IPSOP21 Cleaning Management Protocol SOP v1 by Provide Community

Cleaning Management Protocol

Standard Operating Procedure (SOP)

Version: V1

Ratified by:

Infection Prevention and Control Group

Date ratified: 25/06/2025

Job Title of author:

Reviewed by Committee or Expert Group

1. Introduction

Ensuring that healthcare facilities are clean and safe is essential in the provision of effective healthcare. A clean and tidy environment helps prevent and/or control the spread of healthcare associated infections (HCAI), provides the right setting for the delivery of good patient care and is fundamental in helping patients to recover.

This cleaning Standard Operating Procedure (SOP) outlines the measures required to ensure everyone is cared for in a clean, safe, secure healthcare environment:

This will cover:

• Ensuring all relevant parties are aware of the responsibilities for performance of cleaning tasks in each area.

• Staff clinical and domestic are trained and can determine the cleaning methodology

• IPC and E&F will ensure cleaning tasks are performed in a safe, efficient and consistent manner, in compliance with safety legislation.

• IPC team, E&F team in collaboration with the various settings and sites will monitor the cleanliness, share the outcomes of audits and level of compliance.

• Audits will be carried out to ensure the process of cleaning meets the requirements of the organisation and consistent cleaning standards are delivered.

• Faults are rectified in a timely fashion, and star ratings are displayed with cleaning scores regularly analysed

• Steps are taken to ensure continuous improvement of cleanliness through analysis of scores and review of the functional risk (FR) ratings as per the NHS England National standards of healthcare cleanliness 2025.

• Cleanliness outcomes are regularly reported at Board level

2. Purpose

This protocol discusses the principles of cleaning within healthcare environments and defines the responsibility and accountability of healthcare staff using shared multi use clinical spaces/mobile spaces and non-health care settings e.g community halls in ensuring that those principles are adhered to, so that the organisation can be assured that its IPC environmental cleaning measures are robust and appropriate.

The protocol is in relation to implementing the National Standards of Healthcare Cleanliness updates - 2025

3. Types and Methods of Cleans

Clean Type Frequency of clean Description

Routine clean Everyday cleaning as per cleaning schedule The physical removal of contamination and micro-organisms

Enhanced clean On request by IPC or on notification of infection present Method of cleaning using products that provide a level of disinfection

High touch point clean Part of routine clean or on additional request

Clean frequently touched surfaces of a

Chemicals Used

Neutral detergent

Chlorine releasing tablets or disinfectant wipes

Routine. Neutral detergent/disinfectant wipe

Outbreak clean (in the event of an incident/infection concern that occurs within the clinic /treatment room area)

Discharge clean (in the event of an incident/ concern that occurs within the clinic /treatment room area)

Terminal Clean (in the event of an incident/ infection communicable disease concern that occurs within the clinic /treatment room)

4. Duties

during a period of concern designated element e.g. door handle

An enhanced clean requested following a period of increased infection / outbreak

A clean requested following the discharge of a patient from a room or couch space

A clean requested following a consultation or intervention with a known infection or communicable disease

A full and thorough clean of the environment, including furniture, furnishings and fittings

Chlorine Tablets and Disinfectant wipes (1000 PPM) as advised by IPC

Completed when any patient leaves the clinic / treatment room Routine. Neutral detergent unless advised by IPC

Completed when the patient has vacated the clinic / treatment area or is no longer infectious

Chlorine releasing tablets (1000ppm) and / or use alternative disinfection cleaning as advised by IPC

• The Board and the Chief Executive have collective responsibility for infection prevention and control

• The Director of Infection Prevention and Control (DIPC) is responsible for overseeing the SOP

• Assistant Directors are responsible for ensuring that the policies are implemented in their clinical areas and that the appropriate equipment is available for all staff to access.

