable gloves where linen is soiled/foul), e.g. during bed making.
Hold used linen away from yourself to avoid contamination of clothing from linen
Hand hygiene should be performed following handling of used linen (see Hand
Hygiene Policy)
12.2 When and how to dispose of used linen
12.3 Preparation and staff protection:
Ensure appropriate and clean bags/receptacles, e.g. linen skips, are available as
close to the point of use as possible
Personal protective equipment (PPE) should be worn appropriately to ensure
contamination from used linen does not occur, e.g. disposable plastic apron and
gloves if handling used linen.
12.4 Procedures:
Place used linen immediately into a designated bag/receptacle
Separate used linen carefully. Place each item directly into the designated
bag/receptacle. (However, if linen is soiled/foul, it should be managed separately,
see - How to dispose of soiled/foul linen)
Never place/drop linen on the floor or on other surfaces, which may be touched
frequently as this could lead to contamination, especially during care delivery e.g.
a locker/table top
Staff should avoid shaking linen as this may result in the dispersal of potentially
pathogenic microorganisms and/or skin scales into the environment
Used linen bags/receptacles should never be overfilled
After handling linen, staff should ensure they dispose of any PPE appropriately
Hand hygiene should be performed following handling of linen
13.0 How to dispose of soiled/foul/infected linen:
13.1 Preparation and staff protection:
Ensure appropriate and clean bags/receptacles e.g. linen skips are available as
close to the point of use as possible
Personal protective equipment (PPE) should be worn appropriately to ensure
contamination from used linen does not occur, e.g. disposable plastic apron and
gloves if handling linen
13.2 Procedures:
Linen soiled or contaminated with blood or other body fluids or from infected
patients, should be placed directly into a water-soluble/alginate bag (these are
red in colour) to prevent any further handling and potential contamination,
particularly for those performing laundering procedures. This bag indicates that
linen is soiled/foul. The bag should be secured using a neck tie
Separate the linen carefully.
Staff should NOT shake the linen as this may result in the dispersal of potentially
pathogenic microorganisms and/or skin scales into the environment
The alginate bag once tied should be placed into a red plastic bag.
Soiled/foul linen should not be rinsed or sorted prior to it being laundered,
Never place/drop linen on the floor or on other surfaces which may be touched
frequently as this could then lead to contamination especially during care delivery
e.g. a locker/table top
Bags should never be over filled
After handling linen, staff should ensure they dispose of any PPE appropriately
Hand hygiene should be performed following handling of linen
14.0 Linen Transportation

14.1 Preparation and staff protection
PPE should be worn appropriately to protect those transporting linen, e.g. gloves
Measures should be in place to ensure that linen for use arrives clean e.g.
department or company agreements.
Inspections should be carried out on those transporting linen e.g. auditing of vans
or trolleys to ensure these are clean and that cages are used for storage of linen
in these settings with clear separation of clean and dirty linen
14.2 Procedures
Bags containing used linen that have not been properly secured should not be
lifted
Personnel transporting used linen should not open linen bags/receptacles/cages
nor should they handle linen
If a sharps injury is sustained from an item found during transport of linen, the
trusts standard procedure as per Sharps contamination injuries Policy,
should be followed.
Clean and used linen should never be transported in the same
bag/receptacle/storage cage. Instead, there should be designated
bags/receptacles/storage cages for each
Clean hands should only handle clean linen. The linen should be stored in a
designated, clean area with minimal handling until required for use
Hand hygiene should be performed after handling used linen
bags/receptacles/cages and prior to handling clean linen
15.0 Advice for relatives on taking laundry home to launder
15.1 Preparation
Staff should explain key elements of standard infection control precautions e.g.
PPE, hand hygiene, to relatives/friends prior to them taking linen home to launder
15.2 Procedures
These additional points should also be raised:
Dispose of plastic bag(s) used to carry items promptly

Launder items using as high a temperature as possible and as per machine
instructions
Use normal washing powder
Tumble dry where possible (following manufacturers guidance)
Iron according to manufacturers instructions. A hot iron is best if possible
Hand hygiene should be undertaken following handling of items
Where hand rinsing of heavily soiled items is absolutely necessary, this should be
carried out by fully submersing the items to avoid potential
aerosolisation/splashes while rinsing. Ensure splashing is minimised particularly
when throwing away used water
Generally, personal items do not need to be separated for washing unless soiled
References
1. National Health Service Executive. Hospital Laundry Arrangements for Used and
Infected Linen. HSG (95)18 Leeds: NHSE; 1995; 4.

2. Standard Principles for preventing hospital-acquired infections Journal of Hospital
Infection (2001) 47(Supplement): S21S37

3. Wilson J et al (1999), Infection Control in Clinical Practice. Bailliere Tindall London 1999.
4. Damani N.N. (2000), Manual of Infection Control Procedures: 2nd Edition, Greenwich
Medical Media Ltd. London.
Appendix A
Linen Segregation Procedure
LINEN SEGREGATION PROCEDURE
INFECTED &
USED
THEATRE
LINEN ONLY
HEAVILY SOILED
LINEN ONLY
Used/slightly soiled
linen from non-infected
patients must be
placed into a WHITE
plastic laundry bag
Used linen which has been in

contact with infected
patients OR is heavily
contaminated with body
fluids should be placed into a
RED SOLUBLE BAG (alginate)
and securely tied before being
placed into a RED PLASTIC BAG
Used linen must be placed

into a GREEN PLASTIC BAG
linen that has been heavily
contaminated with body
fluids must be placed into
a RED SOLUBLE BAG
(alginate) prior to going into a
GREEN PLASTIC BAG
ALL BAGS SHOULD BE NO MORE THEN 2/3 FULL

NO LINEN SHOULD BE PLACED INSIDE A YELLOW CLINICAL OR DOMESTIC WASTE BAG ENSURE
ALL SHARP ITEMS ARE REMOVED PRIOR TO PLACING LINEN INTO BAG
APPENDIX B
Basingstoke and North Hampshire NHS Foundation Trust

Laundry operational procedures for the BNHFT
1st April 2008
EFM Domestic and Laundry Service
Content
Heading
Section
Purpose
1.0
Overview of service
2.0
Arrangement for thermal infestation/infection control
3.0
Appendix
1. Sunlight service schedule HSG (95)18 and KPI

2. Service requirement
3. PASA cost schedule
4. Laundry returns procedure
5. Sunlight BCP and escalation data
1.0
Purpose
This procedure document details the Basingstoke and North Hampshire NHS Foundation
Trusts (BNHFT) Laundry and linen service arrangements. This includes the contracted
services provision for laundry and its respective governance and compliance with HSG(95)18.
2.0
Service overview
Healthcare linen provided by external laundry contract

External linen supplier delivers clean stock to site determined by volumes ordered or
agreed by Trust
Storage and distribution of linen is operated by the Trusts EFM Laundry team
supported by the Porter team for site distribution
Storage and distribution of linen stock at ward level is controlled by the ward team
along with collection and return of dirty and faulty stock to designated collection points
Dirty and faulty linen is collected and returned to the EFM laundry team for collation
and return to external linen supplier
External linen supplier collects dirty stock and launders as per schedule (HSG(95)18
The Trusts EFM laundry team manages
Contract performance management with external supplier

Stock control and distribution of stock
Safe delivery and return of clean and dirty stock
Support of linen service users in the Trust to ensure performance of service
Attendance at the Trusts Cleaner Hospital committee
Liaison with IC team and Health and Safety team on operational issues
Carry out annual duty of care visit to supplier/contract providers operation. Appendix
? Duty of care visit report.
This is led by the:

EFM domestic and Laundry manager
Laundry Supervisor
Linen room team
3.0
Arrangement for thermal infestation/infection control
The Trusts contracted service provider Sunlight Ltd operate to ensure compliance with
HSG(95)18 the below statement is provided as part of the operating protocols of the laundry
service contract at the BNHFT.
Sunlight Ltd operational governance of HSG (95)18
EFM/Laundrydoms/Proc/2008
3.1 Thermal disinfection of laundry

We comply with HSG(95)18, which gives guidance on infected linen and notifiable diseases.
We would conform to relevant guidance from the Trusts Control of Infection Officer where
appropriate.
The wash process will be designed to maintain at least two wash cycles. The first will attain a
temperature of 32 degrees centigrade. The second will attain a temperature of 71 degrees
centigrade or more which will be maintained for at least five minutes. Additional time at this
temperature will be added for heavily soiled work.
At least one sluice cycle will proceed the high temperature washes and controls will be so set
on the machine as to ensure the programme timer does not proceed until the set temperature
has been reached. The timer will stop each time the temperature falls below the set level.
Depending on the classification Peroxide or Chlorine bleach will be used.
The final load each day in every washing machine will be of a classification that will allow
Chlorine bleach to be used during the rinse cycle. No work will be left in washing machines
overnight. CBW's will be thermally disinfected before the start of work each day.
3.2 The prevention of subsequent re-infection
We comply with HSG(95)18, and refer to working practices, i.e. restricting movement of staff
from clean to dirty areas, gowning protocols and proper receptacles for storage of work in
process, trolley disinfection procedures, covering trolleys with polythene and vehicle cleaning
and disinfection routines.
3.3 The processing of fouled articles
We comply with HSG(95)18, and would advise additionally there are designated areas within
the sorting room, a designated processing washer extractor, sealed drains and vent to
atmosphere for the processing of infected articles. Work that is delivered in alginate bags with
surrounding red bag is processed unopened, which is then thermal disinfected in washer
extractor and then reprocessed again using the normal wash procedure.
Appendix 1
NATIONAL FRAMEWORK AGREEMENT FOR THE PROVISION OF LAUNDRY
AND LINEN SERVICES TO THE BNHFT
Service Specification
Contents
Section
1
Overall service options

