Food Hygiene Policy

Food Hygiene Policy
Version: 4.0
Authorisation Committee: Infection Prevention Committee
Date of Authorisation: 26TH July 2013
Ratification Committee (Category 1 QGSG (Policy Ratification and
documents): Monitoring Group )
Date of Ratification (Category 1 28th August 2013

documents):
Signature of ratifying Committee John Pappachan – Chair PRAM
Group/Chair(Category 1 documents):
Lead Job Title of originator/author: Clinical Lead EMT
Name of responsible committee/individual: Infection Prevention Committee
Date issued: August 2013
Review date: August 2016
Target audience: Trust wide
Key words: Food safety, food hygiene, food, drink,
infection prevention, baby formula
Main areas affected: Trust wide
Consultation: IPC Catering Group, Dietetics, PEXPG
Main Changes: Minor changes to policy.
Equality Impact Assessments completed June 2010

and policy promotes Equity
Number of pages: 12
Type of document: Level 1
The Trust strives to ensure equality of opportunity for all, both as a major employer and as a
provider of health care. This Food Hygiene Policy has therefore been equality impact assessed
by STS, food safety consultants, to ensure fairness and consistency for all those covered by it,
regardless of their individual differences, and the results are available upon request.
Issued: Page 1 of 42
Disclaimer: It is your responsibility to check against STAFFNET that this printout is the most recent issue of this
document.
Contents
Paragraph Page
Executive Summary/ Policy Statement/Flowchart 3
1 Introduction 4
1.2 Scope 4
1.3 Purpose – outline objectives and intended outcomes 5
1.4 Definitions – if necessary 5

2 Related Trust Policies 6
3 Roles and Responsibilities or Duties 6
4 Trusts Food Safety Standards 10
5 Implementation 10
6 Process for Monitoring Compliance/Effectiveness 11
7 Arrangements for review of the policy 12
8 References 12
Appendices
Appendix A Trust’s Food Safety Standards 13
Appendix B HACCP plan 24
Appendix C Essential Food Safety Training – Non Catering Staff 27
Guidelines for Health Professionals on Safe Preparation, Storage
Appendix D 31
& Handling of Powdered Infant Formula
Appendix E External Caterer Questionnaire and Declaration 36
Appendix
Cancer Care exception to Food Hygiene Policy 39
F
document.
University Hospital Southampton NHS Foundation Trust (UHS) has a moral and legal duty to
protect all patients, visitors and staff from food-related illness, and other harm arising from
food contamination.
Within the Trusts operations, there are various processes by which patients, staff and
visitors are provided with food and drink:
Provision of
food/drink to
patients, staff &
visitors
High & low risk Low risk food

High & low risk Food/drink via provided ‘in house’
Food/drink via Contracted food via Trust staff
Contracted retailers (E.g. nurses,
caterers (Charitable & non volunteers, care
charitable) staff)
By law, food safety must be managed using a documented, HACCP (Hazard Analysis
Critical Control Point) based approach, and food handlers must be appropriately trained in
food safety.
This policy identifies how the Trust helps to ensure these requirements are met; both for the
food/drink that is provided by contractors, and that which is provided by Trust staff ‘in house’.
The ultimate aim is to ensure food safety, and to ensure the Trust is able to demonstrate it
has taken all reasonable precautions and exercised all due diligence to ensure that food is
safe and wholesome.
document.
1 Introduction
1.1 UHS firmly believe in providing safe and wholesome food. The Trust wholly accepts
its moral and legal duties to protect food from contamination and to comply with
current food safety legislation, of which key legislation includes:
▪ The Food Safety Act 1990

▪ Regulation (EC) No. 852/2004 on the hygiene of food stuffs
▪ The Food Hygiene (England) Regulations 2006
Furthermore, the Trust aims to, where possible, set standards in line with best
practice, as set down in the Industry Guides to Good Practice.
This food hygiene policy sets out the management arrangements and standards
required to ensure that the Trust and all contractors employed by the Trust that carry
out catering or retail of food/drink comply with legal requirements, with the ultimate
aim to protect the Trusts patients, staff and visitors from food-related illness, or other
harm which may arise from the chemical, physical or microbiological contamination of
food.
1.2 Scope
This policy and food safety legislation applies Trust wide, across all UHS sites, and
applies to all food and drink provided by or on behalf of the Trust to patients (adults
and children), staff and visitors. This policy applies to all staff, Supervisors and
Managers who have an involvement in food handling, including Trust staff and staff
who are employed by contracted caterers and food retailers. This policy applies to
both permanent and temporary staff such as agency staff and students, whilst on
Trust premises.
This policy also applies to food brought in by visitors for patients when it is stored or
handled by Trust or contracted catering staff. The policy and legislation does not
apply to food brought in by staff for their own consumption, although the Trust expects
the standards in this policy to be followed in relation to staff food and staff kitchens.
In house services
Some food handling is carried out by Trust staff, for example nursing staff and
housekeepers who provide snacks, drinks and food supplements to patients.
Appendix A details the food safety standards that Trust food handlers, Supervisors
and Managers must follow and adhere to – these are not repeated in this document.
A HACCP plan for the Trust is detailed in Appendix B.
Contracted services
A significant proportion of the catering and food retail services, including vending, at
the Trust are contracted out to external providers who are contract caterers and
retailers. These may be commercial (for example Compass Medirest) or charitable
organisations (League of Friends).
Please see appendix F for specific information relating to Cancer Care Group
document.
1.3 Purpose
The objectives of this policy are to:
Specify the management arrangements and responsibilities for ensuring food safety
for food provided by Trust staff.
Specify the management arrangements and responsibilities for ensuring food safety
for food provided by contracted caterers and food retailers.
Provide specific food hygiene guidance to be followed by food handlers.
Set out the reporting and assurance framework to ensure food safety within the
Trust.
1.4 Definitions
‘Food’ is defined as articles and substances for human consumption. Food includes
food ingredients, drink and ice. Food also includes enteral feeding. Food does not
include parenteral feeding or drugs.
‘High risk food’ is defined as food which supports the growth of micro-organisms
and which is ‘ready to eat’ (i.e. there is no further step in the process, such as
cooking, which will eliminate or reduce hazards to a safe level).
Examples of high risk foods are cooked meat and meat products, cooked fish and
fish products, dairy products, cooked rice and pasta, enteral feeds and infant
formulas.
‘Low risk food’ is defined as foods which:
 will not support the multiplication of micro-organisms, or

 foods which do support the multiplication of micro-organisms, but which will be
subject to further processing such as cooking which will eliminate or reduce any
hazards to a safe level.
Examples of low risk foods are many ambient stable foods such as bread, biscuits,
sponges, cereals, and raw meat/fish.
NB. Low risk foods such as raw meat may be contaminated and transfer
contamination to ready to eat foods, therefore controls must be in place to prevent
such contamination.
‘Food handler’ is defined as any person involved in the service provision who
handles or prepares food whether open (unwrapped) or packaged.
‘High risk food handler’ is a food handler who prepares open, high risk foods.
‘Low risk food handler’ is a food handler who handles low risk or wrapped food
only.
document.
‘HACCP’ is a systematic way of analysing the potential hazards in a food operation,
identifying the points in the operation where the hazards may occur, and deciding
which points are critical to consumer safety. These are the critical control points
(CCP’s). The CCP’s are then monitored and corrective action is taken if conditions at
any CCP are not within safe limits. By law, food businesses must manage their food
safety using a documented system based on HACCP principles. CCP’s are defined
as a step at which control can be applied and is critical to prevent or eliminate a food
safety hazard or reduce it to an acceptable level.
‘Appropriate training’ for food handlers is as stipulated in the Industry Guide to

Good Practice and as detailed within Appendix A.
2 Related Trust Policies
▪ Outbreak of Infection Policy

