Since publication of the National standards of healthcare cleanliness in 2021, NHS managers have welcomed the opportunity to measure performance and benchmark against similar healthcare environments to drive higher standards of cleanliness across the NHS, achieving better patient experience in a uniformed way.

A collaborative approach is essential to continuously improve cleanliness: organisations have seen the benefits of involving a board nominee, clinical colleagues, partner organisations and patients in setting and monitoring cleaning standards for consistent high levels of service. Having such an expert multidisciplinary team facilitates the enhancement, elaboration and modernisation of the standards to ensure that they can be applied to all healthcare settings.

Note: It is the user’s responsibility before implementing this guidance to check on the NHS Collaboration Hub whether any enhancements to cleaning regimens are required as a result of a national pandemic, circumstance or incident (also see section 5.7 Cleaning through a pandemic).

Summary

Healthcare establishments must be able to demonstrate how and to what standard they are being cleaned. The NHS has rightly earned a high reputation for the cleanliness of its environments.

The National Standards of Healthcare Cleanliness 2025 apply to all healthcare organisations and replace the National Standards of Healthcare Cleanliness 2021. To encourage continuous improvement they combine guidance, recommendations and good practice across all healthcare settings. This new version now encompasses the various challenges in ambulance facilities.

The standards seek to drive improvements while being flexible enough to meet the different and complex requirements of all healthcare organisations. Healthcare establishments can decide how their cleaning resources are best organised for their local environment and services, but meeting aspects of these standards is mandatory. The compliance grid details what is mandatory and we have provided a toolkit for ambulance organisations to help them recognise relative functional risk elements. Compliance with the standards and the auditing processes should be written into contracts with cleaning service providers. Cleaning service managers and providers should ensure all staff are familiar with this document.

The 2025 standards reflect modern methods of cleaning, infection prevention and control (IPC), other changes since 2021 (particularly, but not restricted to, Regulation 13 of the Health and Social Care Act 2022), and important considerations for cleaning services during a pandemic; and emphasise transparency to assure patients, the public and staff that safe standards of cleanliness have been met.

To continue to drive improvement in cleanliness, the standards:

• Focus on the need for a collaborative approach. Different staff groups, both clinical and non-clinical, will be responsible for cleaning different elements within an area; they need to work together to meet the cleanliness standard for the whole area. Published ratings will reflect the cleanliness score for whole areas, not the performance of individual parties responsible for cleaning certain elements. Taking this approach makes it clearer to patients, staff and visitors how clean an area is and encourages collective responsibility, which ultimately inspires people to work together to achieve high standards.
• Require a star rating to be displayed to give patients, staff and the public an easily understood visual score of the standard of cleanliness being met. It reflects the cleanliness of a functional area regardless of which staff group is responsible for cleaning each element. It is optional for ambulance trusts to display star ratings across their estate, except where areas are patient facing (excluding vehicles).
• Increase flexibility so they can apply to all healthcare settings. Two risk rating score categories have been added to the original four. Organisations can remain within their existing scoring regime if they choose to do so, but the expanded scoring approach enables them to increase or decrease the risk rating in individual functional areas as appropriate, either to facilitate the better use of resources or to recognise that the cleaning of an area needs to improve.
• Provide an updated elements list. Organisations will need to determine which elements are applicable to their setting and add to the list as appropriate.
• Detail efficacy audits, widening the audit function to include the cleaning process, as well as measure the technical cleaning outcome.
• Provide an option to blend functional risk areas, if organisations wish to do so, to provide greater flexibility and to maximise resource allocation. If used, this methodology can be applied to whole risk categories or to individual areas based on a hybrid approach.
• Link safe cleaning frequencies to each element to allow the requisite cleaning frequencies for each functional risk (FR) area to be determined.

The 2025 standards promote a Commitment to cleanliness charter to continue the ethos of the 2021 standards, particularly by highlighting the importance of a collaborative approach. Signing up to this charter publicises an organisation’s commitment to achieving a consistently safe and high standard of cleanliness.

Commitment to Cleanliness Charter

The Commitment to Cleanliness Charter sets out an organisation’s commitment to achieve a consistently high standard of cleanliness in all its healthcare facilities using the functional risk category, cleaning frequencies and cleaning responsibilities for each functional area.

The charter demonstrates an organisation is serious about providing a safe clean environment by referencing the star rating system, which reflects the cleanliness of the whole area regardless of who is responsible for cleaning it.

All organisations are required to display the charter where it will be seen – for example, in or near ward and department entrances, outside lifts used by the public, and in circulation areas and waiting rooms. Templates have been provided so that charters throughout the NHS are of the same standard and format, so easily recognised by patients, the public and staff.

Organisations can edit the charter template – for example, to insert logos and contact details – but some fields and headings are fixed and cannot be changed, such as cleaning task, cleaning frequency and responsibility, as this information must be retained to appropriately inform patients, the public and staff about cleanliness. For this reason, Appendix 5 gives more information on how to complete the charter, as well as editable templates for all functional risk areas and for blended areas, as well as worked examples.

1. Introduction

All those involved in providing healthcare cleaning services should work towards high quality, safe cleaning services that meet the needs and expectations of patients, staff and the public, to contribute to the overall patient experience and to high quality patient-centred care.

Delivering a high-quality healthcare cleaning service is complex, demanding and not to be underestimated. The aim is to ensure all cleaning-related risks are identified, minimised and managed on a consistent, long-term basis, irrespective of where the responsibility for providing cleaning services lies.

Regulation 13 of the Health and Social Care Act 2022 (Regulated Activities) Regulations 2014 requires that healthcare premises are clean, secure, suitable and used properly, and that a provider maintains standards of hygiene appropriate to the purposes for which they are being used (see Health and Care Act 2022 Impact assessments summary document and analysis of additional measures). Further, the code of practice for preventing and controlling infections, and related guidance, states NHS bodies and independent providers of healthcare and adult social care in England must adequately resource local provision of cleaning services. They should also have a strategic cleaning plan and clear cleaning schedules and frequencies so that patients, staff and the public know what they can expect.

An effective healthcare cleaning service should:

• be patient and customer-focused
• provide clarity for all personnel responsible for ensuring the healthcare environment is clean and safe
• enhance quality assurance systems
• address governance and risk assessment
• be consistent with infection prevention and control (IPC) standards and requirements
• meet the requirements of Care Quality Commission (CQC) outcome standard Regulation 15 key criteria (1 and 2) in the Health and Social Care Act Code of Practice 2015 in terms of legal responsibilities for a cleaning lead, personal responsibilities, the need for audit, governance and reporting
• set clear outcome statements that can be used as benchmarks and output indicators
• have clear objectives that provide a foundation for service improvements
• be flexible to meet the needs of specific healthcare environments, circumstances and priorities
• have well-documented cleanliness policies and procedures
• provide for a culture of continuous improvement
• be flexible, to meet the ongoing needs of operational service delivery
• consider the health, safety and wellbeing of patients, staff and the public
• be efficiently delivered

The National Standards of Healthcare Cleanliness 2025 apply to all NHS trust settings regardless of the way cleaning services are provided. They provide a common framework detailing the required cleaning services and how ‘technical’ cleanliness, and the efficacy of the cleaning process should be delivered and assessed. They replace the National Standards for Healthcare Cleanliness 2021. Together with the Health and Social Care Act 2022 and associated regulations, these provide an assurance framework to support compliance with the core cleanliness standard and the code of practice. The cleaning operating procedures referred to are provided for guidance only.

The standards do not state precisely how cleaning services should be provided, for example, by direct employment or contracting out. Such matters are for local determination. Ultimately, local management teams are accountable for the effectiveness of cleaning services.

The standards provide clear advice and guidance on:

• what cleaning is required
• how organisations can demonstrate cleaning services meet these standards

Recommendations are based on sound evidence and accepted good practice relating to using equipment and avoiding the transfer of healthcare-associated infections (HCAIs) in the UK (see Healthcare associated infections (HCAI): guidance, data and analysis; Reducing HCAI – What the commissioner needs to know).

The standards are:

• the basis for developing specifications for service-level agreements or local procedures
• a benchmark against which to compare services
• the optimum levels of resource to deliver safe cleaning standards
• part of an ongoing performance management process
• a framework for auditing and monitoring
• a tool, for improving patient and visitor satisfaction

2. General principles and definitions of cleaning and disinfection

The principles behind effective cleaning and disinfection must be understood and applied to all cleaning tasks or equipment.

2.1 Definitions

The terms cleaning, disinfection, decontamination and sterilisation are not interchangeable, and their differences need to be understood.