(a)
Wash and return
(b)
Linen Hire
(c)
Total Linen Management
(d)
Hire of CE marked, reusable barrier theatre textiles
Service standard
(a)
For service options 1a,1b and 1c
Collection and delivery for all service options
Storage for all service options
Packaging for all service options
Processing of articles of laundry

(a)
For service options 1a,1b and 1c
(b)
For service option 1d
Standard of finish for all service options
Quality assurance and control for all service options
Key Performance Indicators
10
Documentation-management information
11
Contingency planning
12
Emergency supplies (major incident)
Schedule 1
Schedule 2
Schedule 3
Schedule 4
Schedule 5
HSG (95) 18
Performance standards
Menu of services
Key finish definitions
Standards of finish
Standard service requirements

1
Service options
The Contractor shall provide laundry and linen services based on all or some of the
following service options:
(a) Wash and return which consists of:
A laundering and finishing service
Collection and delivery to and from NHS clients
All linen owned by client trust
Product mix may include:
(a)
Flatwork
(b)
Uniforms
(c)
Theatre linen (traditional cotton based products)
(d)
Patient Clothing (personal & non personal)
(b) Linen hire which consists of:
A laundering and finishing service
All linen owned by contractor with the exception of wash and return
Contract may comprise an element of wash and return (see above)
Provision of linen articles that may include:
(a)
Flatwork
(b)
Uniforms
(c)
Curtain Hire
This service is to supply curtains with additional options to fit and take down as
required, in accordance with participating trusts requirements. All curtains to be flame
retardant in accordance with HTM87.
The unit costs for curtain hire to be shown in a two tier format that consists of a
separate charge, per metre, for hire of the curtain and an associated charge for
laundering as a wash and return item.
(c) Total linen management which consists of:
A laundry and finishing service
All linen owned by contractor with the exception of wash and return
Contract may comprise an element of wash and return (see above)
Collection of soiled linen from each ward and department
Delivery to each ward and department of clean linen
Sewing Room Service (optional)
Provision of linen articles that may include:
(a)
Flatwork
(b)
Uniforms
(c)
Theatre linen (traditional cotton based products)
(d)
(d) Hire of CE marked, reusable barrier theatre textiles, which consists of:
Provision of a laundry and finishing service for theatre textiles that meet the
requirements of the European Medical Devices Directive 93/42
Provision of CE marked reusable barrier theatre textiles in compliance with EN

13795
Theatre top up service (optional)
In view of the wide range of drapes and gowns available, offerors are requested to list
a sample range of high usage product lines e.g. top 20 items, together with the
maximum price the NHS would pay for those product lines.
Under this framework agreement trusts will use this information as the basis of
identifying their bespoke requirements. Participating trusts will then use this to secure
more detailed information both in terms of products and prices that reflects local needs
2
(a)
Service standard for service options1a, 1b and 1c

The Contractor shall supply a service to HSG 95(18), as a minimum standard; to
ensure that service standards are reflective of the aims associated with relevant
Government best practice e.g. Peat standards. Organisations appointed to the
national framework agreement will be expected to comply with all future government
guidance, regulations and standards in the provision of this service. To assist
interpretation of these standards, a copy of HSG (95) is attached in Schedule 1.
Collection and delivery for all service options

The Contractor shall collect all used/infected linen from specified storage facilities, at
times agreed with NHS clients. All clean articles of laundry shall be delivered by the
Contractor to agreed delivery points within an agreed time frame.
Used/infected articles of laundry must be transported, stored and sorted in containers
and in accommodation separate from those used for clean linen and must not at any
time come into contact with clean linen.
Clean articles of laundry shall be transported in containers and vehicles that have been
appropriately cleaned by the Contractor before each occasion on which they are used.
Each stillage/roll cage will be appropriately covered.
Storage for all service options

The Contractor shall operate and maintain appropriate storage and handling systems
for all linen held within their facility. The storage areas must provide for the
segregation of clean and used/infected articles of laundry and prevent the damage or
soiling of clean articles of laundry from any source.
Packaging for all service options

Clean articles of laundry must be packed in such a manner as to prevent re-soiling.
6
(a)
Processing of articles of laundry

For service options 1a, 1b and 1c
All articles of laundry must be washed, thermally disinfected unless the fabric or
product does not allow for this, in which case chemical disinfection is allowed.
Laundering must be undertaken in accordance with HSG (95)18, relevant statutory
requirements and reflect good industrial practice.
(b)
For service option 1d

C.E marked barrier theatre drapes and gowns (medical devices) are to be laundered
from the soiled side via a barrier washing machine into a clean room certified and
validated to ISO 14644 Class 8 Clean Room. There they are to be dried, inspected,
folded and packed for sterilisation. Entry and exit to be controlled via an airlock
system, with staff changing and washing facilities.
7
Standard of finish for all service options

All clean articles of laundry, including CE marked barrier theatre drapes and gowns, on
each occasion they are supplied shall be thoroughly clean and fresh, free from
infection, in good usable condition and a good state of repair and in every respect fit for
immediate use.
Quality assurance and control for all service options

The Contractor will provide evidence of its own quality assurance and control
procedures including any accreditations to ISO standards or equivalents. A quality
assurance plan is required to ensure that systems and procedures are in place to
guarantee that services are provided according to the standards laid down within the
Contract, on each and every occasion throughout the Contract Period.
Key Performance Indicators

The service provided will be in accordance with the standards specified and will meet
those key performance indicators detailed in Schedule 2
10
Documentation- management information

Documentation must be adequate to identify and control all articles of laundry being
held or processed by the Contractor and to substantiate invoices. Additionally
documentation must be sufficiently detailed and capable of manipulation to enable
computer modeling and management forecasting to be undertaken by NHS clients.
11
Contingency planning
The Contractor must put in place appropriate contingency plans, prior to the
commencement of Contract. The Contingency Plan is to detail how the Contractor
proposes to allow for the continuance or earliest resumption of services in the event of
an emergency or breakdown of normal services. This contingency response is to
cover all areas of service and must be 100%operational within 24hours of each service
failure.
12
Emergency supplies (major incident)

The Contractor must maintain sufficient supplies of linen to cover unforeseen increases
in demand. Such emergency supplies must be accessible within 1 hour, 24 hours a
day, 7 days a week.
Schedule 1
HSG (95) 18
Hospital Laundry Arrangements for Used and Infected Linen
Health Service
Guidelines
Hospital Laundry Arrangements for Used and

Infected Linen
Executive Summary
The provision of adequate laundry services is a fundamental
requirement of direct patient care and a major feature among a
hospitals man activities which contribute to its commitment to
meet Patients Charter standards of quality services. Hospital
Laundry Arrangements for Used and Infected Linen sets out the
recommended procedures to help meet this commitment. In
particular it covers the handling and laundering of linen; the
importance of securing the disinfection of used and infected linen;
and the basic principles of infection control.
Background
The NHS has an obligation under the Health and Safety at Work
Act to take steps to prevent the risk of infection to staff handling
and laundering linen. There is also a need to deal with the
potential for harm to staff and damage to linen by a failure to
separate sharps from dirty linen before it is placed in laundry
bags.
Action
NHS managers are asked to draw the accompanying guidance to
the attention of all staff, including contract staff, which may need
to apply it.
Managers should ensure that relevant legislation, including the
requirements of the Registered Homes Act in respect of laundry
from small units, is complied with.
Management should adopt procedures to ensure that patients
and staff are not put at risk of infection from used and infected
linen.
Management should ensure that all staff, and laundry contractors,
responsible for handling or laundering linen are appropriately
trained.
The advice contained in the HSG should be incorporated into
contracts where laundry services are not provided in-house.
The help of the Society of Hospital Linen Services and Laundry
Managers, in conjunction with the industry technical association,
FCRA in drawing up this guidance is acknowledged.
HSG(95)18
Hospital
Laundry
Arrangements for Used and
Infected Linen
This replaces HC(87)30
which
expired
on
1
December 1992
21 April 1995
LAUNDERING PROCEDURES TO SECURE DISINFECTION OF USED AND INFECTED