▪ Hand Hygiene Policy
▪ Pest Control Policy
▪ Standard Infection Control Precautions Policy
▪ Enteral Feeding Guidelines
3 Roles and responsibilities
The roles and responsibilities for the food safety of food/drink provided by Trust staff
and contracted caterers and food retailers are as follows:
 The Chief Executive holds ultimate responsibility for implementation of this

policy
 Director of Nursing and Organisational Development holds delegated

Executive responsibility for the implementation of this policy and for infection
prevention and control.
The Chief Operating Officer has executive responsibility for food safety services
within the Trust.
Contracted caterers and food retailers are responsible for:
o Ensuring that their organisation have robust systems in place to ensure food
safety for the service they provide to the Trust. This will include a
comprehensive, effective, documented food safety management system
based on HACCP (Hazard Analysis Critical Control Point) principles, and
appropriate staff training, instruction and supervision.
o Ensuring that their safety system for the operations which they carry out on
behalf of UHS is appropriate for this operation, and incorporates requirements
from within this policy and standards identified within Appendix A
o Ensuring that the safety training and instruction provided for their employees
incorporates requirements from within this policy and standards identified
(see Appendix A and C)
document.
o To maintain accurate HACCP documentation in an organised manner, and
make documentation and the food safety system available for inspection or
audit at all times.
o Promptly informing the Trust of visits from local Environmental Health

Practitioners, and providing the Trust Environment Team, Infection Prevention
Team, Associate Director for Governance and Trust Board with copies of all
correspondence and reports to and from the local Environmental Health
Practitioner.
o Ensure that any deficiencies within their defined areas of operation in respect
of building and engineering elements, and all equipment are remedied in a
timely manner. Any matters not within their defined areas should be reported
immediately to the Trust contract manager.
o Ensure that recommendations made by pest control contractors are actioned,

or reported to the Trust as necessary.
o Informing the Trust (Environment Team and Infection Prevention Team) of

and serious or recurring food complaints, or allegations of food poisoning.
o Inform the Trust, if for any reason the contractor is unable to effectively
control critical control points, and/or meet legal requirement for food safety.
The Environment Team is responsible for:
o Carrying out documented food safety audits of at least three wards per week
and providing a copy of their findings and recommendations to the contracted
caterer.
o In consultation with the Infection Prevention Team, for liaising with contract
caterers and food retailers to help ensure that actions required from
Environmental Health Practitioner’s Inspections, internal and external audits
are taken.
o Liaising with the Infection Prevention Team and Care Group Manager for Non-
Clinical Support regarding food hygiene issues and concerns in relation to the
catering contract.
o In consultation with the Infection Prevention Team organise the timely review of
this policy, in consultation with external food safety consultancy as required.
Liaising with the external food safety consultants to ensure that external food
safety audits are carried out on an annual basis.
o In consultation with the Infection Prevention Team, handling any food

complaints or allegations of food poisoning arising from food/drink provided by
Trust staff.
document.
o In consultation with the Infection Prevention Team, liaising with contracted
caterers or food retailers to ensure that allegations of food poisoning and
serious or recurring food complaints are handled appropriately by the
contracted caterer or food retailer.
o Report to the Care Group Manager for Non Clinical Support, serious or
recurring food safety issues, and matter which they are unable to resolve.
The Infection Prevention Team is responsible for:
o In consultation with the Environmental Monitoring Team, for liaising with

contract caterers and food retailers to help ensure that actions required from
Environmental Health Inspections, internal and external audits are taken.
o In consultation with the Environmental MonitoringTeam are responsible for

organising timely review of this policy.
o Liaising with the Environmental Monitoring Team and Care Group Manager for
Non-clinical support regarding food hygiene issues and concerns in relation to
the catering contract.
o Providing advice to the Trust on food safety matters, and for providing advice
on any catering contracts placed with external providers as required by the
Health and Social Care Act (2008).
o In consultation with the Environmental Monitoring Team, handling any food

complaints or allegations of food poisoning arising from food/drink provided by
Trust staff.
o In consultation with the Environmental Monitoring Team, liaising with

contracted caterers or food retailers to ensure that allegations of food
poisoning and serious or recurring food complaints are handled appropriately
by the contracted caterer or food retailer.
o Report to the Care Group Manager for Non Clinical Support, serious or
recurring food safety issues, and matters which they are unable to resolve.
Care Group Manager for Non Clinical Support is responsible for:
o Managing the Trust catering and food retail contracts.
o Liaising with the Infection Prevention Team and Environmental

MonitoringTeam regarding food hygiene issues and concerns in relation to
the catering contract.
o Reporting regularly to the Infection Prevention Committee on food safety

matters.
document.
Estates Department: is responsible for:
o Overseeing the service provided by the pest control contractor, ensuring that
visits are carried out at the correct frequency and those recommendations are
actioned.
o Ensuring a response within agreed Service Level Agreements, to defects

which are the responsibility of the landlord and not included in any contract by
a third party, which may impact on food safety standards.
Ward and Department Managers are responsible for:
o Ensuring that this policy and the Trust’s food safety standards (Appendix A)
are implemented within their area.
o Staff working in their ward or department are appropriately trained and/or

instructed and supervised to help ensure they adhere to these principles at all
times.
o Escalating concerns relating to catering and food hygiene through the defined
escalation framework.
Consultant Medical Staff are responsible for:
o Ensuring their junior staff read and understand this policy and the Trust’s food
safety standards (Appendix A), and adheres to the principles at all times.
Divisional and Care Group Management Teams are responsible for:
o Monitoring implementation of this policy and for ensuring action is taken if

staff fail to comply with the policy.
Divisional Director of Operations, Division C is responsible for:
o Placing the Trust catering and food retail contracts and ensuring the Infection
Prevention Team are fully consulted at every stage of the contract as required
by the Health and Social Care Act (2008).
All staff (including permanent and temporary staff) are responsible for:
o Adhering to this Food Hygiene Policy

o Adhering to the Trust’s food safety standards (as detailed in Appendix A).
o Reporting breaches of this policy or the food safety standards to the person in
charge and to their line manager.
o Ensuring they have received the appropriate training before handling food.
Non-compliance with Trust policy by contract caterers and food retailers may result
in termination of contract.
document.
4. Food safety standards
Appendix A details the food safety standards that Trust food handlers, supervisors
and managers staff must follow and adhere to – these are not repeated in this
document.
This document also includes guidelines to be followed for staff in the preparation and
storage of powdered infant formula (see Appendix D)
The Trusts HACCP plan is detailed within Appendix B. Appendix A supplements and
provides additional detail to controls cited in the HACCP plan and HACCP pre-
requisites such as personal hygiene, pest control, structure and cleaning and
disinfection.
Regardless of charitable or commercial status, all organisations involved with

providing catering or food retail services to the Trust will be expected to have their
own, robust systems in place to ensure food safety. This will include a
comprehensive, effective, documented food safety management system based on
HACCP (Hazard Analysis Critical Control Point) principles, and suitable staff training,
instruction and supervision.
The food safety systems which contractors have in place must ensure compliance
with food safety legislation, and wherever possible best practice as identified by the
Industry Guides to Good Practice. Relevant standards set down in Appendix A will
be expected to be also met or exceeded by contracted caterers and food retailers i.e.
although primarily designed for Trust food handlers, these standards must also be
met by contractors, and where appropriate integrated into their own food safety
systems.
External caterers may occasionally supply the Trust with food for events such as
buffets for conferences and functions. Such potential caterers must complete an
‘external caterer questionnaire and declaration’ (Appendix E). Before being
permitted to supply, a nominated, competent person with food safety training within
the Trust must review the response to the questionnaire and declaration. The caterer
must only be permitted to provide catering on the Trust premises if the response to
the questionnaire and declaration are complete and satisfactory, and this
documentation must be held on file. The external caterer must be able to
demonstrate that they have a suitable, documented food safety management system
based on HACCP (Hazard Analysis Critical Control Point) principles, and suitable
staff training, instruction and supervision. Relevant standards set down in Appendix
A will also be expected to be also met or exceeded by external caterers. The use of
such suppliers who have not provided satisfactory food safety information may
compromise the Trusts due diligence defence should food safety incidents arise from
use of such suppliers.
Please see appendix F for food safety standards relating to Cancer Care Group.
5 Implementation (including training and dissemination)
The Support services - Contracts Performance Manager will communicate this policy
to contracted caterers and food retailers.
document.
This policy will be communicated within the Trust via:
▪ Staff net announcement

▪ Divisional and Care group leaders will cascade this policy to all ward and
department leaders
▪ Briefing for all food handlers
6 Process for Monitoring Compliance/Effectiveness
Monitoring will be carried out to ensure that this policy is implemented, and
verification will be in place to ensure its effectiveness in preventing food borne illness
and food contamination.
Processes in place in order to monitor and verify this policy include:

▪ Day to day supervision Trust and contractor’s supervisory and management staff,
and
Environmental Health Practitioner reports:

▪ Mandatory inspections of catering and food retail outlets will be carried out the
local Environmental Health Practitioner. Copies of reports will be provided to the
contractor, the Associate Director for Governance, the Trust Board, the
Environmental Team and the Infection Prevention Team.
Internal audits:
 The Environment Team will monitor the performance of the food hygiene
standards achieved with regard to patient feeding at ward level. This will be
carried out via a programme of audits at ward level, three ward kitchens will be
audited per week. Audits will be documented, and the contractor and ward
manager provided with a copy of each audit report. If significant concerns are
identified, this will be escalated as necessary.
 Special Feeds Units (i.e. milk kitchen facilities) will also be included in the internal
audit programme.
 Audit of ward and department kitchens and associated food hygiene practices in
accordance with the Trust annual published infection prevention audit
programme.
 Reports to Infection Prevention Committee on food safety within the Trust,

including results of ward audit programme.
External audits:
 The Trust contracts the services of a food safety consultancy, STS, in order to
carry out food safety audits on an annual basis. STS audits include the whole of
the Medirest operations with regard to food safety, although only a sample of
ward kitchens will be audited each annum.
 STS will also audit a representative sample of food catering and food retail
outlets operated by contractors other than Medirest.
 STS will provide feedback and copies of audit reports to Clinical Lead Nurse –
Environment team, for onward distribution.
document.
Complaint/Incident monitoring:
▪ Levels of food complaints, incidents and allegations received will serve to verify
the effectiveness of the system.
▪ Patient feedback/customer satisfaction:
▪ The results of patient and customer feedback surveys and questionnaires will
indicate the effectiveness of the food safety system (for example whether the
temperature of food served is satisfactory).
Reporting Framework
TEC and Trust Board
Quality Governance
Steering Group
Infection Prevention Division C Governance

Committee: Committee (via Supporting
Chaired by DIPC Services Governance Group)
Food hygiene
Food hygiene standards standards
(excluding Trust catering Main catering
service) service
7 Arrangements for review of the policy
This Policy is to be reviewed after 3 years or as any changes arise which impact on the
policy such as changes in legislation or the nature of the operation. Review will be initiated
by the Environment Team in consultation with the Infection Prevention Team.
8 References
Industry Guide to Good Practice – Catering Guide

Industry Guide to Good Practice – Retail Guide
Food Standards Agency – Food Handlers – Fitness to Work 2009.
HM Government 2007– Guidelines for making up special feeds for infants and children in
hospital. WHO guidelines for the safe preparation, storage & handling of powdered infant
formula 2007.
DoH Guidance for health professionals on safe preparation, storage and handling of
powdered infant formula (Appendix D)
document.
Appendix A – Trust Food Safety Standards
Appendix A details the food safety standards that Trust food handlers, Supervisors and
Managers must follow and adhere to.
Relevant standards set down in this document will be expected to also be met by contracted
caterers and food retailers.
Purchase and delivery
Only food which has been purchased and delivered via the main kitchen will be served or
sold within the Trust. The contracted caterer has systems in place to ensure only reputable
suppliers are used, and that monitoring at the point of delivery is carried out to help ensure
that all food accepted into the Trust premises is suitable.
For organisations who’s food is not purchased and delivered via the main kitchen (for
example League of Friends), must have suitable procedures in place to ensure they are
purchasing from reputable suppliers with regard to food safety. This organisation must also
have suitable arrangements in place to ensure food is delivered in a safe and hygienic
manner.
For food brought into the hospital premises by patients and their visitors, see section
‘Storage of food brought in to hospital’ below.
Food Storage
Food must be stored in an appropriate area, covered and away from sources of
contamination and at the appropriate temperature.
A system of stock rotation must be in place (place items with the shortest shelf life at the
front and always use the oldest first). Date checks must be regularly carried out, and food
disposed of as necessary to ensure that food is not stored past its ‘use by’ or ‘best before’
date.
It is the responsibility of the ward housekeeper (or person nominated by the ward manager if
no housekeeper) to check dates and dispose of food as necessary to avoid the storage of
out of date food in beverage point on wards, and the responsibility of the hostess from
Medirest for in the Steamplicity pantry.
Refrigerated & frozen storage
High risk foods must be stored in the refrigerator, by law maintaining a food temperature of
between 0 ºC and 8 ºC at all times (target air temperature 5ºC or below). Freezers should
hold at -18ºC, maximum -13ºC. Temperature is to be monitored and recorded daily and
corrective action taken and recorded as required.
All refrigeration units should be in a good state of repair to facilitate cleaning.
Specific guidelines must be followed for the production, chilling, storage and transport of
special feeds for infants and children. It is the responsibility of senior ward staff to ensure
these rules are adhered to.
It is the responsibility of the ward Housekeeper (or person nominated by the Ward Manager
if no housekeeper) to monitor and record the temperature of fridges in the beverage point on
document.
wards, and the responsibility of the hostess from Medirest to monitor in the Steamplicity
pantry. If unsatisfactory temperatures are identified, the following procedure must be
followed:
Breakdown procedure
If refrigerator or freezer temperatures are unsatisfactory the person checking the

temperature should advise the manager.
For refrigerators, if high risk food is not above 8oC, transfer food to another
refrigerator. If high risk food is above 8oC it must be discarded.
For freezers, if food temperature is above -18oC but below -13oC, food can be
transferred to another freezer. If temperature increases to above -13oC but is not
above 8oC, subject to its suitability, it should be stored in refrigerated conditions and
used within 24 hours. Alternatively the food may be appropriate to be cooked,
cooled, refrigerated and used within 24 hours.
If ice cream is above -13oC it must be disposed of.
Corrective action/discarded food should be recorded.
All food in refrigerators and freezers must be covered and date labelled.
All special formula feeds for infants and children must be labelled as per specific guidelines.
Refrigerators should be cleaned daily and as spillages occur, and deep cleaned on a weekly
basis.
On no account must raw meat, poultry or shell eggs be stored in the ward refrigerator.
Refrigerators are to be used for storage of food items ONLY (no specimens, drugs etc).
Tubs of ice cream must not be put in the freezer compartments of ward refrigerators for
consumption at a later time.
Dry storage
Dry Goods must be stored in cupboards or storage containers designated for food storage
only. They must not be stored on the floor, in open packages or left uncovered.
Goods stored in bins or containers will be allowed to run down completely before refilling, to
avoid topping up. Storage containers will be emptied, cleaned and disinfected atleast
weekly, and allowed to air dry or dried with disposable paper towel at least weekly.
Storage of food brought in to hospital
Patients and their visitors should be strongly discouraged from bringing any food on to the
ward other than ready to eat non-perishable snacks and fruit and non-alcoholic bottled or
canned drinks.
The following foods can constitute a serious health risk if inappropriately handled:
cooked meats & meat products