Cleaning: Involves ‘fluid’ – usually detergent and water, and ‘friction’ – the mechanical or physical removal of organic matter including dirt, debris, blood and bodily fluids. Micro-organisms are removed rather than killed. Effective cleaning leaves a surface or equipment visibly clean. This alone may be enough in foyers, offices, corridors and other ‘low risk’ environments, but cleaning also serves as a pre-requisite to effective disinfection in many healthcare environments. Some disinfectants are readily deactivated by organic matter.

Disinfection: Process of eliminating or reducing harmful micro-organisms from inanimate objects and surfaces.

Sterilisation: The process of killing all micro-organisms through physical or chemical means. Sterilisation is used only for critical items; that is, objects or instruments that enter or penetrate sterile tissues, cavities or the bloodstream.

Decontamination: Cleaning, disinfection and sterilisation are all decontamination processes. In the context of the environment or non-critical equipment (that is, equipment or devices that are in contact with intact skin only), the term usually refers to cleaning and disinfection, either using separate cleaning and disinfecting agents in a 2-step process, or a ‘2 in 1’ product that cleans and disinfects in 1 step.

2.2 Choice of cleaning/disinfecting agent

Local policy should outline where and when detergent and water are enough and where a detergent and disinfectant (or combined cleaning and disinfecting agent) are required.

Staff should be:

• familiar with the local policy and how to make up any cleaning/disinfecting solutions in line with manufacturers’ instructions
• trained in how to prepare any disinfectants safely in a well-ventilated area and wearing the appropriate personal protective equipment (PPE)
• know how to store unused product and how to dispose of it safely

2.3 Contact time

A disinfectant must be in contact with a surface for a specified time and the surface needs to remain wet for that time. Staff should know the contact times for the disinfectants in use locally. Products with realistic contact times for use in a busy healthcare environment should be selected.

2.4 Direction of cleaning

To minimise recontamination of an area and transfer of micro-organisms, clean from top to bottom, and clean to dirty.

Dusting technique should not disperse the dust (that is, use damp cloths/dusting devices). High horizontal surfaces should be cleaned first.

Floors should be cleaned last, with adequate signage placed while floors are cleaned and until dry to prevent slips, trips and falls on wet floors. Once floors are completely dry, the signage must be removed as it presents a trip hazard.

2.5 Manual cleaning action

Large and flat surfaces should be cleaned using an ‘S’ shape motion, starting at the point furthest away, then overlapping slightly but without going back over the area to avoid recontamination.

2.6 Frequent touch points

Frequent touch points in patient care and procedure areas, such as door handles, call bells, light switches, cot sides and bedtables, should be cleaned more frequently than other surfaces.

2.7 Transference

Cleaning solutions can become contaminated during use and need to be regularly replaced in accordance with manufacturers’ instructions to prevent transfer of micro-organisms from one surface to the next. They may need to be replaced more frequently when cleaning heavily soiled areas, when solutions appear visibly dirty, and immediately after cleaning blood and body fluid spills, for example when using a socket mop.

Micro-organisms can be transferred between surfaces on cleaning cloths and wipes as well as hands. Care should be taken to avoid cross-contamination.

3. Cleaning responsibilities

Those responsible for cleaning will vary [cleaning services providers, nursing, and other clinical and non-clinical staff (including housekeepers) and estates staff], depending on the size of healthcare establishments and the clinical and non-clinical equipment they house.

Assigning responsibility for specific cleaning functions is a significant and essential task. Cleaning professionals’ experience suggests items such as patient-related equipment can easily ‘fall through the gaps’. To capture all items that require cleaning, clinical and non-clinical teams must be consulted when agreeing local cleaning responsibility frameworks.

Healthcare establishments must produce a local schedule of cleaning responsibilities detailing all items to be cleaned and who is responsible for cleaning each one. This must allow enough time to complete specific training tasks, and training to do this, regardless of the team member assigned to the task.

To help you with this:

• Appendix 1 gives an example cleaning responsibility framework with suggested cleaning frequencies and responsibilities to meet safe standards. Clear assignment of responsibilities and cleaning whole items in one process by one individual and/or group of colleagues help with compliance. The example framework can be adapted to meet local needs. Every organisation must regularly review its cleaning responsibility framework.
• Appendix 2 lists the 60 broad elements of clinical and non-clinical ‘items’ that require cleaning in healthcare environments. A national list of all items that may require cleaning is impractical.

4. Safe cleaning frequencies

Discussions with NHS cleaning service providers indicates that one national set of safe cleaning frequencies cannot meet every organisation’s needs and is therefore inappropriate. It would also stifle the ability to allocate cleaning resources where they are most needed, and potentially compromise the ability to control where available cleaning services are best deployed.

However, the safe cleaning frequencies in Appendix 2 are a required baseline. They include additional elements and safe cleaning frequencies applicable to vehicle cleaning within the ambulance sector. Bespoke vehicle cleaning frequencies have been added to the appendices, aligned to sector-specific IPC procedures, and this document contains guidance and good practice to assist ambulance trusts to meet the standards.

If an organisation chooses to enhance frequencies or take a blended approach (see section 8.6 Other options), all settings must have a clear written rationale and risk assessment for this, as well as a supporting local safe cleaning schedule.

5. Risk categories and standards for functional areas

5.1 Purpose

All healthcare environments should pose minimal risk to patients, staff and visitors, but because different functional areas do not carry the same degree of risk, they will require different cleaning frequencies and levels of monitoring and auditing. For example, a records storeroom will not require as frequent cleaning as an intensive care unit.

Adoption of all 6 functional risk (FR) categories where practicable is considered good practice but is not mandatory; for example, an organisation may choose to use FR1 98%, FR2 95%, FR4 85% and FR6 75%, or any other combination. Healthcare organisations must have a sound written rationale for deciding not to adopt all 6 FR categories (see section 8.6 for governance for functional risk areas) as this must not jeopardise achieving safe standards in individual or collective functional areas.

Identifying the FR category for functional areas is the crucial first step in applying the standards: the cleaning, monitoring and audit frequency, and audit target scores are all directly linked to this. 

All functional areas should be assessed and assigned to functional risk categories (FR1–6, or the number decided locally) in accordance with organisational needs (see Table 1 in #section 8.5).

To help you:

• Appendix 3 is a guide to which functional areas might be allocated to each FR category, but ultimately risk identification must be locally decided.
• Use the relevant FR audit score and cleaning frequency to help determine which areas qualify for which category.

The toolkit for ambulance organisations supports their adoption of the standards and the processes this involves.

5.2 Cleaning specification – elements, cleaning frequencies and performance parameters

Once an organisation has identified its functional area risk categories, it must produce a ‘cleaning specification’ with more detailed information on how cleaning will be carried out. This specification should include:

• cleaning elements – a list of individual items/categories of items that require cleaning
• performance parameters – the expected standard of each item (element) after cleaning
• cleaning frequencies – how often each item (element) should be cleaned, broken down by FR category

Organisations may also include information on who is responsible for cleaning each item (element), but this should be in addition to, not instead of, developing a cleaning responsibilities framework (see Appendix 1).

The frequency of cleaning must be broken down by FR category. In the same way that functional areas need to be categorised according to risk, the frequency with which individual elements need to be cleaned will depend on the risk category they fall in. For instance, a toilet in an A&E department or a busy ambulance control room will need to be cleaned more often than one in a low traffic admin area.

To help you:

• Appendix 2 is an example cleaning specification template that can be adapted for local use. Organisations do not have to follow the same format if what they use covers the key information detailed in this section. The frequencies outlined in the appendix are designed to help organisations achieve the required outcomes.

The example specification is a guide only because a single national approach is unlikely to meet the needs of every healthcare organisation and setting. But in adapting it for local use, cleaning frequencies must not be reduced below the levels suggested; these are based on what are regarded to be the safe standards for meeting the performance parameters and achieving cleaning audit target scores. Meeting the required cleaning frequencies may be achieved via several different groups of staff including clinical colleagues: for example, theatres. Organisations should base their frequency decisions on IPC risks but also consider patient/public confidence and aesthetics. A floor in a public corridor will not generally be considered a high IPC risk, but its cleanliness significantly impacts on confidence.

The example cleaning specification gives details for the cleaning elements found most often in healthcare settings (see appendix 2), and the list is not intended to be exhaustive. Healthcare organisations may delete elements from the specification if they are not used in their organisation or add elements to meet their individual needs. For example, an organisation may create a separate element on the specification for picture frames but for auditing purposes will need to consider it under ‘high surfaces’. Any added elements should be reflected in an organisation’s cleaning responsibility framework.

The example cleaning specification details the performance parameter; that is, the expected standard of cleanliness of each element after cleaning.

5.3 Cleaning frequency definitions

To make best use of resource and meet all requirements, organisations are strongly recommended to differentiate between types of cleaning in their cleaning specification. For instance, many items may not always need to be cleaned daily, but it may be important to validate this – the intention of a ‘check clean’.