LINEN
1.
1.1
INTRODUCTION
This guidance, which should be applied to all laundry facilities including launderettes
and on-premise laundries associated with small units, is issued to promote practices
which will reduce the possible risk of infection to laundry staff during the laundry
process and to secure the disinfection of used and infected linen. These practices will
also help to eliminate possible damage to linen and laundry equipment from the failure
of staff to separate potentially dangerous items (sharps in particular) from dirty linen
before it is placed in laundry bags.
1.2
It is essential for a laundry and its associated operations to ensure that it provides
health care units with adequate and timely supplies of the necessary requirement of
clean items. This is a major feature in the many aspects of a hospitals activities which
also helps them to meet their Patients Charter commitment of providing quality
services. Even minor variations in the levels of service provided can have serious
consequences.
1.3
The main problems demonstrating the need for revised advice involve the sorting and
categorising of linen. Although handling of foul linen is undesirable there is a need to
separate articles requiring different treatment and to detect sharp objects that may
damage the whole load. This is a particular problem when dealing with linen from
some units e.g. geriatric and psychiatric where up to 80% of its linen is in the foul or
infected category. The separation of soiled and foul linen is often not carried out in the
wards and items likely to damage linen, or machines, are commonly found in pockets
of garments or accidentally placed in the laundry bag. Positive efforts should be made
to encourage ward and theatre staff to use the bagging procedures as in Appendix A
and to avoid putting extraneous items into laundry bags. Linen from patients with
diseases likely to be transmissible to staff should be transferred to a washing machine
without handling by the laundry operative.
1.4
The local control infection committee should use this advice when determining local
policy procedures. It should also take into account HC(91)33 Decontamination of
contaminated equipment, linen or other surfaces contaminated with hepatitis B and/or
Human Immunodeficiency Virus (HIV). The committee could also usefully urge staff
not to send sharp items with linen to the laundry.
1.5
All staff handling linen should receive appropriate training to carry out their duties
efficiently and safely.
2.
2.1
CATEGORIES OF LINEN
It is recommended that linen (in this document linen refers to all articles for
laundering) should be divided by staff in wards and departments into three categories.
2.1.1
Used (Soiled and Foul) all used linen, irrespective of state, but on occasion
contaminated by body fluids or blood, apart from linen from infectious patients, those
suspected as being infectious and linen covered by 2.1.2 and 2.1.3. Handling policy
for used (soiled and foul) linen will be determined at local level with advice from the
local infection control committee whether the foul linen is to be categorised with the
used or infected linen.
2.1.2
Infected linen from patients with or suspected of suffering from enteric fever, and
other salmonella infections, dysentery (Shigella spp), hepatitis A, hepatitis B,
hepatitis C and carriers, open pulmonary tuberculosis, HIV infection, notifiable
diseases and other infections in hazard group 3 COSHH 1994 Approved List of
Biological Agents (see Advisory Committee on Dangerous Pathogens) and other
infections specified by the infection control officer as hazardous to staff. Linen from
patients infected with hazard group 4 organisms (haemorraghic fever viruses such
as Lassa Fever) must be steam-sterilised by autoclaving within the group 4
containment unit before laundering see Memorandum On The Control of Viral
Haemorraghic Fevers, HMSO 1986. It is most important that linen likely to infect
staff should be put immediately into a water-soluble bag or bag with a water-soluble
stitched seam or membrane which will release its load in the wash process and
which is sealed with an appropriate soluble tie and labeled as to its origin. The
containers should be correctly coloured in accordance with the amended SIB(10)20.
(See Appendix A.)
2.1.3
Heat-Labile fabrics damaged by the normal heat disinfection process and likely to
be damaged at thermal disinfection temperatures.
3.
3.1
DISINFECTION OF USED (SOILED AND FOUL) LINEN

This category accounts for the vast majority of used linen from hospitals. For
transportation, such linen should be placed into polythene or nylon/polyester laundry
bags, colour coded in accordance with Appendix A. Bags must be securely fastened
before being sent to the laundry. Care should be taken to prevent linen or foul
seepage (body fluids or blood) escaping from laundry bags and contaminating other
items or staff. Use of a water-soluble bag as a liner is recommended.
3.2
The washing process should have a disinfection cycle in which the temperature in the
load is maintained at 65C (150F) for not less than 10 minutes or preferably at 71C
(160F) for not less than 3 minutes. With both options, mixing time must be added to
ensure heat penetration and assured disinfection. For machines of conventional
design and a low degree of loading (for example, below 0.056 kg/litre) 4 minutes
should be added to these times to allow for mixing time. For machines with a heavy
degree of loading (for example, above 0.056 kg/litre) it is necessary to add up to 8
minutes. A sluice cycle should be included as necessary when dealing with foul linen.
3.3
All washing machines should be checked prior to purchase to ensure that they have
the specified programming ability to meet the above disinfection standards, and on
commissioning to ensure compliance with disinfection standards. The special
requirements for continuous batch washing machines are set out in paragraph 8.
3.4
All washing machines should be fitted with accurate heat sensors. The sensing
elements must be correctly placed to register the true wash temperature, i.e. the
temperature of the wash water in contact with the load. Wash temperatures should be
subject to a monitoring system and heat sensing systems should be tested at six
weekly intervals and calibrated accordingly. Records should be kept of the six weekly
testing and the necessary calibration.
3.5
Categorisation of linen should be done at local level with the appropriate coloured
coded containers. However, water soluble bags or bags with a water-soluble stitched
seam or membrane are recommended for heavily fouled linen.
DISINFECTION OF INFECTED LINEN

4.1
Linen in this category should not be sorted, but should be sealed in a water-soluble
bag or bag with a water-soluble stitched seam or membrane immediately on removal
from the bed or before leaving a clinical department. This primary container should
then be placed in a nylon or polyester bag with the appropriate colour code in
accordance with Appendix A and labelled if considered necessary locally. The inner
bag should be transferred to the designated washer extractor without opening,

followed by the outer bag which should be washed in a similar fashion. Due to the
potential for blockages and a need for staff to enter the machine in this even, under no
circumstances should infected linen be processed in a batch continuous washing
machine.
4.2
The provision of a designated storage area should not be necessary but infected linen
should be stored under secure conditions prior to treatment.
4.3
The recommendations on the washing process for used linen regarding the thermal
disinfection stage, set out in paragraph 3.2, also apply to the process for infected
linen.
4.4
The temperatures recommended in paragraph 3.2 should inactivate HIV but there is
some uncertainty as to minimal temperatures required to inactivate hepatitis B virus.
However, the heat inactivation at these temperatures, combined with the considerable
dilution factor stage, should render the linen safe to handle on completion of the wash
cycle.
4.5
Where central disinfection areas exist it is not expected that the arrangements will
automatically be dispensed with but, if necessary, they will continue because of the
financial and practical implications of making the alteration. However, where laundries
are also producing linen and laundry for other than hospital purposes i.e. commercial
contracts which may include food industry or related work, it may be a contractual
requirement that a barrier operation is provided to effectively separate unprocessed
work from clean work. In this situation, a central disinfection area or barrier room for
infected work may be desirable.
4.6
Where a known infection occurs in a small unit all used and patients personal clothing
must be disinfected in accordance with the preceding guidance and advice from the
control of infection officer.
5.
5.1
DISINFECTION OF HEAT-LABILE LINEN

The purchase of fabrics which will not withstand the temperatures set out in paragraph
3.2 should be avoided where possible.
5.2
Heat-labile materials, for example, patients clothing articles manufactured from

knitted polyester, need to be washed at low temperatures (40C - 104F) to avoid
damage. The temperature in tumble driers, if used, must be limited to 60C and
calendars should be avoided wherever possible.
5.3
Disinfection with chemicals at low temperatures is possible with hypochlorite but the
performance of hypochlorite is often restricted by the presence of soiling, detergents
and alkalis in the wash. However, in clean conditions hypochlorite is active at a
temperature below 60C (140F) in low concentrations and will not damage fabrics
outside acceptable limits.
5.4
Disinfection of heat-labile materials, only if suitable, may be achieved by the addition

of sodium hypochlorite to the penultimate rinse. This should be a medium or high dip
rinse of at least five minutes duration and sufficient sodium hypochlorite must be
added to achieve a concentration of 150 ppm available chlorine. Overriding of
washing programmes must be avoided. Hypochlorite must not be used on fabrics
treated for fire retardance. Other chemical processes may be used if approved by the
Control of Infection Committee.
6.
6.1
DESIGN FEATURES TO REDUCE CROSS-CONTAMINATION

The provision of a barrier between the section which receives the used or infected
linen and the rest of the laundry is not considered necessary. It is recommended that
infected linen should be washed in designated water extractors as set out in
paragraph 4.1. Any vent pipe associated with such machines should be routed
outside.
6.2
Effluent from the drains of such machines must be sealed (closed piped) from the
machine to the manhole (preferable situated outside the laundry) to prevent crossinfection. If machines drain into an open sump or pit immediately below the machine
drain valve, the sump or pit should be covered to reduce the risk of bacteria being
spread by the aerosol effect when the water is pumped from the machine.
6.3
When laundering infected linen at launderettes or in on-premise laundries associated

with small units the machine requirements set out in the preceding paragraphs are
necessary.
6.4
There must be a physical barrier between clean and used or infected linen when
carried on a vehicle at the same time. No bag of linen that is not securely fastened
should be placed in a vehicle.
6.5
Trolleys for clean linen in transit should be covered with washable or disposable
cover. Fully enclosed and sealed containers with a lockable door may be used in
preference, in which case these covers are not required.
7.
7.1
PROTECTION OF LAUNDRY WORKERS

Staff in the sorting areas handling used unwashed linen should wear protective
clothing e.g. waterproof aprons and gloves. Any exposed lesion should always be
covered with a waterproof dressing. Although care needs to be given to proper
protection at all times, the use of surgical face masks is not considered necessary.
Hand washing and changing facilities must be provided in accordance with current
legislation and clean overalls should be available to staff at each new shift or work
period change.
7.2
Staff should be fully trained in all laundry operations. Guidelines setting out cleaning
and operational procedures for plant, equipment and laundry buildings should be
made available.
7.3
Detailed policy on the occupational health supervision of laundry staff should be

determined locally in the light of guidance given in such documents as HN(82)33,
HC(78)3 and on vaccination for NHS staff.
8.
8.1
BATCH CONTINUOUS WASHING MACHINES