fish and fish products
soft cheeses
fresh cream products e.g. trifles, cream cakes etc
document.
shell eggs
cooked rice and pasta
Relatives must be informed of the need to ensure food is covered, and if it requires
refrigeration, that it is brought from home without delay so that it can be placed into the ward
fridge.
Food of this nature requiring refrigeration must be labelled with the patients name and date it
has been brought on to the ward. If items are not consumed by the use-by or best before
dates they are to be returned or discarded.
For food that does not have a best before or use-by date on it, staff must label the item/s
with the date bought in and discard or return within 24 hours if not used. This should be
clearly explained to relatives.
Food brought in by staff
Foods brought in by staff should not be stored with food and drink designated for patient
consumption due to the risk of cross contamination. Storage in catering areas including
ward kitchens is therefore not permitted. Staff food should be stored either in a designated
staff fridge or cool bags/boxes should be used.
Access to ward kitchens
On acute wards, patients & patient friends & relatives should not have access to the ward
kitchen or the ward refrigerator.
Where it is deemed therapeutic for patients to have access to the ward kitchen then they
must be supervised by a member of staff trained in food hygiene practices at all times.
Patients or patient relatives cooking in a ward kitchen may only produce food for their own
consumption or in the case of a friend or relative, for the patient they are visiting. Facility to
do this must only be allowed in extenuating circumstances and at the discretion of the Ward
Manager. Where this situation arises, a local risk assessment will be put in place by the
Ward Manager, which will be signed-off by the Environment Monitoring Team.
It is the responsibility of senior ward staff to ensure these rules are adhered to.
Animals must not be allowed in ward kitchens.
Food Service to Patients
The service of food to patients must begin immediately once the food arrives. Delays could
lead to both bacterial growth and deterioration.
If not consumed immediately, cold food should be placed in the refrigerator on arrival to the
kitchen area and should not be removed until just before serving.
Cooked and reheated foods much then are kept at a temperature of 63ºc or above prior to
service. Once re-heated, foods not served must be treated as food waste and disposed of
according to waste policy procedures. Steamplicity meals must not be heated more than
once.
document.
Meals and snacks should not be left with patients for excessive lengths of time (longer than
1 hour) due to the risk of microbiological growth at room temperature. Any food served to a
patient must be discarded, if not eaten.
Opened cartons, or made-up sip feeds (such as Build Up, Fortisip Compact, Fortijuce)
should not be left standing on the bedside locker for longer than 4 hours, after which they
should be discarded.
Infant feeds should be placed immediately into the designated refrigerator on arrival on the
ward. They should be stored in the main body of the refrigerator (not in the door). All unused
feeds must be discarded after 24 hours in accordance with the “use by date” and time
indicated on the feed label. ( ref Operational policy for milk kitchen)
Baby’s feeds should not be left standing at room temperature for more than 1.5 hours before
refrigeration. Refrigerated feeds should be used within 24 hours.
Holding back of hot patient meals after service is strictly prohibited. Meals must NOT be
kept to one side at ward level for re-heating by microwave and neither must bought-in ready
meals be re-heated via the microwave by non-catering staff. If a patient is unable to eat at
the planned mealtime an alternative meal should be provided. The original meal must be
discarded.
Patient trays should be checked after removing to check for any extraneous items e.g.
dentures, sputum pots, dressings etc. which must be removed at ward level. All unused
food, hot or cold, must be returned to the kitchen with the food trolley. Any other food must
be disposed of via a waste disposal unit. Waste food should not be disposed into plastic bin
sacks and held at ward level as this could encourage pest infestation.
Temperature Control
In addition to the temperature of refrigerators and freezers at ward level, effective

temperature/time control of high risk foods at all stages of food production from delivery
through to service is required. For example, temperature monitoring and associated records
must be in place for cooking/re-heating (75ºC or above) and cooling/blast chilling. If
temperatures/times are outside target, corrective action must be taken and recorded. Such
stages in the food operations are generally the responsibility of the contract caterer or food
retailer.
Temperature checks should be taken using a probe thermometer that is regularly calibrated
for accuracy, and records of calibration maintained. Temperature check records must be
retained for six months.
Infection Prevention Precautions and Patient Food Service
Where there is a cohort or isolation barrier nursing and/or nursing of specific outbreaks of
infection such as diarrhoea and vomiting:
Protective clothing must be worn and changed immediately before exiting the area.
Hands must be washed with soap and water.
The food trolley must not enter these areas – only the patient tray with crockery and
cutlery should be taken in to the patient.
Particular attention must be paid to personal hygiene especially hand washing and
the cleanliness of all equipment.
document.
Enteral Feeding
Enteral tube feeding can be associated with complications relating to the possibility of
microbial contamination. The use of a nutritionally complete, sterile feed is recommended at
all times, unless directed otherwise by a doctor or dietician. A technique that maintains the
sterility of the system, and minimises handling, must be used to attach feeds to
administration equipment. Dilution of feeds is bacteriologically undesirable. If dilution is
unavoidable, feed and container should not hang for more than 4 hours and should
thereafter be discarded. Refer to Enteral Feeding Guidelines for further guidance
Milk kitchens
The World Health Organisation Guidelines for safe preparation, storage and handling or
powdered infant formula must be followed as far as is practical. ref WHO 2007
National “Guidelines for making up special feeds for infants and children in hospital” must
also be followed.
Use of water coolers
Water coolers provide ready access to fluids in many staff and patient areas. However, if
these machines are not cleaned and maintained correctly they may pose a risk to infection.
Two types of cooler
Bottled water ( BW) coolers use a container of water which need to be emptied. point of use
( POU) coolers are connected directly to the buildings water supply and provide mains
filtered water.
Location of BW coolers
The department of health guidelines recommend that patients should not be given water
from free-standing water coolers, only from the coolers attached to the mains ( UHS FOOD
HYGIENE POLICY) And bottled water should not be used for babies or infants. Therefore
these coolers should not be placed in patient areas.
Water-dispenser and unused bottle should not be located in areas where the equipment has
the potential to become contaminated with chemicals, bacteria, radiation, or harmful
substances. It should be away from direct sunlight.
BW should not be stored for more than 30 days. Like many other food products, bottled
water normally contains low numbers of harmless bacteria, during prolonged storage at
room temperature these bacteria can multiply rapidly.
Once a bottle is positioned on the cooler the water should be drunk ideally within 3 weeks.
Once the water bottle is empty it must be removed from the base.
The cooler should only be installed by a certified professional.
POU Filters
Filters are sometimes fitted in water coolers to further improve the taste of the tap water.
Filters should be changed every six months.
document.
For all water coolers the following must be adhered to:
A named individual must be responsible for the machine

A full maintenance contract is purchased and documented, maintenance must be
carried out as per manufacturers instructions
The outside of the machine and the drip tray must be cleaned and dried daily, and
when visibly dirty using a solution of detergent and hot water and sanitiser.
A cleaning record should be kept along with a record of maintenance carried out by
the company.
NB: Department of Health guidelines recommend that patients should not be given water
from free-standing water coolers, only from the coolers attached to the mains.
Ice making machines
Ice making machines have been implicated in hospital outbreaks of infection and it is
therefore essential that the potential risks within each specific location are assessed prior to
purchase.
Responsibilities for maintenance and cleaning must be agreed prior to purchase

Schedules should be prepared which reflect individual roles and responsibilities.
A machine directly plumbed in to the water supply, with a u-bend and break in the
drain to prevent reflux is preferred.
The water reservoir and ice storage compartments should be well insulated.
The design and mechanism should assist regular and thorough cleaning.
There should be adequate separation of the air inlet and outlet in the heat exchange
mechanism to permit efficient cooling.
Ice making machines should be included within a planned maintenance programme agreed
by prior arrangement with the Estates Department.
Ice making machines should be cleaned in accordance with manufacturer’s

instructions.
Documented cleaning schedules should include the person responsible for cleaning,
the frequency, the cleaning regime and names/signatures.
The outer areas of the machine and ice-making compartment must be cleaned daily.
New purchases of ice machines should be of the type that automatically dispense and do not
have a storage compartment open to the user. Older-style machines in use must be
meticulously managed to minimise risk of ice contamination.
On a weekly basis the ice storage compartment should be emptied and any remaining ice
discarded. The compartment should be cleaned, thoroughly dried using disposable paper
towels and then disinfected with sanitiser or a 100 ppm sodium hypochlorite solution (Milton
diluted 1:100)
The scoop should be stored outside the machine in a lidded container and washed daily in
the dishwasher. The door of the machine should be kept closed when not in use and the
area around the machine kept clear.
Prior to administering ice, hands must be decontaminated in accordance with the Trust Hand
Hygiene Policy. The scoop must be used for handling ice, and the scoop must never be left
with the handle in contact with the ice. Any unused ice must not be returned to the machine.
document.
Training
It is a legal requirement that all food handlers are supervised and instructed and/or
trained commensurate with their work activities.
It is essential that all ward-based food handlers undergo induction training relevant to
their post.
At induction, staff should be supplied with written guidelines on food hygiene, a
signed copy of which should be recorded on their personal file (Appendix C).
In general, nursing staff and housekeepers will be involved only in the preparation of
low risk food items, and therefore no additional specific training will be required for
this group.
Staff who are involved in the preparation of high-risk foods, or whose main role
function is catering will be required to complete additional food hygiene training,
equivalent to Level 2 standard.
The summary table below provides the level of training required by food handlers,
supervisors and managers within the Trust and working as external catering or food
retail providers to the Trust.
Summary of Food Safety Training required:
Staff Group Initial, Level 2 Level 3 Level 4