5 routine cleaning frequency definitions should be used:

• Full clean – cleaning all elements using an appropriate method to remove all visible dust, dirt, marks and contamination, leaving the item in accordance with the required performance parameters.
• Spot clean – cleaning specific elements using an appropriate method to remove all visible dust, dirt, marks and contamination, leaving the item in accordance with the required performance parameters.
• Check clean – a check to assess if an element meets the performance parameters. If it does not, a full or a spot clean should be undertaken (in line with the above) to bring the element up to the performance parameter level.
• Periodic clean – full clean of an item at a set interval as part of routine environmental maintenance where daily or weekly activity is not required. This becomes periodic; fortnightly, monthly (4 weeks), quarterly (12 weeks), 6 monthly or annually. Periodic cleaning of items less frequently than fortnightly or monthly (for example, carpet washing, floor stripping/polish/sealing and external window cleaning) is not considered routine and should form part of a planned and documented annual programme.
• Touch point clean – a full clean of items that are frequently touched (identified in section 5.5; see also appendix 4) using an appropriate method to remove contamination.

5.4 Enhanced cleaning

The above frequency definitions are based on routine service provision. Organisations should recognise as part of their planning process that events may increase the resources their cleaning service requires, for example, to manage IPC cleaning and during outbreaks.

Cleaning planning should clearly identify and document the specific extra steps required before, during and after a full clean in such circumstances. Organisations should base their identification of the extra steps required on local IPC policy and advice, in line with national guidance and good practice.

5.5 High frequency touch points

Hand-mediated transmission is a major contributor to the spread of infection in healthcare environments. Cleaning plans must recognise the importance of keeping frequently touched surfaces clean in minimising organism transfer between individuals and surfaces.

Organisations should give elements that are high frequency touch points (previously referred to as contact points) consideration when developing their cleaning specification. Appendix 4 provides a non-exhaustive list of high frequency touch points, but each organisation should make its own assessment depending on the area and service delivered.

Their cleaning frequencies should be adjusted accordingly: this can be done by focusing on the specific high-risk parts of an element: for example, cleaning the door handle more frequently than the door. The example cleaning specification in Appendix 2 includes weighting towards high frequency touch points.

5.6 Optional blended area approach

The blended area approach for functional risk areas is an option for healthcare organisations wanting more flexibility and to maximise resource allocation. It does add a layer of complexity as it requires in-depth profiling of an establishment and an electronic audit system. Calculating the blended percentage scores without an electronic audit system is very complicated and, across a large organisation, would require significant administrative resource.

The methodology for categorising whole FR areas is based on applying the same risk rating to each room within an area. However, individual rooms within a functional area may require a different cleaning frequency and clinical outcome, and hence a different risk rating. Categorising the whole of a functional area under one FR rating – that is, FR1, FR2, FR3, FR4, FR5 or FR6 – could result in certain parts of it being cleaned either too much or too little.

For this reason, within each FR area and based on risk assessment according to activity, a different risk category can be allocated to individual rooms – the blended approach: for example, FR5 for an office or a meeting room, FR3 for a staff room and FR2 for an inpatient room. These rooms will then be cleaned according to their risk category, not that of the functional area within which they are located.

This approach may also facilitate better use of resources by focusing on the risk of individual rooms rather than that of an entire area.

If this approach is adopted, it must be based on activity, not the type of room. For example, if clinical staff use an office in a clinical area, it is likely to need the same frequency of cleaning as the rest of the functional area. It is important to determine the risk each individual room or area poses and make a pragmatic decision based on this.

The proportion of areas in each risk category within a functional area will determine the overall functional area risk assessment, and a new overall target score can be calculated: see examples 1 and 2 in section 8.6. If most rooms fall into one FR category, that will be the overall rating for the functional area: for example, if 10 rooms are in FR2, 5 in FR3 and 1 in FR4, the rating for this area would be FR2 blended. If there is an even split across the rooms in a functional area, then the highest FR rating must be adopted: for example, if 10 rooms are in FR3 and 10 in FR4, the rating for this area must be FR3 blended.

While the cleaning frequency for FR blended areas is controlled by the FR rating of individual rooms, to facilitate the set up and maintenance of an electronic audit system, the auditing frequency for FR blended areas and FR areas will be the same.

5.7 Cleaning operations through a pandemic

The cleaning service is always key but never more so than during a pandemic.

Many local protocols cease, and guidance from governing bodies such as the UK Health Security Agency and NHS England can be issued nationally. The director of IPC will be the conduit for risk-based assessments of the care environment and assist in the interpretation of the national guidance to maximise cleaning services locally.

The specific advice will depend on the organism causing the pandemic but generally organisations should:

1. Follow all issued operational guidance such as standard operating procedures (SOPs) and methodologies.
2. Ensure staff are trained in all new procedures and guidance and that all staff have appropriate risk assessments to monitor personal risk factors.
3. Personal protective equipment (PPE) must be available and suitable for the guidance issued.
4. Where possible, dedicate staff to the areas of the building that are affected by the pandemic.
5. Review with the director of IPC and the IPC team whether the frequency of cleaning for all FR categories, and especially that for touch points, is appropriate to the organism.
6. Review the auditing frequency and consider minimising activity within affected areas. An agreed monitoring protocol for use during the episode should be drawn up and documented for future reference.
7. Ensure consistency across all facilities management services.

6. Importance of effective cleaning: infection prevention and control

These standards support the development of local risk management plans by providing a framework for assessing the effectiveness of cleaning programmes. The director of IPC – or nominated lead for non-NHS providers – and IPC teams must be involved in their development and implementation, as well as being regularly updated with the results of assessment, monitoring and audit.

Personal responsibility and accountability are crucial to maintaining a clean and safe environment. Objectives should reflect the deliverable outcomes for cleanliness, to incorporate them in the healthcare organisation’s performance frameworks and ensure staff are accountable for meeting them.

6.1 Classification of infection risk and cleaning frequencies

The type and frequency of cleaning spaces require depend on what activities are carried out in them and the level of infection risk.

Staff should fully understand the cleaning frequencies their work areas require and follow these closely. When room use or priorities change, the cleaning frequencies for the area should be reviewed.

6.2 National colour-coding scheme

A national colour-coding scheme for all cleaning materials and equipment is widely applied throughout healthcare organisations to reduce cross-contamination risk between different types of area: for example, bathrooms and kitchens. The simplicity of this scheme means staff can easily observe this safe working practice.

For example, cloths (reusable and disposable), mops, buckets and non-disposable gloves that are colour-coded red are only used in bathroom facilities.

The colour coding should be clear and permanent. Any deviation/derogation from this requires approval from NHS England via england.estatesandfacilities@nhs.net

Cleaning products (chemicals and detergents) do not need to be colour coded and the coding does not extend to catering equipment (for example, chopping boards and knives), which already has well-recognised and established procedures for food hygiene and food separation.

6.3 Employer responsibilities

Under the Health and Safety at Work Act 1974, an employer has a legal duty to protect employees and others (agency workers, contractors) from workplace injuries and ill-health, including work-related dermatitis.

Organisations are required to ensure all their staff are appropriately trained in using gloves and other PPE.

6.4 Disposable plastic aprons

Disposable plastic aprons should be worn for all cleaning tasks where clothing is likely to be splashed. An organisation can procure colour-coded aprons if it wants to limit the likelihood the same apron will be worn in different risk areas. Cleaning methodologies should clearly indicate if aprons should be worn when cleaning rooms occupied by patients being cared for in isolation because they have specified infections.

For certain specialised cleaning tasks involving large amounts of fluid (for example, flood response), risk assessment may indicate overalls and waterproof footwear need to be worn.

6.5 Protective gloves

Protective domestic gloves should be worn for all cleaning tasks. These should be sturdy, suitable for purpose and comply with the national colour-coding system. Gloves should be inspected before use to ensure that they are intact. Where the task involves the use of chemicals, the gloves should be certified as suitable for chemical resistance and comply with the PPE Directive (89/686/EEC).

Local IPC teams may advise on the use of single-use gloves in certain circumstances such as outbreaks or nursing patients in isolation for specified infections.

Gloves should be cleaned regularly between cleaning tasks. Use of gloves does not reduce the requirement for hand washing. Latex free gloves that comply with the above directive should be available for staff with an identified latex allergy.

6.6 Hand hygiene

Hand washing is one of the most important steps in reducing the risk of transferring infections in a healthcare environment. The correct hand washing technique should form part of all mandatory training, with a programme of ongoing monitoring for all staff.

Good hand hygiene helps stop organisms being transferred from one patient to another, known as cross-contamination. It is important to stop the transfer of organisms in this way as this can cause infections.