• The Infection Prevention and Control Team (IPCT) is responsible for developing the SOP and for the provision of expert advice on the management with collaboration with E & F, Service lead and the Domestic Supervisor

• Ward/divisional leads are responsible for ensuring staff compliance with this SOP

• Estates & Facilities are responsible for ensuring that waste management and environmental cleaning policies and guidelines are kept up to date

• Housekeeping staff have been trained to undertake terminal cleans and routine cleaning of isolation areas/rooms and are aware of the sequence and frequency of cleaning these areas

5. Determining the cleaning responsibilities

Cleaning is a vital part of the overall IPC process, which aims to provide a clean,

hygienic environment for delivering patient care. Areas that are not cleaned properly could aid the transfer of harmful organisms in a healthcare environment, potentially causing infection.

All members of the cleaning team, as well as healthcare staff and anybody else undertaking cleaning tasks, should be clear about their roles and responsibilities.

Roles/Responsibilities of Cleaning Furniture/Equipment in Patient Areas

All spillages of bodily fluids must be cleaned up by nursing staff following the procedure set out in the Infection Prevention and Control Manual. The domestics will be advised of the area needing to be cleaned after the nursing staff have attended appropriately to the blood / body fluid spillage.

The cleaning references detailed below apply for all cleaning except where there is a known or suspected enteric infection e.g. Norovirus/Clostridioides difficile.

All general services cleaning schedules for healthcare premises should be accessible or available as agreed by Estates and facilities. Cleaning records on display must be visible dated and signed by the site cleaning staff for the designated area e.g clinical/consulting room/kitchen/ toilet area.

Estates Department carry out Planned Preventative Maintenance (PPM) on certain items however it is the ward/department manager’s responsibility to report any faults between these visits to Estates and record the call log number.

If the cleaning schedule specification for clinical equipment cannot be maintained for any reason, the person in charge of the ward/department should carry out a risk assessment and inform their Line Manager. Equipment cleaning records must be maintained by ward/departmental staff.

6. Examples of responsibility for cleaning

Hoist

Manual handling equipment e.g.

Pat slide and banana slide, walking aids

Mattress and base of bed

Hospital bed frame below mattress base

Therapeutic mattress and motor

DressingTrolleys

Couches

Use of couch role/covers

staff

or Domestics/cleaning operatives

staff

Betweenclientsorweekly if not used.

operatives

Domestics/cleaning operatives

should be risk assessed before use – see appendix 3 Waste receptacles

Empty at end of day/clinic Place at point of collection / wheelie bin as directed by site instructions

Medical equipment- BP machine/pulse oximeter/scales

Clinic staffClinical waste to be removed at end of clinic.

Clinic staff

Domestics/cleaning operativesGeneral waste/dry recycling to be emptied by Domestic cleaning operatives at end of shift

Clinic Staff Clinic staff

Clinic staff between patient use.

7. Cleaning Clinic room checklist - see Appendix 1

• Floors are free from stains and spillage.

• Empty and remove waste – place in waste receptacle.

• Wipe over (disinfect) all touch points e.g. door handles.

• Clean sink and countertop.

• Disinfect medical equipment.

• Dust and damp wipe the furniture

• Remove dirt and debris from the floor and clean

• Declutter workspaces by putting away any unnecessary items

• Wipe over phones, keyboards, and mice.

• Restock paper towels soap and gel dispensers.

• Room/area cleaning schedule on display is signed and dated.

Within a specified clinic room, cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone.

Steps to ensure area and equipment is cleaned ready for the next clinical team's session, this includes topping up and replacing of any consumable supplies used e.g. gloves, aprons. Empty waste bins when waste bag is three quarter full or malodour and replace bin with new waste bag. Segregation and waste disposal should follow EPOL05 Healthcare Waste policy and IPC guidance for the segregation and management of clinical waste SOP.

Step 1.

Carry out hand hygiene before commencing any cleaning as appropriate within the clinic / treatment room

Step 2.

Clean working from top to bottom, clean to dirty and wipe in an S shape to ensure full surface contact

Step 3.

Clean these surfaces – use green clinell wipes for:

Touch points and surfaces - taps, door handles, nurses’ desk work area, hand dispensers

Step 4.

Remove any rubbish posing risk to trip, slips and falls and empty clinical waste bin. Any small, soiled areas and dirty marks - wipe over with clinell wipe Step 5.