Awareness Award in Award in Award in
level Food Food Safety Food Food Safety
Safety Safety
Training
Low risk food handlers X
(includes nurses, volunteers
& other staff who serve food,
and/or handle low risk or
wrapped food only)
High risk food handlers X X
(includes staff who prepare
open, high risk food)
Supervisory staff who X X
supervise low risk food
handlers.
Supervisory staff who X X X
supervise high risk food
handlers.
Catering Managers X X X X
Hand hygiene
All food handlers are required to wash their hands before and after contact with food.
Hands must be washed properly using liquid soap and running water and then dried
thoroughly using disposable paper towel.
Hand washbasins are for hand washing only and must not be used for any other
purpose.
Minor cuts or abrasions to the hands must be covered with a blue waterproof
dressing.
Jewellery (with the exception of a plain wedding band), nail varnish or false nails
should not be worn.
document.
A “nothing below the elbows” policy should always be adopted.
When serving food to patients, hand hygiene should be undertaken in accordance
with the Trust Hand hygiene policy
Staff must never have direct hand contact with food. Utensils or disposable gloves should
be used. If gloves are used, hands much be washed before putting them on, and they must
be changed on occasions when an ungloved hand would usually be washed.
Protective Clothing
All main catering food handlers shall wear the uniform / protective clothing as provided by
the employer. Uniform will be kept clean and in good repair by the food handler and will be
changed into at work and not worn outside of the workplace to and from work. Protective
clothing should be laundered at a temperature of at least 60ºC.
All other occasional food handlers (i.e. housekeepers, nursing staff) shall wear a plastic
white disposable apron during any food or drink preparations. This should not be worn for
any other purpose, and disposed of after each use.
Staff Health
For all staff:
All Trust staff designated as food handlers are to be screened before appointment via
the Occupational Health Department (this includes agency/bank staff).
All staff must report if they are suffering from, or have suffered from diarrhoea or
vomiting, throat infections, skin rashes, boils or any other skin lesion.
Staff suffering from diarrhoea are not allowed back to work until they have been
symptom free for 48 hours.
Occupational Health should be consulted if there are concerns regarding symptoms,
and The Food Standards Agency ‘Food Handlers Fitness to work guidelines’
observed.
It is important that if a ward/department manager has more than one member of staff
off duty at one time with gastro-intestinal illness that the Infection Prevention Team is
informed.
In addition, for staff whose main role is food handling:
Any member of staff who has had a gastro-intestinal illness whilst abroad on holiday
should report this whether they have recovered of not before commencing work.
Staff with an immediate family member, living in the same house, who has a gastro-
intestinal illness, must report this to the immediate manager.
Contracted caterers/food retailers must have procedures similar to the above in place to
ensure food handlers are fit to work. Procedure must have regard to the Food Standards
Agency – Food handlers – Fitness to work guidelines.
Disposal of waste food
Collection and disposal of food waste must be carried out safely and in accordance with
Waste Regulations and the Trust Waste Policy.
document.
Generally food waste should be disposed of via a waste disposal unit as opposed to being
bagged as this lessens the attraction of pests to the kitchen areas.
Structural/equipment standards for ward/department kitchens and pantries
Catering accommodation must be adequate for the total food service requirements and
should:
Be adequate for the number of meals required and type of catering system in use
Allow for safe and hygienic production and service of food
Meet the personal hygiene requirements of food handlers and other users
The layout, design, construction and size of the premises must in particular:
Permit adequate cleaning and disinfection

Permit food hygiene practices including protection against cross contamination and
by processes (i.e. separation of clean & dirty activities, such as food preparation and
pot washing)
Food handling areas and stores for cleaning equipment used in food handling areas must be
separated physically from sanitary and sleeping accommodation, and must not be directly
accessible from them. The Trust must provide adequate:
Numbers of wash hand basins, designated for hand washing & so sited as to
encourage use by all.
Toilet facilities (number according to Workplace regulations) that must not open
directly into a food room.
And should provide:
Separate changing rooms (for the main food handlers who wear protective uniform).
Such rooms should include mirrors, clothes hooks, and secure storage for personal
effects, sanitary bins and chairs. Changing accommodation should be as such to
encourage the very highest standards of personal hygiene.
Structural defects should be reported the Estates Department, and a record of the report
kept.
Equipment including purchase, servicing and maintenance
All equipment purchased for use in kitchens that provide food for patients, staff and the
public must meet minimum criteria to ensure food safety. Advice should be obtained from
the Procurement department, the Estates department and the contract caterer or food
retailer consulted as required.
All equipment purchased must carry a CE mark or be to a recognised standard and must be
approved by the Estates Department. This will ensure that:
The equipment meets the required safety standard

The equipment is suitable for the environment where it will be used
The equipment is entered onto the equipment inventory to ensure that it is safety
checked at the required intervals
The equipment is entered onto service contracts
document.
Any necessary routine maintenance can be carried out
Any spares that require routine replacement can be carried
The type and range of equipment and facilities provided in food handling areas must ;
aid effective cleaning
where necessary aid disinfection
minimise risk of contamination of food
ensure where appropriate that food temperatures are maintained and can be
monitored
Facilities should include:
Stainless steel tabling and sinks in preparation and cooking areas

Adequate refrigeration for fresh foods and cook-chill meals
The Estates Department are required to carry out Planned Preventative Maintenance on
essential equipment, e.g. refrigeration, and respond appropriately to requisitions.
Equipment defects should be reported the Estates Department, and a record of the report
kept.
Pests
Pests present a health risk to both patients and staff and the presence of pests are contrary
to the Food Hygiene Regulations.
Premises should be regularly checked by a pest control contractor and any

recommendations made by them should be acted upon.
Pest infestation or signs of pest infestation of any kind must be reported immediately to the
hospital pest control officer so that the pest control contractor can be alerted to deal with the
problem. If pest activity is present in any food handling or storage areas, food must be
protected from contamination i.e. Kept covered in pest proof containers, and food contact
surfaces and equipment sanitised before use.
Cleaning & disinfection
Food contact equipment/surfaces (e.g. knives, chopping boards) and hand contact
surfaces must be cleaned and sanitised after use by either a dishwasher (rinse cycle
82◦ºC or above) or by use of a sanitiser.
Before using any cleaning agents staff should be trained in their correct use and the
importance of observing the manufacturers instructions in respect of chemical
concentration and application (e.g. contact time).
Staff should be trained in how to clean, how often and when to clean, what
equipment and chemicals to use and what safety equipment is to be worn.
Cleaning schedules will be provided in all kitchens to instruct staff. All fixtures,
fittings, equipment and surfaces should be included in the schedules. The schedule
should indicate the person responsible for each cleaning task.
A daily record should be maintained to indicate the equipment cleaned, and who
checked the standard of cleaning. Any failure to clean effectively and action taken
should be recorded.
The schedule should be reviewed regularly to ensure new equipment is included, and
frequency of cleaning may need to be revised as use changes.
document.
Cleaning Equipment and Chemicals
Cleaning equipment should be easy to clean, kept clean and in good condition.
Disposable cloths will be used for cleaning using detergents, and disposed of after
dirty tasks, and atleast daily.
Disposable paper roll/towels will be used for cleaning/disinfecting using sanitiser, and
disposed of after each use.
Mop heads will be laundered daily. In between use mop heads should be wrung out
and stored in drying rack, head uppermost.
Cleaning equipment and chemicals will be stored in a purpose built chemical room or
cupboard, within or adjacent to the food handling area. In the absence of a room or
cupboard, cleaning equipment and chemicals should be kept away from food.
Bulk storage of chemicals must not be in a food room or food store.
Chemicals should only be stored in clearly labelled containers, which cannot be
confused as food containers.
To help prevent any spread of infection, a colour coded system will be used to avoid
cleaning equipment used in catering areas also being used in ward or WC areas.
This includes mop head, buckets, gloves and disposable cleaning cloths.
Mechanised Cleaning:
The use of tea towels on equipment, crockery and utensils will be avoided. Instead
air drying should be allowed or disposable towels used.
The operation of mechanical wash up equipment shall be periodically monitored to
ensure an adequate supply of cleaning chemicals and that the optimum temperatures
of 65oC wash cycle and 82oC rinse cycle are being met.
Where a dishwasher is fitted with a temperature display, the temperature of the final
rinse cycle will be checked and recorded on a daily basis.
document.
Appendix B HACCP Plan for University Hospitals Southampton NHS Foundation Trust
Important notes:
The HACCP plan below is for stages in the food operation at the Trust which are carried out by Trust staff. Other stages in the operation (e.g.
purchase, delivery, thawing, high risk preparation, cooking/reheating, cooling, hot holding etc) are carried out by contract caterers and food
retailers. The contractor will conduct and implement appropriate HACCP system for these stages.
Personal hygiene, cleaning, pest control and structure & equipment are considered to be pre-requisites for the HACCP system.
As these pre-requisites apply as controls at each step in the operation, these have not been detailed in the HACCP plan below, which
concentrates on hazards and corresponding controls, monitoring procedures and corrective actions specific to each step.
Step Hazard Control measure CCP Critical limits Monitoring procedure/ Corrective action
documentation
Refrigerated Bacterial multiplication. Target temperature for all fridges Yes 8ºC for high risk Check temperature of Follow fridge/freezer breakdown
o
Storage 5 C or below. refrigerated refrigerators daily. procedure.
foods.
Foods to be dated, within date and Daily date checks. Any out of date, food not dated or
stock rotated. No out of date contaminated foods to be disposed
food. Visual checks. of.
Microbiological, physical No raw food to be stored at ward
or chemical level. Complete refrigerator
contamination. monitoring form daily
Food to be kept covered.
Disclaimer: It is your responsibility to check against STAFFNET that this printout is the most recent issue of this document.
documentation
Frozen Storage Bacterial multiplication. Target temperature for all freezers - Yes -13ºC for high Check temperature of Follow fridge/freezer breakdown
o
18 C or below. risk frozen foods. freezers. procedure.
Foods to be stock rotated, dated
and within date. Date checks. Any out of date or contaminated
foods to be disposed of.
Microbiological or Food to be kept covered. Visual checks to check
physical contamination. food is covered, stock
rotated.
Complete freezer
monitoring form daily.
Dry storage Microbiological, physical, Manufacturer’s guidance to be No Check dates weekly. Any contaminated or out of date
chemical contamination. followed for all dry foods. foods to be disposed of.
Visual checks.
Opened foods to be stored in
plastic lidded containers.
Food to be dated, within best