When working in a healthcare environment there are 3 important questions around hand hygiene:

When? With what? How?

When should I clean my hands during work?

The Five Moments approach for hand hygiene defines the key moments when healthcare workers should perform hand hygiene. The approach was developed by the World Health Organization and is used by the national cleanyourhands campaign to help everyone working in healthcare decide when to clean their hands. The Five Moments are: before touching a patient, before clean/aseptic procedures, after body fluid exposure/risk, after touching a patient and after touching patients’ surroundings.

What should I use to clean my hands and how should I use it?

There are 2 things you can use to clean your hands: soap and water (see NHS guidance on the best way to do this), or alcohol hand rub. Both are acceptable ways to clean your hands, except in the circumstances listed below. It is important to make sure your hands are cleaned thoroughly to ensure acceptable decontamination is achieved.

Although alcohol hand rub is a quick and easy way to clean your hands, especially when a sink is not easily accessible, there are times when you must wash your hands with soap and water:

• Always wash your hands with soap and water when hands are visibly soiled. This is because alcohol hand rub kills germs on clean hands, but because it is not soap it cannot dissolve grease or oil, so if hands are soiled, they need to be washed. Usually this is after so many uses of alcohol hand rub and will be advised as part of your training.
• Hands that have come into contact with body fluids. This is because the mechanical action of washing is important in removing any body fluid material that may be on the hands.
• Cleaning in an area where a patient has diarrhoea and/or vomiting. This is because alcohol hand rub does not kill some of the germs that cause diarrhoea and vomiting.

Important tasks

Cleaning staff are important members of the healthcare team; in fact, cleaning is one of the most important tasks in keeping patients safe from infection. It is therefore important that cleaning staff are kept informed of patients requiring isolation cleaning, both barrier and protective.

Remember that gloves can move organisms around just as well as hands. Wearing gloves does not replace the need for hand hygiene.

Training and support

All healthcare establishments in England and Wales have access to the national cleanyourhands campaign. If your organisation is already part of the campaign you will have a co-ordinator, usually in your IPC team, who can supply you with more information on the Five Moments as well as training material. It is the responsibility of the organisation to ensure staff have the appropriate training for their job. Hand hygiene training must be part of healthcare training for all staff and reviewed regularly.

6.7 Training

Cleaning is a vital part of the overall IPC process, which aims to provide a clinically clean and safe 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. For this reason, the importance of robust training is paramount. All levels of the cleaning team, as well as anybody else undertaking cleaning tasks, should be clear about their roles and responsibilities.

Cleaning regimens should be underpinned by standard operating procedures and any other national guidance, as well as the NHS England cleaning manual (2022).

6.8 Accidental exposure to blood or substances

Inoculation injuries, such as needlestick, other sharps injuries, bites, scratches and splash contamination of broken skin, require immediate action and organisations should ensure that staff know what the local policies are.

The staff member should contact either the occupational health department or A&E department for further advice, whichever is specified by the healthcare provider’s policy. The incident should be reported to a manager who should ensure it is recorded.

Splashed intact skin should be washed immediately with warm soapy water. If the mouth is splashed it should be rinsed out with large quantities of water and reported. Splashed eyes should be irrigated immediately with water or, if available, sterile saline from an eye station, and reported.

6.9 Spillages of bodily substances

‘Bodily substances’ refers to fluid or tissue issuing from a patient either directly or indirectly in the form of, for example, a specimen. Staff with cleaning responsibilities are most likely to encounter wound exudate, blood, vomit, sputum, urine and faeces.

Spillages may be cleaned up by nursing/departmental staff or cleaning staff. A healthcare provider’s local policy on cleanliness will have clear instructions on whose responsibility this is. Staff members performing this duty must have been trained in spillage cleaning and follow the method statement for this.

6.10 Uniforms and Jewellery

The guidance in this section is consistent with NHS England’s Uniforms and workwear: guidance for NHS employers (2020).

Hand and wrist jewellery can harbour micro-organisms and reduce compliance with hand hygiene. Wristwatches and rings (other than plain wedding bands) should be removed at the beginning of a shift. The organisation’s policy for jewellery should be followed where extra precautions are required.

Line managers should ensure that all staff follow local uniform policy and follow up issues of non-compliance.

Uniform sleeves should either end above the elbow or be kept rolled up above the elbow when undertaking cleaning duties.

Staff should change into a clean uniform before each shift and, if the uniform becomes visibly contaminated or soiled during a shift, they should change into another one as soon as they can.

Uniforms should be worn only while on duty, except where a local healthcare provider policy specifies otherwise.

Wearing numerous badges should be avoided. All staff should follow their organisation’s policy for name badges and/or ID.

6.11 Waste management

Waste management is the generic term for a range of waste-associated activities – its generation, handling, storage and transportation from point of source (for example, treatment or consultation room) to final place of disposal (recycling, alternative treatments and composting or incineration). Improper waste management risks staff safety and could affect a wider network of people, including patients, visitors and waste contractors.

Organisations are responsible for ensuring compliance with legislation around the segregation of waste. They have a duty of care for waste from ‘cradle to grave’ (including incineration) and therefore need to understand the different disposal routes for all the waste they produce.

The segregation, collection, storage, handling, transportation and disposal of waste must be undertaken with care and in line with local policy and procedure.

Cleaning and waste management are intrinsically linked. The safe and effective management of each one relies on the successful application of the other. Organisations should ensure that cleaning processes and systems, including the adoption of these standards, reflect local policy relating to waste. All waste management activities should also comply with national guidance and good practice [see Health Technical Memorandum 07-01: Safe and sustainable management of healthcare waste (2023)].

As a starting point, consider:

• roles and responsibilities relating to waste
• waste training
• waste classification, categories (streams) and colour coding
• waste storage and transport arrangements
• PPE and standard precautions
• application and use of waste disposal equipment
• risk management and incident reporting
• spillage management procedures, including accidental exposure

7. Governance

The national standards require all healthcare organisations to meet safe standards of cleanliness to minimise risk to patient safety from inadequate cleaning.

Healthcare organisations should therefore have a strategic plan detailing how they will ensure a clean and safe environment for everyone using or working in their healthcare facilities, and develop cleaning policies that are ratified by a relevant committee with board membership: for example, the IPC committee.

The policies should cover all cleaning activity within the organisation – that is, undertaken by cleaning teams as well as estates technical services staff, clinical staff and other staff groups such as housekeepers, catering, laboratory and portering staff – and, where relevant, underlying specifications and procedures.

They need to identify the strategic aims and how, through liaison between the director of IPC, facilities management and the IPC team, the requirements of the national standards will be met.

The responsible board members should ensure that staff responsible for cleaning understand their personal responsibilities; develop systems and procedures that support good practice and delivery of the national standards; implement and follow guidance and procedures; follow reasonable instructions and procedures; and are trained in these procedures.

Local managers will update the organisation’s cleaning policy to ensure the national standards are met.

Responsible departmental managers will be required to investigate substandard performance and report the remedial actions to improve – for example, changing cleaning frequencies – to the appropriate committee, and provide assurance that these actions have been. The committee will review any resource implications required to deliver improvements identified in the improvement plan (see section 8.7).

7.1 Committee and board reporting

Committee/board papers may include a report on each functional area’s cleaning performance, including audit scores and the frequency of audit.

Reports should detail:

• cleanliness audit scores and any areas where remedial action is required
• details of any areas that have failed to achieve a 5, or 4, star rating and the actions taken to improve in the areas
• efficacy audit plan and scores against the plan, with any areas for concern identified
• any recommended strategic changes for agreement by the committee/board, including the resource implications of changes
• assurance that star ratings are correctly displayed and updated
• assurance that cleaning frequencies are displayed using the Commitment to Cleanliness Charter
• assurance that efficacy audits are carried out and that they meet agreed standards and remedial action is taken to rectify any non-conformance
• confirmation that an annual external audit is undertaken to assure the quality and methodology adopted by the healthcare organisation

8. Auditing and monitoring information

8.1 Purpose

Healthcare organisations need to provide assurance at all levels that their establishments are meeting and maintaining safe standards of cleanliness, and be able to demonstrate to patients, staff and the public that their cleanliness meets the required standards. This supports IPC good practice by ensuring patients, staff and the public are confident that the use of both visual and efficacy audits provides the assurance that safe standards of cleaning are met.

Auditing in all types of healthcare setting should provide clear evidence that cleanliness standards are being met safely and responsibly, and where they are not, detail any service deficiencies and areas for improvement.

8.2 Principles

The audit principles for the national standards provide a national approach to auditing healthcare cleanliness in all types of healthcare settings. The overarching aim is to encourage safe standards of cleanliness in all healthcare environments. The audit process is designed to be easy to use and adaptable to local requirements.