All batch continuous washing machines must be fitted with the necessary controls and
interlocks to ensure work being processed is not recontaminated during the rinsing
stages of the wash process. To satisfy this requirement, rinse sections must be
thermally disinfected before production commences each working day.
8.2
The apparatus used to thermally disinfect rinse sections of the batch continuous
washing machine must be interlocked with the normal running control of the machine
in order to prevent the machine being set to work before the thermal disinfection of the
cool stages of the machine have been satisfactorily completed. The requirements are
as follows:-
i.
All sections of the machines, following the high temperature sections, which do not
reach a minimum temperature of 65C (150F), shall receive a thermal disinfection
cycle. The disinfection cycle shall be considered satisfactory when the water
temperature has been raised to 65C (150F) and held at this temperature for a
period of not less than 10 minutes or at a temperature of 71C (160F) for a period
of not less than 3 minutes. During the period of thermal disinfection of the rinse
stages, it is essential that the machine cage/drum rotates to ensure that all
surfaces are in contact with high temperature liquids. The disinfection process
should be controlled by a timer.
ii. A timer shall be incorporated into the control system to override the necessity to
proceed through the thermal disinfection of the cool stages of the machine if the
machine is stopped for short periods during the day. This timer however shall be
so interconnected that if the machine is shut down for a period of 3 hours or more
the cool stage thermal disinfection cycle will proceed, and at the same time lock
out the washing controls. The lock out shall include any mechanical devices,
interlocked with the washing cycle or not, for feeding work into the machine.
iii. It is expected that the cool stage disinfection cycle will be initiated by a single
button operation and that the cycling of any steam and/or water control valves
necessary to raise the temperature of these stages to that required for thermal
disinfection shall be automatic in operation. The incorporation of hand operated
valves in this system is not acceptable.
8.3
Due to the growth of bacteria which may take place overnight, it will be necessary to
run out all linen for the batch continuous washing machine at the end of the day to
avoid reinfection. The adequacy of disinfection procedures must also be considered in
the following ancillary areas:i.
Tanks which are used to collect water for reuse within the batch continuous
washer, from the extraction device or the conveyor leading from the washer to the
extractor to the shuttle, shuttle platform and tumblers.
ii. If the installation of a heat exchanger in the recovered water system is envisaged,
special consideration to thermal disinfection needs must be given.
iii. Machinery should be kept clean and free from algae.
iv. Attention to the cleaning and regular disinfection of all conveyor belting and
surfaces used to transfer clean, processed work from the press/extraction device
to tumblers is essential to avoid recontamination of the work.
v. Under no circumstances should infected linen be processed in batch continuous
washing machines. These may suffer blockage at any stage, though the pre-wash
section is the most likely. The pre-wash sections cannot be thermally disinfected
as a routine. In the event of a blockage neither the pre-wash sections nor the wash
sections would be safe to enter without exposing staff to an unacceptable level of
risk. Until such blockages could be removed the machine could not be operated or
any thermal disinfection routine undertaken. Washer extractor systems should be
used for infected linen or foul linen where this has been categorised with infected
linen following advice at local level from the local infection control committee.
Circulars mentioned in this document

HC(87)30
HC(91)33
HN(82)33
HC(78)3
Hospital Laundry Arrangements for Used and Infected Linen

Decontamination of Equipment, Linen or Other Surfaces Contaminated
With Hepatitis B and/Or Human Immunodeficiency Viruses
Memorandum on the Control of Viral Haemorraghic Fevers, HMSO 1986
Occupational Health Services for NHS Staff
Control Of Tuberculosis in NHS Employees: Limitation of X-Ray
Examinations
APPENDIX A
COLOUR CODING
1.
All DMUs and Trusts are asked to work towards implementing the National Colour
Standard.
2.
The following procedures should be adopted by ward and theatre staff:a. Used (Soiled and Foul) linen (Category 2.1.1) containers should be coloured
white or off-white.
b. Infected linen (Category 2.1.2) containers should be coloured red or, at least,
include red a prominent feature on a white or off-white background. Additionally
the container should carry a bold legend on a prominent yellow label such as
INFECTED LINEN. It should be noted that some red bags used for this purpose
may not be colour-fast.
c.
Heat-labile linen (Category 2.1.3) containers should be coloured white with a

prominent orange stripe.
The use of red for infected material should be regarded as mandatory and the
use of blue or yellow for this type of laundry should be avoided
d.
Schedule 2
Performance Standards - Key Performance Indicators

Description
Tolerance
Financial
Penalty
SSG Proposed Escalation Procedure
Factory
to
monitor
daily. No
more
than 3%
shorts of
each
specificat
ion
volume
supplied
per
invoice
period.
0.1% credit of
total invoice for
every 1%
above 3%
tolerance
If at the end of the month Sunlight

has failed to provide the service
within the tolerance stated the
General Manager will be notified.
They will work with the Trust
authorised officer to resolve the
issue by the end of the following
month. If Sunlight fail to rectify this
by the end of the second month the
Sunlight Regional / Business
Development Director will be
notified who will work with a Senior
Trust Representative to resolve the
issue. If the failure is not resolved
by the end of the 3rd month the
Commercial Director of Sunlight will
be notified. At this point the Trust
can issue a "PERFORMANCE
NOTICE" in line with the PaSA
Terms and conditions of the
contract. If the failure is still not
resolved by the end of the fourth
month the Trust may issue a
"REMEDY NOTICE" in line with the
PaSA Terms and Conditions of the
contract, giving Sunlight 30 days to
Actions to be undertaken
by Contractor
1. Each delivery meets ordered
requirements with no shortages,
provided ordered requirements
are no more than 120% of
average daily order. If a
shortage does occur, the
customer must be informed by
10.00am on the day of delivery
and remedial actions agreed to
rectify the stock shortage within
24 hours. If the shortage is not
rectified with 24 hours the first
stage of the escalation
procedure will be implemented. If
it is not rectified within the next
24 hours the second stage of the
escalation procedure will be
apply with a performance notice
being issued if a further 24 hours
passes without resolution.
remedy the failure to the Trust's

reasonable satisfaction. If at the
end of the 30 days the failure is still
not remedied, the Trust may serve
written notice of "TERMINATION
OF CONTRACT" in line with the
contract.
2. Clean linen is delivered to

designated location(s) during 2
hour delivery window which has
been agreed with the NHS client.
If the delivery will be outside of
the delivery window, the
customer must be informed prior
to the earliest time within the
agreed delivery window.
Factory
to
monitor
daily. No
more
than 2
late
deliveries
per
invoice
period.
As long
as delays
are within
Sunlight
control.
0.1% credit of
total invoice for
every delivery
outside the 2
times delivery
tolerance

contract.
3. Soiled linen is collected from

designated location(s) during the
2 hour delivery window which
has been agreed with the
participating NHS client. If any
on site logistics prevent this from
being achieved this must be
immediately communicated to
the NHS client and remedial
action taken within a 24 hour
period.
Factory
to
monitor
daily. No
more
than 2
late
collection
s per
invoice
period.
0.1% credit of
total invoice for
every collection
outside of the 2
times collection
tolerance
4. Provide evidence of the wash

processes utilised within the
factory. Including:-(i)
Water usage
(ii)
Water retention
(iii)
Detergent dosing
(iv)
Acidity/alkalinity
(v)
PH
(vi)
Temperature at
least 72oC for 3 mins or 65 oC
for 10 mins.
(vii)
Reflectance tests
average of 20 items
Tests to
be
complete
d on a 4
weekly
basis
minimum
and
results
supplied
to
customer
.
Variations from
standards to
trigger full
investigation
and start the
escalation
process

contract.
If any part of the laundering process
that is key to ensuring UHL is not
put at risk fails an alarm system
sounds immediately in the factory.
The machine will cease operating
automatically and reparative action
can be taken before the machine is
put back into service again. At this
point, Sunlight must notify the Trust
immediately and in writing if a
system/ operational failure will
affect delivery to the Trust or if linen
has already been delivered that has
been compromised or affected
before the detection of the
system/production failure. If at the
end of the 4 week period any issues
have arisen Christeyns (External
Company who complete Testing on
all Parts of the Laundry operations)
will rectify these immediately (where
applicable) and will issue the
General Manager with a written
report on the results and any
actions that need to be undertaken
before the next set of tests are
5. EMPA test pieces to be

passed through the wash system
every 6 months. Reflectance
values protein 40% (manual
washer), vegetable dye 48%,
vegetable oil 50% and mineral oil
50%.
Tests to
be
carried
out every
6
months.
Variations from
standards to
trigger full
investigation
and start the
escalation
process
carried out. If the failure is not

resolved by the end of the 4 week
period the Commercial Director of
Sunlight will be notified. At this point
the Trust can issue a
"PERFORMANCE NOTICE" in line
with the PaSA Terms and
conditions of the contract. If the
failure is still not resolved by the
end of the fourth month the Trust
may issue a "REMEDY NOTICE" in
line with the PaSA Terms and
Conditions of the contract, giving
Sunlight 30 days to remedy the
failure to the Trust's reasonable
satisfaction. If at the end of the 30
days the failure is still not remedied,
the Trust may serve written notice
of "TERMINATION OF
CONTRACT" in line with the PaSA
Terms and Conditions of the
contract.
If at the end of the 6 months
Sunlight has failed to provide the
information within 4 weeks of the
due date the General Manager will
be notified. They will work with the
Trust authorised officer to resolve
the issue by the end of the following
contract.
6. Demonstrate a system that

ensures:(i)
stained or
contaminated items are diverted
to rewash or special wash
processes
(ii)
damaged items are
diverted to repair or rag
(iii)
any Trust owned
items that are not fit for purpose
should be bagged separately
and returned to the NHS client
Factory
produce
weekly
record
that
details
pieces
processe
d and
rewash
percenta
ge.
Defective items
supplied to
customer to be
replaced free of
charge within
48 hours
7. Linen is finished in
accordance with the agreed
specifications. The tolerance
level of 5% rejects will be applied
to the amount of linen inspected.
Monthly
check to
take
place to
ensure
specificat
ions are
being
met.
Factory
to
complete
internal
quality
check of
100
items on
a weekly
basis and
record
results.
Sunlight
Represe
ntative to
be in
attendan
0.1% credit of
total invoice for
every 1% of
rejects above
the 5%
tolerance
identified by the
customer.
If at the Trusts request Sunlight fail

to provide proof of the weekly
records in relation to the tolerance
stated the General Manager will be
notified. They will work with the
Trust authorised officer to resolve
the issue by the end of the following
contract.
8. Operate best practice to the

security of NHS client owned
items.
ce when
audits
take
place (if
available)

contract.
Factory
will
polymark
all NHS
clients
goods
that are
not
labelled.
Full audit
trail
utilising
duplicate
paperwor
k.