Stains, soiling – ensure spillage kits are available for blood/body spillages

On leaving the clinic / treatment area – close windows and doors – lock as appropriate

Clinic room waste

At end of clinic, waste receptacles for clinical/offensive (tiger stripe/) infectious waste (orange) should be emptied ready for next clinic by clinical staff. General waste and dry recycling will be removed by Domestic /cleaning service operatives all waste must be placed at point of collection as directed for site.

8. References

Control of Substances Hazardous to Health Regulations amended 2004 (COSHH)

Control of substances hazardous to health (COSHH) - health and safety topics in cleaning (hse.gov.uk)

Health and Safety at Work etc. Act (1974) amended 2015

Health and Safety at Work etc Act 1974 – legislation explained (hse.gov.uk)

Health and Social Care Act (2008): code of practice on the prevention and control of infections and related guidance (2022)

Health and Social Care Act 2008: code of practice on the prevention and control of infections - GOV.UK (www.gov.uk)

National Institute for Health and Clinical Excellence (NICE) (2020) Pathway for the prevention and control of healthcare associated infections in primary and community care. Healthcare-associated infections | Topic | NICE

National standards of healthcare cleanliness 2025: cleaning policy https://www.england.nhs.uk/publication/national-standards-of-healthcare-cleanlinesscleaning-policy/

Appendix 1: Cleaning Clinic room checklist

Checklist Item

Floors free from stains and spillage, dirt and debris.

Empty and remove waste when waste bag threequarters full or malodour –replace with new waste bag. Tiger stripe waste bag should be used for clinical waste.

Empty at end of session

Place at point of collection / wheelie bin as directed by site instructions

Wipe over (disinfect) all touch points e.g. door handles

Clean sink and countertop

Disinfect medical equipment at beginning of clinic and end of clinic

Wipe over furniture as check clean

Remove any obvious dirt and debris from the floor, including loose papers, wrappings from packaging and wipe over dirt, stain marks.

Declutter workspaces by putting away any unnecessary items

Wipe over desk surfaces, phones, keyboards, frequent touch points

Ensure PPE available and replace consumables- Restock paper towels soap and gel dispensers when required.

Room cleaning schedule on display is signed and dated.

Appendix 2: Flow chart for Clinic room checks

A healthcare environment must be clean and safe for use to ensure all cleaningrelated risks are identified, minimised, and managed on a consistent basis, irrespective of where the responsibility for providing cleaning services lies.

Clinic room is visibly clean floor is free from spillages and soiling, debris, dust- there is a signed cleaning schedule -where a schedule is not visible report to Estates and facilities helpdesk

Wastebinsarefreefromsplashspillages andodour,arefootoperated.Tigerwaste (blackandyellow)stripebagsareinuse forclinicalwasteinclinicroomand replacedwhen¾full.Blood-bodily spillagekitisavailable

MedicalEquipmentiscleanfreefrom dust/soilingandhasafrequencyof cleaningscheduleordatedIamgreen stickerinplace

Hand wash sink is free from clutter, there is soap available in dispenser and paper towels. Handgelavailableatpointofuse in a wall or bottle dispenser

PPE apron/gloves available in Dispenser- aprons stored covered when not in use, and all PPE replaced when empty.

Surfacesarecleanandtouchpointsarefrequently wipedclean,keyboards,telephones,chairs,door handles.Treatmentcouchesarewipedclean betweenpatientsandcouchrollreplaced.Sharps injuryfirstaidposterisavailable.

Appendix 3: Risk Assessment for the use of blue roll/couch covers

Risk Assessment for the use of blue roll/couch covers

1. Use blue roll/paper couch cover to cover area of potential contamination for each patient

2. Upgrade couch to meet this criteria.

Dispose of blue roll/ paper couch cover in appropriate clinical waste bin.

Is the couch material in good condition? I.E. no holes or tears?

Does the patient currently have a known or suspected infection?

Will the patient be likely to leak blood and/or body fluids whilst on the examination couch? (i.e. smear tests, prostate or rectal examinations)

No need to use blue roll or couch covers. Clean the couch before and after each patient contact.

Will the patient have to be fully undressed from the waist down to sit on the examination couch?