Cleaning and IPC are intrinsically linked. It is therefore essential to demonstrate cleaning efficacy by auditing both the outcome of cleaning and the process by which the cleaning standards are achieved. To meet safe standards, the efficacy of the cleaning process is as important as the technical outcomes of cleaning, which is why it is now an area of focus.

Providing assurance that cleanliness has been delivered is critical; therefore, displaying the overall cleanliness result is an important part of the audit process.

8.3 Audit risk categories

As described in section 5.1, the audit standard operates according to 6 functional risk (FR) categories and 6 target audit scores. Each cleanable clinical and non-clinical functional area in a healthcare facility is allocated to a FR category, the crucial first step in applying the standards since the level of monitoring and audit directly link to the allocated FR.

Section 9 provides full guidance on the recommended audit frequencies for each of the 6 FR categories.

8.4 Audit scores

The audit scores for each functional area are represented in 2 ways: a percentage score and a star rating score. The percentage score is for internal verification and scrutiny that a safe standard has been achieved, whereas the star rating score is for external verification of this.

Percentage scores are still split by responsible staff group – cleaning, nursing, estates, etc – to understand if there are any gaps in performance. However, the star rating score is determined from the average percentage for all responsible staff groups.

Star ratings are widely used in many other industries such as hotels, restaurants and the media, as well as professional organisations, such as the food safety ratings provided by local authority environmental health departments for food premises. Such a system for healthcare cleanliness will be instantly recognisable and easy for patients, the public and staff to understand.

8.5 Percentage score

The target percentage scores for the 6 FR categories are shown in Table 1.

Table 1: Functional risk categories and associated audit target scores

8.6 Other options

Not adopting all functional risk categories

Adoption of all 6 FR categories is considered good practice but is not mandatory: for example, an organisation may choose to use FR1 98%, FR2 95%, FR4 85% and FR6 75%, or any other combination. Healthcare organisations must have a sound written rationale for deciding not to adopt all 6 FR categories (see governance for FR areas in section 8.6) as doing so must not jeopardise achieving safe standards in individual or collective functional areas.

Blended area option

The target for a blended area is based on the combined targets for rooms in each functional area. The final star rating is capped; the functional area is assigned the highest rating from:

• the combined calculated score for the entire blended area or
• the score for the highest risk category audited

Blended example 1: Outpatient area

Targets

This outpatient area has 12 rooms, 2 of which are minor operations suites that are higher risk.

The overall functional risk category is FR4 blended with an overall target score of 86.66% (rounded to 87%) and an audit frequency of every 3 months.

While the overall target is 87%, the star rating is capped to the average score of the rooms audited at the highest risk category. If the highest risk category target is not achieved for the room(s) to which it is assigned, then the combined score of the lower risk categories cannot result in a 5-star rating. The FR2 room(s) must achieve 95% to achieve a 5-star rating (refer to the star rating percentages in Appendix 6).

Calculations and rating

The overall score is 98.1%. This surpasses the blended target of 87% for the functional area. However, a 5-star rating is not achieved because the FR2 rooms have not achieved their 95% target. The rating for the functional area is capped at the 4-star rating achieved for the FR2 rooms.

* As stated in section 9.1, in small areas with 10 or fewer rooms it is good practice for all the rooms to be audited at the same time. Please note classifying 1 room as an FR area will not give an accurate reflection of the quality of cleanliness across the healthcare organisation. However, where a room attracts a higher risk score compared to the overall blended category, then it must be audited according to its risk audit frequency.

Blended example 2: General inpatient ward

Targets

This is a general inpatient ward with rooms in a mix of FR categories.

The overall category is FR2 blended with a target score of 93.25% (rounded to 93%) and an audit frequency of monthly.

Calculations and rating

The overall score is 94.8% (rounded to 95%). This surpasses the blended target of 93% for the functional area. A 5-star rating is achieved because the FR2 rooms have surpassed their 95% target (96.6%).

Governance for functional risk areas

Whether a healthcare organisation decides to adopt the 6 FR categories or the blended approach, it must ensure documentation clearly outlines the allocation process it is using. This should cover:

1. A written rationale for how the risk category has been derived for each functional area, or room/group of rooms if blended.
2. Regular review of the functional area (at least annually, or when there is a significant change in clinical activity) to ensure that the rationale and risk ratings are still appropriate.
3. A written record of the functional area review.

8.7 Star rating score

Star ratings are a simple and effective means of providing meaningful information about quality to patients, the public and staff (see Figure 1). When used in the correct way, they will reassure patients, the public, departmental and clinical leads, and staff about cleanliness, and enhance the profile of cleaning. They are based on the cleanliness not the condition of the building and reflect the cleanliness of a functional area regardless of who is responsible for cleaning each element of it: for example, cleaning, nursing, estates and other staff (physiotherapists, ward housekeepers, porters, catering, laboratory, etc).

Figure 1: Star rating display

When agreeing where to display the star ratings, organisations should consider disparate sites, type of healthcare setting and the logistics of administering this process. Organisations may deem it impractical to display these in some areas: for example, in community settings with numerous outbuildings.

We recommend that star ratings are only displayed in areas accessed by patients and where they will be visible: for example, in or near ward and department entrances, outside lifts, and in circulation areas and waiting rooms, and close to the Commitment to Cleanliness Charter.

Ambulances are excluded from this requirement. It is optional for ambulance settings to display star ratings across their estate. However, displaying the ratings may help publicise the organisation’s commitment to achieving consistently high standards of cleanliness and provides an easily understood visual score for each functional area.

The star rating must be derived from the original audit score at the time of audit and cannot be updated as part of any subsequent rectification process. The star rating score can only be updated following the next full re-audit.

The star rating displays allow organisations to set the expiry date, to make the system easier to administer – for example, a longer expiry date can be set for an area that consistently achieves 5 stars at every audit, possibly up to 12 months. Of course, if an area’s star rating changes before the expiry date for the display, it will need to be changed.

Functional areas rated at 3 stars or fewer must be subject to an improvement plan with agreed timescales appropriate to the functional area and the score achieved. Please note that multiple rectifications may need to be co-ordinated by multiple responsible groups: for example, failings could be attributable to both the cleaning and nursing teams, and successfully remedied before the star rating can be revised. Even 5-star or 4-star ratings are likely to generate remedial actions to improve unless the functional area scores 100%.

The star rating rectification escalation chart below details the actions that must be taken following each audit of a functional area.

All areas under automatic review are subject to an extensive improvement plan within a timescale appropriate to the issues identified. The cause of the poor result must be understood and those responsible involved in the rectification. All areas scoring 3 stars or below must be reported to the board representative(s).

Star rating rectification escalation chart

5 stars:

• area has achieved its target score or above
• rectification of failures is signed off and records retained for a minimum of 3 years (or as per local policy if longer)

4 stars:

• 1–3% below target score
• rectification of failures is signed off and records retained for a minimum of 3 years (or as per local policy if longer)

Areas scoring 3 stars or below are automatically under review

3 stars:

• 4–6% below target score
• rectification of failures is signed off and records retained for a minimum of 3 years (or as per local policy if longer)
• area placed under review and audit frequency reviewed
• improvement plan produced, actioned and signed off
• follow guidance below on improvement plan considerations

2 stars:

• 7–9% below target score
• rectification of failures is signed off and records retained for a minimum of 3 years (or as per local policy if longer)
• area placed under review and audit frequency reviewed
• improvement plan produced, actioned and signed off
• follow guidance below on improvement plan considerations

1 star:

• 10% or more below target score
• rectification of failures is signed off and records retained for a minimum of 3 years (or as per local policy if longer)
• area placed under investigation and audit frequency reviewed
• immediate action taken as appropriate
• improvement plan produced, actioned and signed off

Improvement plan considerations

An improvement plan should consider the following:

• an understanding as to how star ratings below 3 stars will affect patient, staff and public perception
• an analysis of the failed elements and which staff group is responsible for cleaning each one
• whether audits have been at the right frequency and whether they indicated an issue
• a review of the cleaning input hours to determine if the resources are adequate or if there have been staff shortages
• a review of cleaning times to determine if the service is being delivered at the right time
• a review of the cleaning frequencies to determine if they are appropriate
• a review of the area to understand if there has been a significant change in its use
• whether the cleaning equipment, materials and consumables are suitable and their supply adequate
• whether staff have been appropriately trained
• whether there is a staff competency issue
• whether there is an access issue
• whether an efficacy audit has been done in the last 12 months
• whether the area’s risk rating has been reviewed and checked
• whether a temporary increase in monitoring has been considered until standards are consistently met and maintained

8.8 Star rating implementation timescales – for ambulance organisations

During the first 6-month implementation phase for the national standards each healthcare setting will continue to display only the cleaning scores as a percentage for each functional risk category, not the star rating. All other operational considerations in the star rating guidance should be implemented fully in this first phase: for example, remedial actions.