contract.
9. Provide management
information on a monthly basis
which shows:
(i)
monthly usage
volumes (standard Sunlight
reports)
(ii)
quality checks at
factory and site
(iii)
complaints
(iv)
van disinfection
(v)
customers own
work issues
(vi)
receipt of clinical
waste
(vii)
delivery
times/procedures
To be
produced
monthly
and
forwarde
d to NHS
client
within 10
days of
month
end.
10. Demonstrate an appropriate

complaints procedure that
ensures that any complaints are
responded to within 48 working
hours to UHL representative on
each site
All
complaint
s to be emailed to
the
helpdesk
(charnwo
od.servic
e@sunlig
ht.co.uk)
and
Commer
cial
Manager
(Johnny.
Wright@
sunlight.c
o.uk) at
the
Leicester
facility

has failed to provide the information
issue within the 3 day timescale. If
Sunlight fail to rectify this before the
next due date for the report the
contract.
If a response has not been received
within 48 working hours of the
complaint being sent the General
Manager will be notified. They will
work with the Trust authorised
officer to resolve the issue within
the 7 day timescale (Where this is
not practical a timescale will be
agreed between both parties for the
resolution of the issue) . If Sunlight
fail to rectify this within the agreed
timescale the Sunlight Regional /
Business Development Director will
be notified who will work with a
Senior Trust Representative to
resolve the issue (within an agreed
timescale). If the failure is not
resolved by the end of the 3rd
month the Commercial Director of
Sunlight will be notified. At this point
the Trust can issue a
"PERFORMANCE NOTICE" in line
with the PaSA Terms and
conditions of the contract. If the
failure is still not resolved by the
end of the fourth month the Trust
may issue a "REMEDY NOTICE" in

line with the PaSA Terms and
Conditions of the contract, giving
Sunlight 30 days to remedy the
failure to the Trust's reasonable
satisfaction. If at the end of the 30
days the failure is still not remedied,
the Trust may serve written notice
of "TERMINATION OF
CONTRACT" in line with the PaSA
Terms and Conditions of the
contract.
10a
11. Verify disinfection of linen

using microbiological testing
including:(i)
Log kill of >5 on all
washing machines when testing
for Escherichia Coli and
Enterococcus hirae.
(ii)
Bioburden of final
clean product for Coliforms,
Escherichia Coli, Enterococci,
Staphylococous aureas, Bacillus
cereus, Clostridium difficile
achievement of <3 colony
forming units per 100cm2 of
linen tested.
(iii)
Employees hands
for Coliforms, Escherichia Coli,
Enterococci, Staphylococous
aureas, Bacillus cereus,
Clostridium difficile.
(iv)
Air settle plates
tested for environmental
bacteria, yeasts and moulds.
(v)
Machine process
waters.
(vi)
Swabs of delivery
van interiors.
(vii)
Swabs of delivery
cages.
Resolutio
n of
complaint
s to be
within 7
days if
possible.
6 weekly
microbiol
ogical
testing to
be
complete
d.
as above
Variations from
standards to
trigger full
investigation
and start the
escalation
process
If at the end of the 6 week period

Sunlight has failed on any of the
key criteria highlighted via the
microbiological testing the General
Manager will be notified
immediately. They will work with the
microbiologists to ensure the issues
are resolved by the end of the next
testing period. If Sunlight fail to
rectify this by the end of the next
testing period the Sunlight Regional
Director will be notified who will
work with the General Manager and
microbiologist to resolve the issue.
If the failure is not resolved by the
end of the 3rd period the
be notified. If the failure is still not
contract.
12. Verify disinfection of delivery

vans following unloading of dirty
linen and before clean linen and
report results to NHS client.
Daily
check
sheets to
be
complete
d by
drivers.
Van
testing to
be
included
in 6
weekly
microbiol
ogical
testing.
13. All linen must comply to UHL

agreed standards including
fabric, reflectivity and fire
retardency.
No
change
to
specificat
ion
without
agreeme
nt of UHL
Variations from
standards to
trigger full
investigation
and start the
escalation
process
If at the end of the 6 week period

Sunlight has failed to provide the
information required or failed to
pass the microbiological testing the
General Manager will be notified
immediately. The General Manager
will liaise with the Trust Authorised
Officer to ensure this is resolved by
the next test date. They will work
with the microbiologists to ensure
the issues are resolved by the end
of the next testing period. If
Sunlight fail to rectify this by the end
of the next testing period the
Sunlight Regional Director and
Senior Trust Representative will be
notified who will work with the
General Manager and
microbiologist to resolve the issue.
If the failure is not resolved by the
end of the 3rd period the
be notified.At this point the Trust
contract.

contract.
Actions to be undertaken
by the Customer
1. Soiled linen is collected at
timely intervals to ensure that
sufficient soiled linen is returned
for processing.
2. No site logistics prevent the
linen from being delivered or
collected within the agreed
delivery/collection window.
3. Linen supplied is used for the

purpose it is provided. Any linen
that has been abused and would
not be fit for reuse will be
charged to the NHS client at full
replacement cost.
4. Any heavily soiled articles
should be sluiced prior being
returned to the factory for
processing.
5. Cages provided should be for
the use of transporting linen only.
6. No clinical waste should be
returned to the factory. This is a
severe health and safety risk.
7. Ensure that bagging
procedure is adhered to.
Factory
to
monitor
volumes
returned.
Factory
to
monitor
and
report in
monthly
review if
any
issues.
Monitore
d at
factory
level, 5%
tolerance
.
Monitore
d at
factory
level.
Monitore
d on site.
Disposal
of clinical
waste will
be
charged.
Overarching Statements
Financial penalties identified in the table will apply for failure of service standards within each
invoice period.
Any Financial Penalties as a result of the Performance Notice being issued are in addition to
any financial penalty as a result of a failure identified against any individual performance
measure identified in the financial penalty column of the performance measurement table
above.
If Sunlight fail to the extent that there are at least 3 Performance Notices active at any one
time, the Trust can issue a Remedy Notice ( for one or more of the Performance Notices),
irrespective of whether the Performance Notice(s) has reached the end of its period or not. If
by the end of the 30 day Remedy period there were still 3 or more active Performance Notices
( or 3 or more active Remedy Notices), then the Trust may issue a Notice of Termination of
Contract in line with the PaSA Terms and Conditions of the Contract.
A notice of Termination of Contract may also be issued at any time in line with the PaSA
Terms and Conditions of Contract.
Schedule 3
Menu of Services
Basic Service
1. The service will include collecting soiled linen and delivering clean linen.
2. At the discretion of each Trust, items will be collected from and delivered to either:
a) a single drop/collection point per Trust or
b) up to 3 points within a single Trust inside a 3-mile radius.
3. Linen will be delivered/collected once per day
4. This service will include traveling the distances required to deliver to all Trusts you
have selected within each region.
5. Delivery and collection will take place during business hours, and/or at night in the
London region
6. The Service will be carried out 5 days per week, Monday through Friday. However
Linen Hire and Total Linen Management stock levels provided must be sufficient for
each day of the week (weekend volume)
7. The frequency of Linen delivery for Total Linen Management service will be carried out
as necessary to maintain the agreed-upon linen stock levels
8. The service will include use of rolling cages
9. Clean linen will be packed in bulk, except for Total Linen Management, where pack to
ward is part of the service
10. Packed to bulk linen will include a plastic cover
11. For Linen hire and Total Linen Management services, management of agreed-upon
stock levels will be included
12. Trust owned linen will be laundered and return to each Trust within 72 hours
13. The service will exclude bank holidays
14. Trusts will use the suppliers standard colour coding for soiled linen bags
15. The items will include the 46 categories listed in the Offer Schedule for each region
16. The product items will be either:
a) Standard supplier product range (Linen Hire or Total Linen Management
Services) or
b) Trust owned linen (Wash and Return)

17. The service will include automated folding as applicable
18. Clean line will have the suppliers finish as appropriate to the linen article (e.g.
calendared finish for sheets, etc)
19. For Trust-owned items, linen repair services are excluded, but for Line Hire and Total
Line Management, they are included
Service variations and enhancements to Basic Service

Transportation
Adjustment for each additional delivery point over and above those included in the
basic service
Frequency of Service
Each additional drop/collection required per day

Discount for each business day deducted from the 5 day per week service included in
the basic service
Saturday service
Sunday service
Bank holiday service, excluding Christmas and Boxing Day
Discount for extending Trust-owned linen turnaround time to two weeks from 72 hours
Discount for extending Trust-owned linen turnaround time to 1 week from 72 hours
Turnaround time of 48 hours for Trust-owned linen
Turnaround time of 24 hours for Trust-owned linen
Packing
Pack to ward onsite