before date, stock rotated.
Low risk food Microbiological, physical, Food & hand contact surfaces to be No Visual checks. Any contaminated foods to be
preparation chemical contamination. disinfected. disposed of.
Foods to be kept away from

sources of contamination during
preparation.
High standards of personal

hygiene, including strict controls
after contact with patients.
Service of Microbiological, physical, Food to be placed in areas away No Visual checks. Any contaminated foods to be
ambient foods chemical contamination. from potential contaminants during disposed of.
service.
documentation
Hot Service Bacterial multiplication. Food served as soon as possible Yes Hot food to be Visual/time checks. Any foods contaminated to be
after heating in microwaves. served within 15 disposed of.
minutes of
Food to be located away from microwaving. Dispose of hot foods left for more
potential contaminants. than 15 minutes of time of
microwaving.
Microbiological, Clean & disinfected crockery,
physical, chemical cutlery & utensils to be provided.
contamination.
Foods to be covered where
possible.
Leftover foods to be disposed of.
Good standard of personal

hygiene.
Cold Service Bacterial multiplication. High risk food to be kept in Yes High risk chilled Visual/time checks Dispose of leftover cold foods at end
refrigerator whilst awaiting service. food only to be of service, or place in refrigerator at
held out of 8ºC or less and serve straight from
Food to be located away from refrigeration for refrigerator.
potential contaminants. service once
only, and for less Any foods contaminated to be
Microbiological, Clean & disinfected crockery, than 1 hour. disposed of.
physical, chemical cutlery & utensils to be provided.
contamination. Foods to be kept covered.
Appendix C Food Safety Training – Non Catering Staff Ward Kitchens / Pantries
As a designated food handler please note and observe the following:
THE 10 GOLDEN RULES FOR PERSONAL HYGIENE
1. Hands must be washed thoroughly (with liquid soap and water) at designated hand
wash basins:
Before starting work, on entering the kitchen and before handling food or
equipment
After using the toilet
After handling any wrapped or unwrapped food
After sneezing, coughing or using a handkerchief
Before and after carrying out cleaning procedures
After touching ears, nose, mouth or hair
After any contact with patients or their immediate surroundings
After removing gloves
After handling waste / dirty laundry
2. Keep fingernails short and clean, do not use nail varnish or wear rings (except a plain
wedding band) or items of jewellery including wrist watches as per ‘nothing below the
elbow policy’
3. Keep cuts and burns covered with waterproof dressing
4. Do not lick your fingers
5. Do not cough or sneeze over food
6. Do not eat, drink beverages, or chew gum in food preparation areas
7. Keep hair tied back and do not scratch your head
8. Do not use an overall, apron or cloth to wipe or dry your hands (use disposable paper
towels)
9. Handle food as little as possible
STAFF HEALTH
All staff must report if they are suffering from diarrhoea or vomiting, throat infections,
skin rashes, boils or any other skin lesions
Staff suffering from diarrhoea or vomiting are not allowed back to work until they have
been symptom free for 48 hours
PROTECTIVE CLOTHING
During any period of food preparation or food service a WHITE plastic apron
and gloves must be worn and not used for any other purpose.
document.
FOOD HANDLING
Never have direct hand contact with food. Utensils or disposable gloves should be
used
Staff serving food to patients should strictly observe the “nothing below the elbow”
policy
THE WARD KITCHEN
Responsibilities & Access:
Ward Managers have overall responsibility for food hygiene in ward kitchens, including
storage of food, temperature control and monitoring the cleaning and fabric of ward
kitchens/pantries
Ward Hostesses – Catering have the day-to-day responsibility for the overall operation and
cleanliness of the ward kitchen. They are the main food handlers that prepare and serve
patients meals, snacks, replenish water jugs and provide clean water glasses
All other authorised ward personnel - have a duty to support, assist and comply with the
following food safety rules and guidelines concerning the ward kitchens/pantries and service
of food and drink to patients when the need arises.
Non-ward personnel - in the interests of safety and prevention of cross contamination, only
authorised ward personnel be allowed access to the ward kitchen areas. No animals are to
be allowed access.
Storage:
Only food and drink intended for the consumption by patients is allowed to be stored
in the ward kitchens / pantries
All food and drink must be stored appropriately away from sources of possible
contamination and at the correct temperature
o Stock must be stored off the floor
o Bare wood will not be used for storage e.g. wooden shelving
o Dry opened food products will be stored in pest proof containers & will be kept
scrupulously clean, dated and labelled
o Cleaning materials must not be stored with or in close proximity to food or
equipment.
Ward refrigeration
o Foods stored in refrigeration must be stored at 5ºc or below at all times. This
temperature must be monitored and recorded daily
o Ward food refrigerators must be used for patient food items and not to store
drugs, transfusion blood or specimens.
o On no account must raw shell eggs, raw meat/fish/poultry, or soft cheeses be
stored in ward refrigeration
Stock rotation / food brought in by friends and relatives

o A system of stock rotation must be in place and adhered to by everyone i.e.
“Always use the oldest first” observing use-by and best before dates
accordingly. Foods beyond these dates should be discarded.
document.
o Whilst food for patients brought in by friends and relatives is not encouraged,
food of this nature must be labelled with the patients name and date it has
been brought on to the ward
o Food brought in that may have been home prepared will not have a best-by or
use-by date therefore label with the date and time brought in, and discard or
return within 24 hours if not used.
Pests
o Signs of any pest infestation should be reported immediately to the senior
person in charge of the ward area so that this can be reported for action with
the Trust Pest Control Officer
Food Service:
When involved with the service of food and drink to patients:

“Steamplicity” chill meals reheated for patients must attain a core temperature of 75ºc
and served immediately and never below 63ºc
Cold meals and snacks should only be removed from the refrigerator just prior to
service to the patient
Meals and snacks should not be left with the patient for long periods of time (longer
than 1 hour) due to the microbiological growth at room temperature.
Any food not eaten by the patient must be discarded as food waste
Sip feeds (e.g. Build-up made with milk) should not be left standing on the bedside
locker for longer than four hours, after which they should be discarded
Babies feeds should not be left standing at room temperature for more than 1.5 hours
before refrigeration. Refrigerated feeds should be used within 24 hours.
Infection Control and Food Service

Where there is a cohort or isolation barrier nursing and/or nursing of specific outbreaks of
infection such as diarrhoea / vomiting:
o Protective clothing must be worn and changed immediately after exiting the area
o Hands must be washed and particular attention paid to personal hygiene and the
cleanliness of equipment
o The food trolley must not enter these areas – only the patient tray with crockery
and cutlery should be taken into the patient
Food brought in by patients or visitors:
Patients and their visitors should be STRONGLY DISCOURAGED from bringing in any food
on to the ward other than ambient snacks; fruit and non-alcoholic bottled or canned drinks.
The following foods can constitute a serious health risk if inappropriately handled.
Cooked meats and meat products