At 6 months the star rating will be displayed. This will be calculated from the percentage calculated scores displayed in the previous 6 months, so based on cleaning performance for elements that are the primary responsibility of the cleaning team.

After a further 6 months, the star rating calculations will include scoring for other responsible staff groups; that is, nursing teams and estates teams.

We acknowledge that adherence to the National Standards of Healthcare Cleanliness is a new requirement for the ambulance sector and, consequently, the displaying of percentage scores was not previously applicable. As mentioned above, ambulances and emergency vehicles are excluded from the requirement to display a star rating. It is optional for ambulance settings to display star ratings across their estate because this is generally not accessed by members of the public. However, displaying star ratings may help publicise the organisation’s commitment to achieving consistently high standards of cleanliness and promote confidence in the cleaning services provided.

9. Audit process

The integrity of the audit process is fundamental to providing assurance that an organisation is delivering safe standards of cleanliness. Accurate, honest and open audit reporting underpins the ethos of the standards – to drive safe standards and continuous improvement, whether a cleaning service is insourced or outsourced.

We expect organisations to have a robust process and transparent approach to auditing, to ensure the standards are met. The audit process will ultimately encourage quality improvements and must not be punitive.

There are 3 audits:

1. Technical audit: checks and scores cleanliness outcomes against the safe standard.
2. Efficacy audit: checks the efficacy of the cleaning process at the point of service delivery; that is, the correct use of colour coding, equipment, materials, methodology, as well as supporting policies and procedures.
3. External audit: provides quality assurance and checks both the technical audit and the efficacy audit.

9.1 Technical audits

These regular audits, undertaken by appropriately experienced staff, are a continuous and integral part of the day-to-day management and supervision of cleaning services.

Timing

Technical audits should be randomly undertaken at different times and on different days, but with consideration of the frequency of cleaning and the cleaning schedule.

The time or frequency of cleaning and associated risk category need to be regularly reviewed and adjusted if indicated to continuously improve safe cleaning standards.

Auditors need to exercise discretion in judging the acceptability of any element (see Appendix 7 for the technical audit process). For example, one or two scuff marks on a floor, an isolated smudge on a window or a hand towel/tissue dropped on a floor in an otherwise clean area should not be scored as unacceptable.

The audit score must accurately reflect the standard of cleanliness at the time. The need for transparency and openness is paramount to drive continuous improvement. For example, if some areas fall below the standard, organisations must be able to identify any areas falling below the standard so they can act to resolve the underlying cause.

Multidisciplinary teams

Good practice is to adopt a multidisciplinary approach to technical auditing periodically, to assess the cleaning from different perspectives. We recognise it may not be possible to routinely deploy a multidisciplinary team (MDT) and the frequency of such audits is for each healthcare organisation to decide. These teams should include both those responsible for delivering the service and those receiving the services: for example, IPC teams and nursing staff, as well as non-clinical staff and service users.

It is also good practice on an ongoing basis for technical audits undertaken by the cleaning services department to be signed off at ward or department level by a member of the clinical/non-clinical team with responsibility for the functional area. The designated member of the clinical/non-clinical team should be agreed locally and will vary according to the needs of each organisation. This sign-off provides an opportunity to discuss the cleanliness of the functional area and validates the audit score.

Audit personnel

Audits, particularly technical audits, should not be the sole responsibility of the cleaning services department. They should be supported by all relevant stakeholders in the healthcare facility. It is important that results are available to all those responsible for cleaning each element in the functional area audited.

Managers and staff involved with audits should:

• have a detailed knowledge of healthcare establishments and procedures and the service-level agreements in place
• be professionally competent to judge what is ‘acceptable’ in terms of cleanliness and IPC (local protocols and agreements should support this)
• be able to make discriminating judgements on risk relating to the areas being cleaned and any associated risks relating to individual elements or items
• be able to make informed judgements on the extent to which existing cleaning frequencies may be insufficient

Those undertaking audits should receive regular training to ensure that they are proficient in making technical assessments of each functional area from considering risk, frequency, environment and footfall. We recommend that managers and staff who audit on a regular basis receive annual training and that this is documented to ensure professional competence, sound judgement of risk and understanding of the frequencies required to meet cleaning standards in different environments. The technical audit process detailed in Appendix 7 could be used as the basis for audit training delivered by the cleaning team.

Process

It is important that organisations agree the principles against which they audit and how to score each element in terms of what constitutes a pass and what constitutes a fail. Appendix 7 identifies questions organisations should ask about their technical audit process, with suggested model responses. It is good practice to work through these questions and agree the standards that technical auditors adopt. This exercise will ensure the audit process is consistent, regardless of who undertakes it.

Sample size

Good practice is for a minimum of 50% of each functional area to be audited in one session, making the audit representative of the whole area. For example, if an area has 20 rooms, a minimum of 10 rooms must be audited, including all elements within those 10 rooms. In small areas with 10 or fewer rooms, good practice is for all the rooms to be audited at the same time.

If 50% of a functional area is audited in one session, the other 50% must be audited in the next session, not the same 50%.

Scoring

The auditor will score elements as either 1 (pass) or 0 (fail) room by room. Together these will give the score for each functional area. Where an element fails and is scored as 0, the reason for failure needs to be recorded. The appropriate time for remedial action has been determined using the rectification table in section 9.4 (table 5).

The scoring will reflect the assigned general responsibility for elements as determined by each healthcare facility and as advised in the cleaning responsibilities section (see section 3).

The electronic version of the score sheet will calculate the percentage score achieved for each functional area. The score sheet can make horizontal (outcome per room) and vertical (outcome per element) calculations, along with the totals.

A room’s number of pass scores will be expressed as a percentage of the possible number of ‘pass’ scores in that room. For example, if 10 of the 12 elements in the sanitary area pass, the overall percentage would be 83.33% (10/12).

The functional area score is the number of pass scores in the functional area expressed as a percentage of the possible number of pass scores in the functional area. For example, in Table 3 it is 177/180 = 98.33%.

Table 3: Example scoring

Overall target score

Once healthcare organisations have determined their target scores in each risk category, an overall target score can be calculated by determining the percentage of the hospital or other type of premises that falls into each risk category.

The overall healthcare facility score is then calculated by taking the number of pass scores expressed as a percentage of the possible number of pass scores in the healthcare facility. For example, in Table 4 it is 7,700/8,930 = 86.23%. Please note this example does not include any blended areas.

Table 4: Example overall organisation scoring

Where an overall score is required, or facilities need to be grouped, an aggregated score can be used to calculate the overall score for cleanliness. However, the relative size of each of the healthcare facilities being aggregated must be considered. Healthcare providers need to determine the configuration of their sites and how they want the reports to be generated.

Demand-led cleaning technology

Under certain circumstances – high usage, depleted consumables, spillages or incidents – reactive cleaning technology using sensors, feedback or call buttons can quickly alert and/or direct the responsible staff group to attend the area that needs to be cleaned. Use of such technology is encouraged as it ensures that areas are cleaned based on need and level of use, rather than according to routine cleaning schedules, reducing the need for rectification.

Trend analysis

We recommend trend analysis of quality data as part of continuous service improvement. This will identify specific areas that require review and where resources are best deployed.

Reporting

Cleanliness audit scores can be determined for the same type of equipment or the same element across a healthcare facility or parts of buildings. Scores can also be broken down further – for example, across all wards or departments, or groupings of wards and departments. This enables identification of variations in quality across similar areas and the causes of failure that need to be addressed to meet safe standards.

9.2 Efficacy audits

The efficacy audit is a management tool to provide assurance that the correct cleaning procedures are consistently delivered to satisfy IPC and safety standards. These audits inform the healthcare organisation that correct training, IPC, health and safety, and safe systems of work are being used.

An integral part of the efficacy audit is observing the cleaning to check that staff use the colour coding correctly, follow cleaning methodologies, wear the correct uniform and PPE, use chemicals appropriately and adhere to safe ways of working.

These audits are intended to provide assurance that cleaning standards are met using good practice. We recommend efficacy audits are only carried out in areas where patients and visitors are present, not in staff-only areas. Each patient-facing area should be audited at least once a year. If an area falls below 80%, it should be re-audited within a reasonable timeframe to check that, following remedial action, it is achieving an audit score of over 80%.

Functional risk areas that have not achieved safe standards consistently or areas that have high rates of infection should be prioritised for efficacy audits. The findings should be used to develop an improvement plan, which may include further training, investment in new equipment and materials, increased supervision, increased resources, changing the times of cleaning, performance management, etc.