Pack to ward offsite
Fabric Type (Applicable items within flat work)
100% Cotton (if not supplier standard)

80% Polyester 20% Cotton (if not supplier standard)
70% Polyester 30% Cotton (if not supplier standard)
Finish/Presentation
Hand finish
Hand fold
On hangers (when applicable)
Additional Services (Applicable to basic service)
Repair service for Trust owned linen

Distribution of linen
Soiled linen collection from ward
Schedule 4
KEY FINISH DEFINITIONS

Standard of Finish
Definition
Condition of receipt
Staining
Major stain
The actual state of an item on return from the Offerer to the Trust
A noticeable variation in colour caused by residue soiling
A fresh stain that is clearly visible and greater than 2cm in
diameter in any area of the article.
A stain of less intensity but still fairly visible to the naked eye and
greater than 4cm in diameter.
A stain which is embedded on to the weave of the material and
which has been washed twice through the normal wash process.
Likely types of staining will be mildew, iron or rust, concrete or
floor marking and medical products. Transfer these products to
the rewash process. Products which are stained with a medical
consumable will need to be discussed with the Trust.
Any stain which falls in the definition of a major or minor stain or
any stain on theatre linen
An alteration to an article which returns it to a serviceable
condition
An article which may have been repaired but requires no further
repair
Theatre linen NO HOLES or perforations are permissible.
Neither are any foreign bodies, tape, plaster of Paris and visually
lint free
All other linen a hole in an article greater than 2 cm in diameter
Material overlap. Definite fold ridges in an article.
Defined as evidence of surface deformation. A wavy distortion
across an article not expected on an ironed finished
Any shrinkage of the article which makes the article ineffective or
unpractical for use
Articles should not have any unpleasant residual odour
Edges should be folded together and squarely, with no overlap
All products must feel dry to the touch.
Articles which feel harsh, particularly towels, nappies etc are not
acceptable for use
A dry cleaning process is required to effect removal of such
stains for the articles to be acceptable for use. Acceptability will
be the decision of the Authorised Officer for the linen article
concerned. These items must then be wash to assure thermal
disinfection
Minor stain
Permanent Stain
Unacceptable stain
Repair
Repair free
Hole
Creasing
Wrinkling
Unacceptable dimensional
distortion
Odour
Presentation
Dampness
Feel
Stains relating to
grease/oil/plastics
Schedule 5
STANDARDS OF FINISH
Linen Item
Standard of Finish
Sheets and
CounterpanesCalender finish
Slight creasing allowed along any edges but must not exceed 15cm
from the edge of the sheet. No creasing allowed in any other area.
Holes are only permitted within 15cm from the edge but must
exceed 2cm in diameter.
Slight creasing is allowed within 15cm of the hemmed edges.
Slight creasing allowed towards both ends of the selvedge edges
but no creasing allowed within the centre section of the selvedge.
Holes or tears are permitted within 15cm from the hemmed edge
but must not exceed 2cm in diameter or length.
Creasing allowed around the opening end and the internal flaps.
Slight creasing allowed near to seamed edges. No creasing
allowed in any other area.
Slight creasing/wrinkling allowed in all areas of the article.
Draw sheetsCalender finish
PillowcasesCalender finish
BlanketsFully dried and folded
TowelsFully dried and folded
Duvet coversFully dried and folded
Scrub suits/Pyjamas
Uniforms/white coats
Trousers
Patients
gowns/nightwear
Curtains (unlined)Calender finish
Curtains (lined or for
dry cleaning)
Slight creasing/wrinkling allowed in all areas of the article.

Slight creasing is allowed near to the seamed edges and around
the opening end of the duvet cover. No creasing allowed in any
other area.
Standard tunnel finish which will include minor creasing allowed
around the collar and along seams and slight creasing and
wrinkling under the armpits and crotch area. Slight wrinkling around
tapes.
Standard tunnel finish as above. The Offerer to be responsible for
the replacement of buttons and other fastenings if damaged during
the laundering process.
Standard tunnel finish as above.
Standard tunnel finish as above.
All selvedges must be crease free. Only very light wrinkling allowed.
Dimensional distortion should not exceed three inches and returned
stacked in cages
Crease free, lightly folded vertically only and returned on separate
coat hangers
Appendix 2
SERVICE REQUIREMENTS
Sunlight Services Group will provide to the Authority a Linen Hire/Launder
service in accordance with the Framework Agreement Service Specification and the following summary of
service;
1. The Basic Menu of Services as defined within the National Framework Specification.
http://nww.pasa.nhs.uk/outsourcing/shared/fmservices/laundry_specification.doc
2. Optional National Enhancements as defined within the National Framework Agreement;
Enhancement
Applied
Contract term (3 7 years)

Transportation
Number of delivery points required

Frequency of Service
Number of drops / collections required per day

Number of business days service require
Saturday service
Sunday service
Bank holiday service (excluding Christmas &
Boxing Day)
Packing
1
6
Yes
No
No
Pack to ward onsite / offsite

Finish / Presentation
No
Hand finish (where applicable)

Hand fold (where applicable)
On hangers (where applicable)
Additional Services
N/A
N/A
N/A
Soiled linen collection from ward

Repair service for Trust owned linen
Distribution of linen [WR & LH only]
Non-standard surgical barrier fabrics
Inspect, pack and fold theatre drapes
New stock purchase
No
No
No
No
No
No
EFM/Laundry/Pro/2008
Details
1st April 2008
Appendix 3
Appendix 1
PaSA Prices for
Linen Hire Service
Item Description
APRON
BLANKET - COT
BLANKET - CRIB
BLANKET-THERMO
BLNKT.CELL.BED
BOILERSUIT
CANVAS - WHITE
CLOTHS-OVEN
COATS-WHITE
COVERS-DUVET
CURTAIN
CURTAIN-LARGE
DRESS-NIGHT
DRESS-NIGHT
GOWNS-CHILDRENS
GOWNS-DRESSING
GOWNS-PATIENT
JACKETS-CHEFS
JACKETS-PYJAMA
MATS-BATH
MISCELLANEOUS
MISCELLANEOUS
MOPS
MOPS
NIGHTSHIRTS
PILLOWCASES-WHITE
PLASTIC BAG-RED
PLASTIC BAG-WHT
PLASTIC PURPLE
S/BOT COB L
S/BOT COB M
S/BOT COB S
S/BOT COB XL
S/BOT COB XXL
S/TOP COB L
S/TOP COB M
S/TOP COB S
S/TOP COB XL
S/TOP COB XXL
Price per Piece

0.235
0.255
0.255
0.285
0.285
0.600
0.335
0.205
0.320
0.335
2.100
2.100
0.265
0.265
0.135
0.385
0.265
0.320
0.265
0.255
0.250
0.250
1.600
1.600
0.265
0.175
0.085
0.085
0.085
0.265
0.265
0.265
0.265
0.265
0.265
0.265
0.265
0.265
0.265
SCR/BOT CEIL LRG

SCR/BOT CEIL MED
SCR/BOT CEIL SML
SCR/BOT CEIL XLG
SCR/BOT CEIL XXL
SCRB MISTY BTM LGE
SCRB MISTY BTM MED
SCRB MISTY BTM SMLL
SCRB MISTY BTM XLG
SCRB MISTY BTM XXLG
SCRB MISTY TOP LRG
SCRB MISTY TOP MED
SCRB MISTY TOP SML
SCRB MISTY TOP XLGE
SCRB MISTY TOP XXLG
SHEET - CRIB
SHEET SLIDE
SHEETS-DRAW
SHEET-TOP WHITE
SS T L CEIL
SS T M CEIL
SS T S CEIL
SS T XL CEIL
SS T XXL CEIL
TENDERCARE/SPENCO
TOWEL-BATH STAFF
TOWELS-BATH
TOWELS-TEA
TROUSER-PYJAMA
TROUSERS-CHEFS
UNIFORMS
BAGS-WATER SOLUBLE
BLANKET - COT
BLANKET - CRIB
BLANKET-THERMO
BLNKT.CELL.BED
CANVAS - WHITE
COVERS-DUVET
COVERS-DUVET
CURTAIN-LARGE
CURTAIN-LARGE
DRESS-NIGHT
GOWNS-DRESSING
GOWNS-PATIENT
JACKETS-PYJAMA
MATS-BATH
MISCELLANEOUS
MOPS
0.265
0.265
0.265
0.265
0.265
0.265
0.265
0.265
0.265
0.265
0.265
0.265
0.265
0.265
0.265
0.175
0.300
0.255
0.265
0.265
0.265
0.265
0.265
0.265
4.750
0.185
0.185
0.235
0.265
0.320
0.260
0.308
0.255
0.255
0.285
0.285
0.335
0.335
0.335
2.100
2.100
0.265
0.385
0.265
0.265
0.255
0.250
1.600
NIGHTSHIRTS
PADS-INCO
PILLOWCASES-WHITE
PLASTIC BAG-RED
PLASTIC BAG-WHT
SHEETS-DRAW
SHEET-TOP WHITE
TOWELS-BATH
TROUSER-PYJAMA
BAGS-WATER SOLUBLE
BLANKET - COT
BLANKET - CRIB
BLANKET-THERMO
BLNKT.CELL.BED
CANVAS - WHITE
CURTAIN-LARGE
DRESS-NIGHT
GOWNS-DRESSING
GOWNS-PATIENT
JACKETS-PYJAMA
MATS-BATH
MOPS
NIGHTSHIRTS
OVEN CLOTH
PILLOWCASES-WHITE
PLASTIC BAG-RED
PLASTIC BAG-WHT
SHEET-COT 54X90
SHEETS-DRAW
SHEET-TOP WHITE
TOWELS-BATH
TROUSER-PYJAMA
BLANKET - COT
BLANKET-THERMO
BLNKT.CELL.BED
COVERS-DUVET
GOWNS-CHILDRENS
GOWNS-PATIENT
JACKETS-PYJAMA
PILLOWCASES-WHITE
PLASTIC BAG-WHT
SHEETS-DRAW
SHEET-TOP WHITE
TOWELS-BATH
0.265
0.300
0.175
0.085
0.085
0.255
0.265
0.265
0.265
0.308
0.255
0.255
0.285
0.285
0.335
2.100
0.265
0.385
0.265
0.265
0.255
1.600
0.265
0.205
0.175
0.085
0.085
0.175
0.255
0.265
0.265
0.265
0.255
0.285
0.285
0.335
0.135
0.265
0.265
0.175
0.085
0.255
0.265
0.265
Laundry returns procedure BNHFT