Fish paste and fish products
Soft cheeses
Fresh or synthetic cream products e.g. trifles, cream cakes etc
Shell eggs
Yoghurts
Chilled ready meals
document.
Essential Food Safety Training – Non Catering Staff UHS
Training completed by:
Name: __________________________________
Designation: ______________________________ Date:

_________________
Employee Declaration:
I have received the aforementioned food safety training and have understood all that has
been explained to me:
Signature (employee) ____________________________________
Name (Capitals) ________________________________________
Date: _________________________________________________
Copy to be placed on Employees file.
document.
Appendix D Guidance for Health Professionals on Safe Preparation, Storage and
Handling of Powdered Infant Formula
Powdered infant formula is not a sterile product and may be contaminated with pathogens
that can cause serious illness. Correct preparation and handling reduces the risk of illness.
The Department of Health and the Food Standards Agency have issued revised guidance on
the preparation and storage of powdered infant formula milk. This guidance covers the
home and other care setting, including nurseries and child minders.
The risks
The European Food Safety Authority’s Scientific Panel on Biological Hazards has issued an
opinion in relation to the microbiological risks in powdered infant and follow on formula. The
panel concluded that Enterobacter sakazakii and Salmonella are the micro-organisms of
greatest concern. Younger infants are likely to be more susceptible to these organisms than
older infants.
Although infections with these micro-organisms from formula milk are rare, the risks can be
reduced by following the guidelines below.
For high risk infants (pre-term, low birth weight and immunocompromised) using readi to
feed liquid formula, which is sterile, in place of making up powdered formula is considered
the safest option.
The Department of Health and the Food Standards Agency advise all health professionals,
particularly nurses, midwives and health visitors, to change/revise/ update their advice to
parents and carers on the preparation and storage of infant formula milk in the home and in
other care settings.
Health professionals should re-emphasise to parents and carers:
that powdered infant formula is not sterile and good hygiene practices are
essential in preparing and storing feeds made from powdered formula
failure to follow the manufacturer’s guidelines may increase the chances of a baby
becoming ill
In order to reduce the risk of infection it is recommended that the following steps are taken:
Cleaning and sterilising feeding equipment

It is very important that all equipment used for feeding and preparing feeds has been
thoroughly cleaned and sterilised before use.
Wash hands thoroughly before cleaning and sterilising feeding equipment

Wash feeding and preparation equipment thoroughly in hot soapy water
document.
Bottle and teat brushes should be used to scrub inside and outside of bottles and teats to
ensure that all remaining feed is removed
After washing feeding equipment rinse it thoroughly under the tap
If using a commercial steriliser, follow manufacturer’s instructions
If your bottles are suitable for sterilising by boiling: fill a large pan with water and
completely submerge all feeding equipment, ensuring there are no air bubbles trapped;
cover the pan and boil for at least 10 minutes, making sure the pan does not boil dry.
Keep the pan covered until equipment is needed.
Wash hands thoroughly and clean the surface around the steriliser before removing
equipment.
It is best to remove the bottles just before they are used.
If the bottles are not being used immediately, they should be fully assembled with the teat
and lid in place to prevent the inside of the sterilised bottle and the inside and outside of
the teat from being contaminated.
Guidance for Preparing Feeds in the Home
Preparing a feed using powdered infant formula

Important Normally each bottle should be made up fresh for each feed. Storing made-up
formula milk may increase the chance of a baby becoming ill and should be avoided.
1. Clean the surface thoroughly on which to prepare the feed
2. Wash hands with soap and water and then dry.
3. Boil fresh tap water in a kettle. Alternatively bottled water that is suitable for infants
can be used for making up feeds and should be boiled in the same way as tap water.
4. Important: Allow the boiled water to cool to no less than 70º C. This means in
practice using water that has been left covered, for less than 30 minutes after boiling.
5. Pour the amount of boiled water required into the sterilised bottle.
6. Add the exact amount of formula as instructed on the label always using the scoop
provided with the powdered formula by the manufacturer. Adding more or less
powder than instructed could make the baby ill.
7. Re-assemble the bottle following manufacturer’s instructions.
8. Shake the bottle well to mix the contents.
9. Cool quickly to feeding temperature by holding under a running tap, or placing in a

container of cold water.
10. Check the temperature by shaking a few drops onto the inside of your wrist – it
should feel lukewarm, not hot.
11. Discard any feed that has not been used within two hours.
document.
Guidance for the Use of Powdered Infant Formula Feeds in Care Settings
When it is not practical to make up feeds just before feeding:

It is best to make up infant formula fresh for each feed but, there are times when this may
not be practical and feeds need to be prepared in advance. For example, when taking an
infant to a nursery or to the child minder or when leaving the house for a prolonged
period of time.
Ready to use liquid feeds are sterile and are the safest option. However, they are a more
expensive option and therefore may not suit all parents.
Preparing powdered feeds for later use

It is the length of time for which the reconstituted formula is stored that increases the risk of
bacterial growth. Reducing the storage time will therefore reduce the risk. For example,
when taking an infant to the nursery it is best to make up the feed(s) on the same morning
before leaving home rather than on the night before.
The steps below outline the safest way to prepare and store feed for later use:
Prepare feeds in separate bottles, not in one large container (e.g. a jug)
Follows steps 1 to 9 of the section above ‘Preparing a feed using powdered infant
formula’
Store the feed in the fridge at below 5º C. Prepared bottles are best kept in the back
of the fridge and not in the door.
The temperature of the fridge should be checked regularly using a fridge