Wherever possible, efficacy audits should be conducted by MDTs that include staff responsible for cleanliness, nursing staff, IPC and other estates and facilities colleagues, to give a rounded view of the cleaning process. It is also good practice to invite patient representatives to be involved from time to time.

To help you, an example efficacy audit template is provided. This can be changed to meet individual healthcare cleaning requirements and the organisation’s priorities. To facilitate comparison and enable benchmarking, the template is split into 38 ‘clean only’ questions that must be answered, and 5 non-cleaning questions that should be answered where appropriate. The template allows the efficacy audit calculation formula to be adjusted so data remains comparable.

Frequency and scoring

We recommend that efficacy audits are conducted annually. Each organisation can decide how to schedule the audits: for example, monthly as a rolling programme with a sample of patient-facing areas audited at a time of day when cleaning is being undertaken.

Except for areas that are being targeted for performance review, other areas should be randomly selected for efficacy audits. The actual number should be determined locally but it needs to be enough to validate that safe standards are being achieved.

The efficacy audit scores do not form part of, or contribute to, the technical audit percentage scores or the star rating scores.

Good practice is to report the findings from efficacy audits at executive level, to acknowledge good service, address poor service and drive continuous improvement.

9.3 External assurance edits

External assurance audits are good practice as they provide an independent view of cleanliness and validate the healthcare facility’s own internally awarded technical and efficacy scores.

Collaborating with neighbouring facilities or NHS healthcare organisations is often the easiest way to get appropriately qualified staff or managers to take part in an external audit process. There may also be value in reciprocal arrangements between healthcare organisations, providing managers that do not know each other are involved and geographical distance separates them. Such arrangements may also provide opportunities to share good practice.

Professional associations may also provide qualified external auditors as well as personnel involved in the patient-led assessments of the care environment (PLACE).

Frequency

We recommend that an external audit is carried out annually and that it considers whether:

• a board member with responsibility for cleaning has been appointed
• a cleaning policy is in place that reflects the National Standards of Healthcare Cleanliness and any specific local requirements
• functional areas have been categorised according to the cleaning policy
• completed Commitment to Cleanliness Charter posters are displayed in all required areas
• the cleaning frequencies meet or exceed the safe standards
• there is evidence that cleaning frequencies are being adhered to (Commitment to Cleanliness Charter, checklists, etc)
• in-date star ratings are displayed in all required areas
• the cleaning standard seen on inspection is consistent with the star ratings displayed
• efficacy checks are being carried out
• the efficacy check results are consistent with the standard seen in the audit
• trend analysis is being undertaken to support continuous improvement
• there is evidence that failings have been rectified for all responsible staff groups
• rectifications are being made in a timely manner for all responsible staff groups
• there is evidence that the introduction of the standards has improved the cleanliness delivered by all responsible staff groups in the facility
• any actions will be recommended as a result of the external audit

Please note that this list of considerations is not exhaustive.

9.4 Timeframe for rectifying technical problems

Regular audits should form part of the cleaning services and quality assurance programme. Lead times for remedial action that are dependent on magnitude and location should be identified: for example, within an hour of the audit for a problem in an operating theatre but within a week or during the next scheduled audit for one in a stationery storeroom. Please see Table 5 below for guidance.

Any urgent issues found during the audit need to be flagged and rectified immediately either by the auditor or by escalation through operational teams. All routine failures picked up during the audit should be rectified according to documented local agreement or as per Table 5.

A multidisciplinary approach to dealing with rectifications needs to be taken to ensure that all failures, regardless of the staff group responsible for cleaning the element, are rectified to the correct standard within the agreed timeframes detailed below.

Table 5: Maximum timeframe for rectifying cleaning problems

10. Digital and technological audit solutions

10.1 Audit technology

The process for the technical audit of cleaning described above focuses on subjective methods; that is, visual checks of the standard of cleanliness. As it relies on the expertise of auditor(s), good practice to minimise auditor bias is a multidisciplinary approach and annual training of audit personnel.

Consideration should also be given to audit technologies that use objective evidence-based methodology to support the subjective measurement and efficacy of the cleaning process.

A wide variety of technical tools are available. Those that identify what has not been cleaned effectively – for example, ultraviolet gels, adenosine triphosphate and ultraviolet black light – can be used to highlight training needs.

Electronic audit systems are useful for highlighting trends and hot spots, as well as greater transparency and more effective sharing of data.

The efficacy of the cleaning process is becoming increasingly important for IPC, particularly for FR1 and FR2 functional risk areas. More advanced technology is being developed to support the objective measurement of environmental cleanliness.

Each organisation should determine its level of investment in technology and electronic audit systems to support the audit process.

10.2 Audit reporting

Information technology plays an important part in the audit process, documenting findings and analysing failures, trends and results.

Factors to consider when developing or procuring an electronic audit tool include:

• ease of use
• ability to meet the needs of the facility; one size does not fit all
• ability to produce metrics from elements, frequency and room data to show compliance with the standard
• ability to ‘build as you go’ to easily capture room function changes, new rooms, etc
• ability to easily build from plans
• ability to transfer data from one service provider to another (ownership of base data)
• ability to export data easily
• compatibility with NHS building regulation data
• simplified reporting functionality
• functionality to work in healthcare facilities with data device capability

Healthcare organisations that choose not to use information technology as part of their audit process should be able to use Excel spreadsheets that provide the same reporting format as an electronic system.

11. PLACE and the National Standards of Healthcare Cleanliness

Patient-led assessments of the care environment (PLACE) is an annual national inspection self-assessment programme, which is managed by NHS England. The assessments mainly apply to hospitals and hospices providing NHS-funded care in both the NHS and independent sectors, but other providers are encouraged and helped to participate in the programme. PLACE replaced the longstanding PEAT (patient environment action team) programme in 2013.

Under PLACE, organisations make an in-depth assessment of the non-clinical, patient-related aspects of the care environment for all qualifying inpatient settings. Responses contribute to scores across six domains, including one specifically for ‘cleanliness’.

Questions within some of the other domains also relate to cleaning and associated services.

PLACE scores are released as an official statistic, and the results are published to help drive improvements in the care environment. The results show how healthcare organisations are performing both nationally and in relation to similar service providers.

Teams taking part comprise staff and patient assessors, who view settings from a non-technical (that is, visual) and non-system focused perspective, giving a good indication of how patients and the public view standards.

In terms of cleaning, it is important that organisations reflect and react to PLACE scores and underlying action/improvement plans to make and maintain required and realistic improvements.

12. Glossary

Various terms in this guide have a specific meaning when used in relation to cleanliness in healthcare premises. The below definitions are not exhaustive.

• Debris includes litter and rubbish, such as crisp packets, drinks cans and bottles, chewing gum, cigarette butts, adhesive tape; grit; limescale.
• Dirt includes mud, smudges, soil, graffiti, mould, fingerprints, ingrained dirt, scum.
• Dust includes lint, powder, fluff, cobweb.
• Element is an item within a functional area, or any part of the fabric or fittings of a functional area, that requires cleaning.
• Functional area is a room or physically contiguous group of rooms deemed by a healthcare organisation to constitute an area of operation.
• Inputs are the resources used to produce and deliver outputs: for example: staff, equipment or materials.
• Outcomes are the effect or consequences of the output: for example, cleaning (output) produces a clean and safe environment for patient care (outcome).
• Outputs are the actual product or service: for example, cleaning.
• Performance parameter is the expected standard when cleaning is completed.
• Processes are the procedures, methods and activities that turn the inputs into outputs: for example, mopping a floor.
• Quality systems refer to integration of organisational structure, integrated procedures, resources and responsibilities required to implement quality management. Taken together, these provide for the development of a comprehensive and consistent service.
• Rooms are a subset of functional areas: for example, on a ward these can be bedded bays and sanitary areas. Their identification allows cleaning managers to more closely audit and manage standards in specific parts of functional areas.
• Service user is a patient or person using the facility who may be impacted by the level of cleanliness.
• Specialist cleaner operative is a trained member of the workforce who can carry out specialist training with proven competencies.
• Spillage includes any liquid, stains and sticky substances.
• Stakeholder is a party that has an interest in cleanliness within the healthcare setting and can either affect or be affected by the outcomes.
• Surface levels: low surfaces include items such as skirting boards, floor edges, low-level pipe work and trunking, low cupboard exteriors; middle surfaces include items such as grab rails, tables, trunking, desks, shelves, ledges, work surfaces, cupboard exteriors and windowsills; high surfaces include items such as filing cabinets, curtain rails, locker and cupboard tops, picture frames.
• Waste HTM 07-01 is the relative waste regulation.