Purpose
This procedure offers a simple flow chart action for the return of faulty or substandard clean laundry
provided by our contract service provider.
fig 1) Action flow chart:

Supply of Pink bags
Pink Polythene Bag (Size 15x29x39 inches 40 micron) order Roll of 50 from supplies.
Reject item identified
Substandard product
Torn / poor repair
Dirty / stained
Poor folding or aesthetic look
Return of reject item to linen

room
Replace item for ward / user
Place item in green plastic bag

and place in returns bin in linen
room.
Laundry team to send

replacement items if required.
Record of items returned
Review of monthly KPI
Laundry team to log on KPI daily

sheet items rejected.
Review of KPI outcomes with

Supplier and Laundry
Management team.
Resolve and communicate
actions
Return to supplier
Items returned to supplier at
delivery/collection, in Pink bag
marked with reject label
Appendix 5
Business continuity plan contract supplier
THE SUNLIGHT SERVICE GROUP LTD, HEALTHCARE DIVISION
TECHNICAL ABILITY & CONTINGENCY

INTRODUCTION
We are able to ensure that there will always be sufficient stock in the system to provide correct levels at the point
of use. This is as a result of the stock holding agreed with Sunlights suppliers, the significant investment that is
made by Sunlight to ensure that the correct amount of stock is installed upon commencement of its contracts and
the continuing investment in stock replenishment during the contract term.
We would propose to leave at least 25% of the daily requirement of linen products in the linen room on site for the
Trust to use as necessary. However, separate emergency cupboards can be provided at other locations within
the Hospital as required.
Sunlight has a bonded warehouse, consistently topped up to a level of 1,000,000, which provides enough linen
to start up two 500 bedded hospitals. This arrangement is by firm contractual agreement with our partner
provider Standard Textile who have planned production in anticipation of our requirements against our
guarantees to purchase.
During working hours Sunlight maintain a special request call out service which will respond within 3 hours for
any urgent linen requirements. Out of hours we operate a call out procedure for emergencies with a maximum
response time of three hours. In the event of major breakdown at our factory we are able to call on spare
capacity at other factories within our division and sister divisions.
Any events that would result in a possible disruption to the supply of service will be communicated at the earliest
convenience to the Trust via the servicing factory.
Our contingency arrangements will be fully operational within 24 hours.
Weekly Capacities
Factory
Basildon
Brixton
Chesterfield
Leicester
Rubery
Whitley
Camberwell
Shrewsbury
Throughput
333,000 pieces
1,112,000 pieces
263,000 pieces
947,000 pieces
361,000 pieces
436,000 pieces
160,000 pieces
150,000 pieces
Spare Capacity
57,000 pieces
61,000 pieces
87,000 pieces
250,000 pieces
50,000 pieces
150,000 pieces
100,000 pieces
150,000 pieces
Chatham
277,000 pieces
28,000 pieces
MAJOR INCIDENT PROCEDURE

FACTORY DOWNTIME
Incidents causing loss of processing time and potential shortages of product to customers must be categorised so
that the appropriate actions can be taken to minimise the effects.
Incidents are categorised based upon the nature of the incident and an estimate of the amount time that it will
take to resume processing at a normal speed.
There are arrangements in place within Sunlight to provide production cover in the event of a breakdown.
The following matrix should be used to decide what action is required:
INCIDENT
Machinery Fire
ESTIMATED
DOWNTIME
< 4 hours
Machinery Fire
> 4 hours
Linen Fire
N/A
Main Washer
Breakdown
All machines
< 4 hours
Main Washer
Breakdown
All machines
> 4 hours
ACTION
Check on
parts
availability
and assess
impact
Check on
parts
availability
and assess
impact
Estimate loss
and the effect
on order
fulfilment
Check on
parts
availability
and assess
impact. Place
other factories
on alert
Extend shifts
and advise
other factories
MANAGEMENT
RESPONSIBILITY
General Manager,
Production
Manager, Engineer
MONITORING
CONTINGENCY
Hourly from first

report
Plan to go to
extended shifts if
required
General Manager,
Production
Manager, Engineer
Hourly from first

report
Plan to go to
extended shifts if
required
General Manager
Operations Director
Main Board if total
loss
Every 2 hours
General Manager,
Production
Manager, Engineer
Hourly from first

report
Advise suppliers
of incident and
arrange for
immediate
delivery of
contingency
stocks. Other
factories to
support with
processing, if
necessary.
Plan to go on
extended shifts if
required
General manager,
Production
Manager, Engineer
Hourly from first

report
Other factories on
standby
FACTORY DOWNTIME - CONTINUED

INCIDENT
Electricity CutOff
ESTIMATED
DOWNTIME
< 4 hours
Electricity CutOff
> 4 hours
Boiler
Breakdown
< hour
Boiler
Breakdown
> hour
Break in
Water Supply
< hour
Break in
Water Supply
> hour
Break in Gas
Supply
< hour
Break in Gas
Supply
> hour
ACTION
Alert other
factories of
incident and
put them on
standby
Generator on
site within 10
hours. Alert
other factories
Check on
parts
availability
and assess
impact
Start spare
boilers
Alert other
factories of
incident and
put them on
standby
Advise other
factories that
processing
time is
required.
Tankers
onsite within 2
hours
Switch to fuel
oil
Switch to fuel
oil
MANAGEMENT
RESPONSIBILITY
General Manager,
Production
Manager
MONITORING
CONTINGENCY
Hourly from first

report
Contact electricity
supplier
General Manager,
Production
Manager,
Engineers
Hourly from first

report
General Manager,
Production
Manager, Engineer
Constantly
Internal logistics
to be arranged.
Arrange for
generator to be
brought on site
No action
General Manager,
Production
Manager, Engineer
General Manager,
Production
Manager, Engineer
Hourly from first

report
General manager,
production
Manager, Engineer
Hourly from first

report
Constantly
General Manager,
Production
Manager, Engineer
General Manager,
Production
Manager, Engineer
In all instances Operations Director to be made aware, in their absence Commercial Director.
Plan to go to
extended shifts if
required
Plan to go to
extended shifts if
required
Contact
Operations
Director. Ask
them to start
arranging tanker
deliveries
DISASTER RECOVERY PLAN

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

-
Internal Contact Details

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

Duties
Customer contact and any arrangements for transfer
Important telephone numbers for key Sunlight personnel
Directory for suppliers in relation to:-
Directory for essential services including:-
Buildings
Demolition
Electrics
Boilers
Pipework
Buildings
Plant
Generators
Cleaning
Water treatment
Compressors
Utilities
Repairs
Directory for fire alarms and sprinklers and security alarms

Directory for sundry suppliers
Directory for transport suppliers
Directory for linen suppliers
Pre-printed letters for:Note:
Customers
Suppliers
Local Residents
In the event of a major outbreak which affects a geographical area it is assumed that
the Disaster Recovery Plan would be invoked
MAJOR INFECTION PROCEDURE INCLUDING BIRD FLU

