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Sunday 25 September 2016
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Keep it clean: national cleanliness specifications for general practice

Premises & Facilities

Graham Jacob

National Lead for Cleaning
National Patient Safety Agency

Graham's repsonsibilities include overall management of the Patient Environment Action Team (PEAT) programme, which assesses inpatient healthcare facilities in England. Graham previously worked for NHS Estates, where he was involved in the development of the original National Specifications for Cleanliness for the NHS, the NHS Cleaning Manual and Guidance on Contracting for Cleaning. He also worked on the Better Hospital Food programme, which aims to ensure consistent delivery of high-quality food to patients

The cleanliness of healthcare premises returned to the agenda with the publication of the NHS Plan in 2000.(1) This recognised that standards of cleanliness were perceived to have fallen below the level acceptable to patients and the public. It therefore set in train a programme to raise standards.

Initially, work undertaken was aimed fairly and squarely at the hospital sector, and led to the publication – in April 2001 – of the first ever National Standards of Cleanliness for the NHS.(2)

Since this initial publication, there has been a number of iterations and a change of name to the National Specifications for Cleanliness (to avoid confusion with Standards for Better Health) – the most recent version being issued in April 2007.(3)

This drive to improve standards received further impetus during 2004/05, when there was a significant increase in public concern around the issue of healthcare-associated infections (HCAIs) – particularly methicillin-resistant staphylococcus aureus (MRSA), but also and increasingly around C difficile.

This is despite the fact there is little evidence to support a direct causal link between (poor) standards of cleanliness and infections. The fact is, patients and the public make no distinction between cleanliness and hygiene, and the work of central bodies such as the Department of Health (DH) and the National Patient Safety Agency (NPSA) needs to recognise and accept that.

Against this background of the increasing number of reported infections and growing public concern, the DH introduced, through Parliament, the 2006 Health Act.(4) Appended to this was the Code of practice for the prevention and control of healthcare associated infections, which extended the duty to provide healthcare environments that are clean and fit for purpose.5 Responsibility for monitoring performance against the relevant Duty 4 of the code of practice currently rests with the Healthcare Commission (see Resources).

Consequently, it became apparent that, as with the hospital sector in 2001, there was a need to provide help, advice and guidance to other areas of healthcare on the standards of cleanliness they should be aiming for and how they might be able to demonstrate compliance with such standards. The most obvious way of achieving this was to produce a further iteration of the National Specifications for Cleanliness aimed at particular
healthcare providers.

The NPSA is soon to publish national specifications for cleanliness that may be applied to ambulance trusts and general practice.

What are they?
These new specifications will set out a process to assist in the provision of cleaning services in general practice premises.
They will detail a range of items that require cleaning, together with suggested standards on how clean they should be and how frequently they need to be cleaned to achieve the required
standard consistently.

In addition, the specifications will set out a detailed monitoring and auditing process, which allows for regular inspection against the standards. They can be a useful tool for those contracting out cleaning services since they provide a clear statement of what is required, which can be used as the basis of a service level agreement or other contractual agreement with providers.

Why are they necessary?
When commissioning services, an NHS body to which the Health Act 2006 code of practice (subject to amendment) applies should satisfy itself that contractors have appropriate systems in place to keep patients, staff and visitors safe from HCAIs, so far as is reasonably practicable. The new specifications provide a vehicle through which compliance with these requirements can be demonstrated.

Are they compulsory?
No. They are intended to set out a framework through which cleaning services can be managed and through which monitoring bodies such as the Healthcare Commission (or in due course the Care Quality Commission) can be assured that appropriate standards of cleanliness are being achieved and sustained.

While this framework is not the only way of providing this assurance, it is hoped that a nationally approved
version will prevent the need for individual practices to devise their own versions, saving practices time while simultaneously providing a system with the potential to ensure that all practices could be assessed against the same standards.

Ultimately it will be for individual practices to decide whether to utilise these national specifications. However, those not choosing to do so will need to be aware that they will need to devise some form of assurance mechanism if they are to be able to demonstrate that they are providing the required standards
of cleanliness.

How much work is involved?
We have endeavoured to make these specifications as simple as possible to apply, while also providing the potential for a high level of assurance. That said, practices choosing to utilise this tool will initially need to spend a little time customising elements of the documentation to their own needs.

As is the case in the hospital sector, practices can vary considerably in size and complexity and in the range of services provided onsite, and all these factors will impact on the production of specifications specific to individual practices. It is simply not possible to produce a one-size-fits-all document.

Individual practices will need to spend a little time producing a document that accurately reflects the items (termed "elements") within their practice that require cleaning, and to determine a cleaning frequency meeting their needs.

The frequency of cleaning should be determined by an assessment of the infection control risk posed by not achieving/maintaining the required standards. So, where some items may need to be cleaned daily or even more frequently, for others a much-reduced frequency may well be appropriate. Practices may find it helpful to seek infection control advice at this point.

A template document will be provided within the specifications, which should list all items that are likely to be present – though not all will be present in all practices. Additionally, it is recommended that practices produce a secondary document, called a Cleaning Responsibility Framework, which further breaks down the elements into their components – eg, where there is an "element" for patient equipment, the Responsibility Framework should detail precisely what this equipment is and who is responsible for cleaning it.

In hospitals this can vary between domestic cleaning services, nurses, estates staff or even external cleaning providers (eg, for windows or carpets/upholstery). In general practice, however, it is recognised that all cleaning responsibility may lie with one person or provider.

Finally, individual practices will need to decide the frequency of audit/inspection but, again, given the size of the average GP premises, auditing should not be burdensome.

Summary
Providing clean, safe premises for the delivery of healthcare is of paramount importance to patients and the general public. These National Specifications for Cleanliness are designed to help practices deliver this in a way that also easily provides documentary evidence of delivery when required.

References
1. Department of Health. The NHS Plan: a plan for investment, a plan for reform. London: The Stationery Office; 2000. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...
2. NHS Estates. The National Standards of Cleanliness for the NHS. London: NHS Estates; 2001.
3. National Patient Safety Agency. The National Specifications for Cleanliness in the NHS: a framework for setting and measuring performance outcomes. London: NPSA; 2007.
4. Office of Public Sector Information. Health Act 2006. Available from: http://www.opsi.gov.uk/ACTS/acts2006/ukpga_20060028_en_1
5. Department of Health. The Health Act 2006: Code of practice for the prevention and control of healthcare associated infections. London: DH; 2006.

Resources

National Patient Safety Agency
www.npsa.nhs.uk

Healthcare Commission
www.healthcarecommission.org.uk