13. References

• Standards for better health
• Cleanliness matters – a regional strategy for improving the standard
• Cleanliness matters toolkit – practical guidance for assessment of standards of environmental cleanliness in HSS trusts
• The revised healthcare cleaning manual
• Code of practice for the prevention and control of healthcare associated infections (Health Act 2006); Department of Health 2006
• An integrated approach to hospital cleaning: microfibre cloth and steam cleaning technology
• NHS Wales health circulars. These provide a streamlined, transparent and traceable method of communication between the department and the NHS. The circulars are divided into categories for different areas of health.
• Health and care standards
• Free to lead, free to care
• Code of practice for the prevention and control of healthcare associated infections
• Commitment to purpose: eliminating preventable healthcare associated infections (HCAIs)
• The communicable disease outbreak plan for Wales (‘The Wales outbreak plan’)
• Antimicrobial resistance – a delivery plan for NHS Wales and its partners
• CQC cleaning outcome standard 15
• Health Protection Scotland – literature reviews on emerging decontamination technologies
• Cleaning policy template

14. Acknowledgements

Special thanks to David Griffiths, who has advised in the making of these standards as technical author of PAS:5748 and editor of the revised healthcare cleaning manual.

Special acknowledgement to Yvonne Fortt and Lynne Evans for their tireless efforts in compiling this document. Thank you to Royal Derby Hospital for the Commitment to Cleanliness Charter.

We also thank all the people who dedicated their time and energy to producing this document.

• Emma Brookes, Head of Soft FM, Strategy and Operations NHS England
• Richard Ashton, Performance and Compliance Manager Gloucester Health and Care NHS Foundation Trust
• Carol Birch, Associate Director of Facilities Synchronicity Care Ltd
• Erika Bowker
• Pauline Bradshaw, Clinical Lead – North West NHS England
• Donna Brown, Divisional Director ISS Facility Services Healthcare
• Charlie Buck, Principal Services Assurance Manager NHS Property Services
• Linda Dempster, Head of Infection Prevention and Control NHS England
• Jenni Doman, Deputy Director, Estates and Facilities St George’s University Hospitals NHS Foundation Trust
• Stuart Douglas, Head of Estate Development NHS Wales Shared Partnership Services
• Gary Ethridge, Director of Nursing and Safeguarding Director Barking, Havering and Redbridge University Hospitals NHS Trust
• Caroline Fennessy, FM Specialist (cleaning) Serco UK and Europe
• Denise Foster, National Chair Association of Healthcare Cleaning Professionals
• Dr Amy Gyte, Capability Team Leader, Exposures and Healthy Consequences Portfolio, Health Capability Group Health &and Safety Executive (HSE)
• Anna Hallas, National Domestic Manager Compass Group
• Ashly Harrison, Quality Assurance and Integrated Audit Lead NHS Property Services
• Alison Carter, Soft FM Specialist (Cleaning) NHS Property Services
• Anne El-Garidi, Head of Facilities Management North West Ambulance Service NHS Trust
• Deborah Banks, FM Regional Officer North West Ambulance Service NHS Trust
• Martyn Hearn, Operations Director MITIE Plc
• Jenifer Holmyard, Head of Facilities (London) West London NHS Trust
• Ian Jackson, Domestic Services Manager Salford Royal Hospital
• Barbara Jeffery
• Rob Jepson, Deputy Director of Estates, Facilities and Capital Northern Care Alliance
• Debbie Jones, Chief Executive Butterwick Hospice Care
• Catherine Leak, General Manager St George’s University Hospitals NHS Foundation Trust
• Christopher Lewis, Senior Environment & Facilities Management Advisor NHS Wales Shared Services Partnership – Specialist Estates Services
• Penny Lewis, Soft FM Solutions Lead Serco Group PLC, TJ Litherland National President Health Estates and facilities Management Association
• Florence Looi, Estates and Facilities Site Manager Basildon University Hospital, Mid & South Essex University Hospitals Group
• Gail Lusardi, Consultant Nurse, HARP Team Public Health Wales
• William McNeill, Deputy Patient Facing Services Manager West London NHS Trust (Broadmoor)
• Leslie Macleod-Downes
• Kathryn Mitchell, Director of Estates and Facilities Manchester University NHS Foundation Trust
• Liz Pass, Patient Facing Services Manager Broadmoor Hospital
• Lee Peddle, Head of Facilities Management – Soft FM and Transport Quality Trusted Solutions
• Ed Robinson, Health and Safety Executive (HSE)
• Delia Rodrigues, Head of Facilities Royal Brompton & Harefield NHS Foundation Trust
• Michael Rollins, Healthcare Specialist IPC Consultant Independent
• Dr Chris Settle, Consultant Microbiologist City Hospitals Sunderland
• Philip Shelley, Senior Operation Manager NHS England
• Amilcar Simoes, Facilities Manager West London NHS Trust
• Louise Simpson, Group Senior Nurse E&F Northern Care Alliance
• Katie Sparrow, Account Manager G4S Facilities Management
• Yvonne Spencer, Clinical Lead, IFM Sodexo Healthcare
• Collette Sweeney, Head of Healthcare Cleaning ISS Facility Services Healthcare
• Yvonne Taylor, Global Head of Cleaning OCS Group Ltd UK
• Maciel Vinagre, Assistant Hotel Services Manager Ashford and St Peter’s Hospitals NHS Foundation Trust
• Jane Ward, Deputy Director of Facilities Epsom and St Helier University Hospitals NHS Trust

Appendix 1: cleaning responsibilities framework

The example cleaning responsibility framework below gives suggested cleaning frequencies and recommends responsibilities to meet safe standards. However, within each of the broad headings is a much greater range of specific items for which a national list is not appropriate.

It is a guide only. Each organisation will need to determine its own cleaning responsibilities, adding further items if required, and frequencies, completing these on the right-hand side.

Cleaning responsibilities framework example

Appendix 2: elements, performance parameters and cleaning frequencies

For cleaning frequency definitions refer to the National Standards of Healthcare Cleanliness – section 5: Risk categories and standards for functional areas.

Note: The list of elements provided is not an exhaustive list and organisations may add or remove elements that are not relevant to their organisation or an area of their organisation.

Elements, performance parameters and cleaning frequencies

Appendix 3: functional risk (FR) category allocation

The table is a guide on functional risk category allocation. The list is not exhaustive, and organisations should assign additional areas not listed through a risk assessed approach.

We recommend that communal areas (for example, public corridors and public toilets) directly associated with all the areas listed under each functional risk should be categorised as the same FR level.

Each FR category has its own audit target score. However, even if a functional area achieves its audit target score (or above), unless it scores 100% it is still likely to generate remedial actions. In these instances, the activity generated through rectification will serve to enhance the focus on the functional area and provide assurance. (Please refer to section 9.4 Table 5 in the national standards.)

* Please note that when determining the FR category for linen and laundry departments other appropriate guidance may need to be considered, such as Health Technical Memoranda (HTMs).

Appendix 4: high frequency touchpoints

Wards and departments:

• light switches / plastic pulls
• taps, dispensers, toilet flush handles
• door handles and push plates
• over-bed table and trays
• bed rails
• grab rails
• patient chair arms and seat
• relevant parts of notes, linen, drug and general-purpose trolleys
• nurse call buttons
• TV remote control
• bedside drawers and locker handles
• kitchen cupboard handles
• patient entertainment system, including any TV remote controls
• patient area multi-user phones and computer buttons and receivers
• fridge and freezer handles
• ice machines, hot water boiler and cold-water machine buttons/levers
• cooker and microwave handles and

Public areas:

• elevator plates and call buttons
• light switches/plastic pulls
• door handles and push plates – all areas
• grab rails
• taps, toilet flush handles, dispensers, and hand dryers in public toilets
• chair arms and chair seat in waiting areas

Note that the list above focuses on environmental cleaning and is not intended to capture items (that is, patient equipment) that require cleaning between use: for example, blood pressure cuffs. For a full list of items that require cleaning between patient use, please refer to local protocols/policies.

Appendix 5: commitment to cleanliness charter

Worked examples of cleaning responsibility displays.

Appendix 6: star rating scores

Appendix 7: technical audit process

We recommend that healthcare organisations review the scenarios listed below and agree their response, which may be the same as the model guidance. The agreed organisation response should be detailed against each scenario if different from the guidance and scenarios added or deleted as appropriate.

It is important that all staff carrying out the audit agree on the process and criteria at the beginning of audit. When auditing, consideration should be given to the time and/or progress of the healthcare cleaning services in the ward/area; that is, before/after the start of cleaning services. Ideally, auditing should be undertaken as soon after cleaning as possible. Where this is not possible the time at which cleaning was performed should be taken into consideration.

Publication reference: PRN00904i