Introduction
An outbreak of infectious disease may affect Sunlights service in a number of ways:
1.
Where infection is localised to a hospital or department and there is a requirement for the linen service to
be adjusted to support the hospital whilst the outbreak is contained and eliminated. An example of this
might be Norwark Like Virus, bacterial food poisoning or other communicable diseases confined
geographically. It is unlikely that, with normal precautions, Sunlight staff will be directly affected through
personal illness.
2.
Where infection is widespread in the community and its effects are amplified within the hospital by virtue
of patient contact e.g. seasonal influenza or bird flu. It is likely that Sunlight staff will be affected by
normal daily contact in the community as well as being exposed within the hospital. Additionally staff
who must act in the role of carer are likely to be unavailable for work. It is possible in a major outbreak
25% of staff could be affected.
3.
Where Sunlight is supplying hospitals with bed linen, towels etc an increase in volume requirement may
result due to the increased number of patients treated, but this may be balanced by a reduction in
elective treatments. An increase in the processing of bed curtains may also result. An increase in the
proportion of infected linen within the returned linen is to be anticipated.
General
1.
Sunlight will be advised of a major outbreak by the Trust Infection Control Team. This must be within 24
hours of the outbreak in order that staff at factory level can be issued with the relevant protective
equipment as deemed necessary and arrangements can be made for any on site staff.
2.
The Sunlight General Manager will act as the local liaison with the Trust. The Operations Director will
also be advised and kept up to date with progress.
3.
The Production Manager will replace the General Manager should the latter become ill or otherwise
unavailable. However this deputisation should be used in an emergency only.
4.
When based at hospitals, Sunlight staff should avoid contact with other hospital staff to the greatest
extent possible commensurate with their duties.
Management
1.
In the event of a major outbreak affecting a significant geographical area and hence a number of
Sunlight sites, the Managing Director will convene a Sunlight Crisis Team to oversee service provision
and use the network of services.
2.
Sunlight is unique in having extensive contingency not only within the healthcare division, but the sister
divisions of linen and workwear who could assist with both personnel deployment and factory processing
capacity in the event of a major outbreak such as bird flu or seasonal influenza. In such cases Sunlight
would convene a high level meeting consisting of Main Board members and Managing Directors of all 3
divisions to discuss the operational profile of the business.
3.
A Key Contact to interact between both the Trust and Sunlight will be established and confirmed to the
Trust. In the first instance it is assumed that this will be the General Manager of the processing factory
with the back up of the Operations Director.
4.
It is the responsibility of this Key Contact Manager to fully understand the impact and depth of the major
outbreak that is being managed in order that sufficient resources are available to support the NHS and
the necessary arrangements can be made once it is understood the nature of the outbreak.
5.
In the event of a major outbreak the necessary arrangements in relation to linen usage within the Trust
must be understood by the Key Contact in order that the correct volumes can be supplied.
6.
The Trust and Sunlight will liaise to understand how the linen returned from the infected areas is to be
collected and processed. In the case of a Trust wide breakout then all linen must be bagged as infected
and will be subjected to washing procedures as outlined in HSG 95 (18). When an outbreak is isolated
to certain wards or departments, only linen utilised within these areas should be bagged as infected in
order that specialist processing is actioned.
Workload
1.
Factories will expect to experience an increase in workload with reduced staff numbers. Overtime
working and the employment of temporary staff may need to be actioned.
2.
Sunlight has unique arrangements within its organisation to source staffing from outside the UK, in
excess of 2,000 personnel are available for immediate employment. It is anticipated that these staff will
be established and trained for work within a 5 day period.
3.
Transfer of staff from other Sunlight factories will be arranged to ensure that service to the NHS is
maintained.
4.
At laundry sites, temporary staff should be preferentially placed in work areas dealing with clean
product. Experienced Sunlight staff should be redeployed to the dirty area.
5.
At laundry sites, management should pay particular attention to segregation of work and should minimise
staff movement between dirty and clean area.
Staff and Work Practices

1.
Staff who are infected by a contagious disease, or who suspect they may be infected, should not attend
work. The site should be alerted by telephone. Staff should not return to work for an appropriate period
after cessation of the symptoms as advised by a General Practitioner.
2.
Personal hygiene will be more than normally important. Frequent and thorough hand washing is
essential. Alcohol hand disinfectant (95% ethanol) is already made available and hand drying should be
by paper towels. Roller and textile towels should be removed from toilet and wash areas (including
offices) and replaced by paper. Regular microbiological testing is completed within factory operations.
The on site staff will be closely managed by the Contract Manager in order to ensure all preventative
actions necessary are taken.
3.
Segregation protocols must be adhered to on all sites. Unnecessary movement of staff and equipment
between areas must be avoided. Necessary movements must take account of cross infection risks and
minimise these.
4.
The General Manager must ensure that all trolleys, boxes, laundry cages etc are thoroughly washed and
dried in accordance with company procedures.
5.
Laundry transport staff currently ensure that vehicles are disinfected internally after each trip.
6.
At the onset of the outbreak the General Manager should check stock of all disposable, PPE, cleaning
materials, plastic bags, detergents, disinfectants etc and increase stock appropriately. The security of
such stock should be assured to prevent pilferage. Current stocks held for such items are approximately
2 months supply at factory level and 6 months supply with suppliers.
7.
All uniforms (including those worn by engineers etc) must be laundered daily and not taken home. PPE
should be of a disposable type wherever possible and placed in Clinical Waste.
8.
Vaccination (if available) and antiviral drugs will be provided in accordance with local Trust policy.
9.
The following procedures will be actioned if any of the following contaminated linen is returned to the
factory for processing:Anthrax
Standard precautions.
Wash formula will include 100ppm Sodium Hypochloride beach at pH 10.2 to 10.8 for a minimum of 8
minutes at a temperature of 71oC.
Smallpox
The driver and all staff in the sorting area must wear protective gloves and a N95 mask.
All linen must be returned in red bags to be processed as infected linen.
Arrange for microbiologist to visit site and make necessary tests to ensure that the virus is not
transferred to the laundry.
Plague
Botulism
Tularemia
Nerve Agents
No linen or clothing exposed to nerve agents should be returned to the laundry for processing.
Common Areas
1.
Work surfaces must be cleaned before and after every shift. Disposable cloths must be used.
2.
Commonly touched surfaces such as door handles should be disinfected frequently by Sunlight staff.
3.
The General manager (or deputy) must make daily check to ensure that cleaning protocols are adhered
to by sub-contract staff. Disposable mops should be used.
4.
Rest areas must be cleaned thoroughly by cleaning staff and surfaces wiped by Sunlight staff before
each break.
5.
All cups, plates and cutlery must be washed in a dishwasher. If no dishwasher is available disposable
items must be obtained.
6.
Drying of crockery etc should be disposable kitchen towel, if required to be done.
7.
Wherever possible, individuals should limit handling to their own property.
8.
Non-essential items such as magazines should be removed from rest rooms.
9.
The use of equipment that creates excessive air movement such as fans, vacuum cleaners and hand
dryers should be avoided where possible.
Training
1.
At the onset of an outbreak the General Manager should instruct staff in the requirements of this policy.
Additionally, staff should be reminded of all standard precautions outlined elsewhere on the QMS.
2.
On recruiting temporary staff, the General Manager should ensure that they are fully trained in this policy
and the reasons for it.
Linen
Sunlight always has a contingency stock to the value of 1,000,000 which would be sufficient to install 2 x 500
bedded hospitals.
Our suppliers also have further bonded stocks in the United Kingdom that can be called upon, this totals in
excess of 2,000,000.
The linen and workwear divisions have similar arrangements with their suppliers in relation to linen supply. If the
total stocks of healthcare linen specifications were exhausted then this could be substituted with the hotel and
workwear products that are very similar.
Contacts & Escalation Procedure

Servicing Factory:
Postal Address:
Phone Number:
Fax:
E-mail:
Coventry
London Road
Whitley
Coventry
CV3 4AR
02476 504 383
02476 504 359
whitley@sunlight.co.uk
Admin/Credit Control:
Phone Number:
Denise Amos
02476 504 383
Direction of Escalation
Service Solutions Manager:
Email:
Phone Number:
TBC
General Manager:
Email:
Phone Number:
Andrea Warrington
Andrea.warrington@sunlight.co.uk
07967 623841
Key Account Manager:

Email:
Phone Number:
Lindsay Ward
Lindsay.ward@sunlight.co.uk
07971 608016
Service Director:
Email:
Phone Number:
Peter Bennett
Peter.bennett@sunlight.co.uk
07966 212788
Operations Director:
Email:
Phone Number:
Ralph Farmer
Ralph.farmer@sunlight.co.uk
07967 623532

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IC/276/10 Linen Policy

BASINGSTOKE AND NORTH HAMPSHIRE NHS FOUNDATION TRUST

IC/276/10 Linen Policy

IC/276/10 Linen Policy

IC/276/10 Linen Policy

IC/276/10 Linen Policy

6.0 General Linen

IC/276/10 Linen Policy

IC/276/10 Linen Policy

10.0 Garments I Work wear/Boiler suits

IC/276/10 Linen Policy

12.0 Safe Management of Linen

IC/276/10 Linen Policy

14.0 Linen Transportation

Dispose of plastic bag(s) used to carry items promptly

Infected Linen. HSG (95)18 Leeds: NHSE; 1995; 4.

Infection (2001) 47(Supplement): S21S37

IC/276/10 Linen Policy

Linen Segregation Procedure

LINEN SEGREGATION PROCEDURE

Used linen which has been in

Used linen must be placed

ALL BAGS SHOULD BE NO MORE THEN 2/3 FULL

IC/276/10 Linen Policy

Basingstoke and North Hampshire NHS Foundation Trust

Arrangement for thermal infestation/infection control

1. Sunlight service schedule HSG (95)18 and KPI

IC/276/10 Linen Policy

Healthcare linen provided by external laundry contract

Contract performance management with external supplier

This is led by the:

IC/276/10 Linen Policy

3.1 Thermal disinfection of laundry

IC/276/10 Linen Policy

Overall service options

Collection and delivery for all service options

Storage for all service options

Packaging for all service options

Processing of articles of laundry

Standard of finish for all service options

Quality assurance and control for all service options

Key Performance Indicators

Emergency supplies (major incident)

IC/276/10 Linen Policy

Standard service requirements

IC/276/10 Linen Policy

Provision of CE marked reusable barrier theatre textiles in compliance with EN

Service standard for service options1a, 1b and 1c

Collection and delivery for all service options

Storage for all service options

Packaging for all service options

Processing of articles of laundry

For service option 1d

IC/276/10 Linen Policy

Standard of finish for all service options

Quality assurance and control for all service options

Key Performance Indicators

Documentation- management information

Emergency supplies (major incident)

IC/276/10 Linen Policy

Hospital Laundry Arrangements for Used and

IC/276/10 Linen Policy

LAUNDERING PROCEDURES TO SECURE DISINFECTION OF USED AND INFECTED