thermometer. A fridge that is opened frequently may need to be set at a lower
temperature to ensure that it does not rise above 5 ºC during times of frequent
access. The thermostat in older fridges without temperature settings may need to be
adjusted to ensure that the temperature is below 5º C.
The risk of infection to a baby will be lower if the feed is only stored for a short time.
Feeds should never be stored for longer than 24 hours and this length of time is no
longer considered ideal especially for young babies.
Alternatively, you may:
Put boiling water in a sealed vacuum flask and use this to make up fresh formula milk
when needed.
Care should be taken to avoid scalding when making up the feed
Re-warming stored feeds
Only remove stored feed from the fridge just before it is needed.
Re-warm using a bottle warmer, or by placing in a container of warm water.
Microwaves should never be used for re-warming a feed.
Never leave a feed warming for more than 15 minutes.
document.
Shake the bottle to ensure the feed has heated evenly.
Check the feeding temperature by shaking a few drops onto the inside of the wrist - it
should be lukewarm, not hot.
Transporting feeds
Because of the potential for growth of harmful bacteria during transport, feeds should first be
cooled in a fridge (below 5º C) and then transported.
Prepare feed(s) and place in the fridge as outlined in section ‘preparing feeds for use
later’.
Ensure feed has been in the fridge for at least one hour before transporting.
Only remove feed from the fridge immediately before transporting.
Transport feeds in a cool bag containing a frozen ice brick.
Feeds transported in a cool bag should be used within 4 hours.
Re-warm at the destination as in section ‘Re-warming stored feeds’.
Alternatively if you reach the destination within 4 hours, feeds transported in a cool
bag can be placed in a fridge and kept for up to a maximum of 24 hours from the time
of preparation - this is not ideal as the risk of illness increases the longer it is stored.
Preparation of infant formula in hospitals and Special Feed Units
Detailed advice about the safe preparation and storage of powdered infant formula for health
professionals in hospitals, especially intensive care units, will be published seperately.
Further Information
Further information on the Safety Guidelines issued by the European Food Safety Authority’s
(EFSA) Scientific Panel on Biological Hazards can be found on:
http://www.efsa.eu.int/science/biohaz/biohaz_opinions/691_en.html
document.
Question and Answers
What is the safest option for feeding babies?
Breastmilk is the safest way to feed a baby. Ready to use liquid feeds are sterile until
opened and are the safest option if using infant formula. Powdered infant formula is not
sterile and should be made using water that is hotter than 70° C.
Why is powdered infant formula not sterile?
The bacteria Enterobacter sakazakii is ubiquitous in the environment and may contaminate
powdered infant formula during manufacture. It is impossible to be sure of avoiding this
contamination. The bacteria may also be present on work surfaces in homes and nurseries
and can contaminate feeds while they are being prepared by parents or carers.
Why should the water be 70 degrees Celcius?
Water at 70° C will kill most of the bacteria present in the powdered formula. This is the most
important step in making up powdered infant formula as powdered infant formula cannot be
guaranteed to be free of bacteria
Why should made up formula be cooled quickly?
Bacteria multiply most quickly between 7 and 63° C. The longer formula is at this
temperature, the greater the increase in the bacterial content and so the risk of infection for
the baby will increase.
Why should storage times of made up formula be minimised?
Even when formula is made up with water at more than 70° C it may still contain some
bacteria which will continue to multiply during storage. At less than 5° C the rate of
multiplication of the bacteria will reduce but will not completely cease.
How long can made up formula be stored in a fridge?
Made up formula can be stored for a maximum of 24 hours but this is no longer considered
ideal particularly for young babies because the bacterial content continues to increase during
storage. This increases the risk of infection for the baby.
Once a feed is ready for feeding, how long before it should be discarded?
Discard any feed that has not been used within 2 hours. All left-over feed should be
discarded and never saved for later.
If you are out and cannot boil water how do you make up a feed?
Mothers should be advised to fill a vacuum flask with boiling water. If the flask is full and
sealed the water will stay above 70° C for several hours. This flask can be safely transported
and used to make up a feed when necessary.
Do vacuum flasks need to be sterilised if they are used to store boiled water for
making up a feed later?
No, the vacuum flasks do not need to be sterilised but they should be washed thoroughly
and rinsed with boiling water before being filled with boiling water intended for the feed. The
boiling water should kill bacteria present in the vacuum flask.
If water is boiled and put into the sterilised feeding bottles can it be stored in the
fridge like this until the powder is added?
No, the water must be above 70° C when the powder is added otherwise the bacteria in the
powder will not be killed.
document.
Appendix E External Caterer Food Safety Questionnaire and Declaration
Example covering letter for external caterer food safety questionnaire;
Insert Department Name:
Insert name and date of event:
Dear Sir/Madam,
As you will be aware, University Hospitals Southampton NHS Foundation Trust operates strict food
safety controls. In order to ensure our customers and staff receive safe food and high quality
product from external caterers provided within the hospital premises, please complete the enclosed
questionnaire and declaration within 1 month prior to the event.
We look forward to your response.
Yours sincerely,
Name
Designation
document.
Catering provided by external organisations
Food Safety Questionnaire
1. Are you registered as a food business with your local environmental health department?
2. Have you received an EHO food safety inspection?
Yes/No
If yes, please attach a copy of your last inspection report.
3. Has the food business been subject to any enforcement action for food safety offences?
If yes please provide detail:
4. Do you have a documented HACCP system?
Yes/No
5. Have food handlers been trained to Level 2 in food hygiene training?
6. Do you maintain temperature checks and records for the following?
Delivery
Fridges, freezers
Cooking/reheating
Hot and cold holding
7. Do you have procedures in place for handling food allergy enquiries?
Please provide detail:
8. Do you have systems in place for assessing your suppliers?
9. Do you have procedures in place to ensure food handlers are fit to work?
Any other comments:
document.
Catering provided by external organisations
Food Safety Declaration
Wholly accepts its legal duty to comply with the Food Hygiene (England) Regulations
2006 and Regulation (EC) 852/2004 of the European Parliament on the hygiene of food
stuffs and all subordinate legislation. It recognises that food production areas must be
maintained to a high standard of cleanliness and that food should be handled in such a way
as to ensure that it does not become contaminated. We further recognise the need for
effective temperature control of all foods likely to support the growth of microorganisms. We
also recognise the need to ensure that we purchase food from reputable suppliers.
In supplying food at Southampton University Hospitals NHS Trust,

We fully accept our responsibility to exercise all due diligence, and regard food safety as a
priority. We will meet or exceed relevant standards set down in Appendix B of the Trusts
food safety policy.
We accept that the Trusts management team will carry out spot checks of our catering
operations and practices, and that the Trust may require our food business to cease
operations if unsatisfactory food safety standards and/or practices are observed.
Signed: Date:
Name:
Designation:
Official use:
I confirm that I have reviewed the food safety questionnaire and declaration for the external
caterer………., and determined that the external cater is ( as applicable):

suitable to provide catering to the Trust
unsuitable to provide catering to the Trust
Signed: Date:
Name:
Designation:
document.
Appendix F Cancer Care Exception to Food Hygiene Policy
1.0 Introduction
The Trust has a legal obligation to comply with the requirements of the Food Safety Act 1990
and the associated legislation relating to composition, labelling, safety, handling, control and
hygiene of food.
The patients’ meals we serve every day are carefully prepared and designed to offer patients
a healthy balanced diet, selected from a menu with a range of hot and cold food and drinks.
Patients are encouraged to select a healthy and safe food choice with appropriate advice
given when required by dietitians.
Many of our patients are vulnerable to pathogens which can cause food poisoning, we
therefore as a trust we need to ensure the hygiene standards for all food consumed by our
patients. In addition to this some patients have disease or treatment which lowers their
immunity, making them ‘neutropenic’ e.g. treatment for acute leukaemia, bone marrow
transplant or peripheral blood stem cell treatment. For this patient group food poisoning can
be life threatening and they are advised to follow a ‘neutropenic diet’. Written information
regarding this will be provided by ward staff whilst on the ward. It is imperative that patients
comply with this and dietary restrictions may exceed those cited in this document.
These guidelines apply to food supplied to patients which is not prepared or supplied by the
Trust catering contract.
2.0 Food brought in by patients or visitors

Whilst it is appreciated that some patients prefer food to be brought in cooked from home,
this has to be considered an unsafe practice and must be discouraged. The trust recognises
for a few patients, there may however be a benefit; on these occasions these guidelines
must be followed to reduce the risk of food poisoning. Nursing staff must advise patients
and visitors on the following:
2.1 Transporting food to the hospital in appropriate conditions:

All chilled food and drink should be stored between 0°C and 8°C.
Chilled food must not be left outside of chilled storage for more than 4 hours.
Any food or drink which requires chilling and is left out of the fridge / chilled
conditions for more than 4 hours should not be consumed and must be disposed of
appropriately.
2.2 Storing food
Any food or drink requiring chilled storage should be stored in the patient’s fridge,
labelled with name and date.
Opened packets of dry goods such as biscuits or crisps should be stored in air tight
containers and used within the use by or best before date.
Any food from a can that is not consumed on opening must be disposed of. On no
account should food be stored in an opened can.
2.3 Reheating food
Commercially sealed pre-cooked food that requires re-heating should only be re-
heated by means of a commercial style microwave oven.
All food reheated must reach at least 83 degrees C the temperature must be checked
using a temperature probe and documented.
Any food re-heated for the patient must be documented, alongside the temperature
after heating as measured by the probe, on the attached sheet which must then be
kept for 7 days.
document.
2.4 Foods which can be brought into the hospital:
Commercially available dry goods e.g. dried soups or noddles requiring the addition
of hot water, breakfast cereal, biscuits, cakes, crisps, crackers, bread. All products
should be stored and used as per packaging instructions.
All the food items below, by the nature of the way they are produced and the strict
hygiene controls placed upon manufacturers, mean that they should be safe to use.
However, these products must be stored as per recommendations on the packaging,
chilled in transit in a cool bag or box, and used within the ‘use by date’ providing they
have remained stored in a suitable environment. The day of consumption must be
within the manufacturers recommended 'Use by' date.
o Commercially prepared foods such as tinned goods or pre-packed
microwavable meals / foods can be reheated on the unit.
o Commercially available cold desserts that do not contain fresh cream or ‘live
bacteria’ e.g. non-bio yogurts, fromage frais, mousse, jelly, cheesecake.
o Processed, pasteurised spreadable soft cheese e.g. dairylea, Philadelphia or
pasteurised hard cheese e.g. Cheddar, Cheshire.
2.5 Foods which must not be brought into the hospital:

Uncooked food which needs cooking must not be brought into the hospital and such
foods must not be microwaved i.e. raw meat, raw fish, raw eggs
Soft cheeses such as brie, goats cheese camembert, unpasterurised dairy products,
pates and eggs of any kind must not be brought in and given to patients. This follows
recommendations from the Department of Health concerning vulnerable groups and
problems associated with Listeria and Salmonella e.g. pregnant women, immuno-
compromised patients.
It is recommended that foods containing cream e.g. cream cakes, topping on
desserts and any home-made dishes particularly those containing meat, fish,
chicken, milk-based sauces or custard, sausage rolls, vol-u-vents, sandwiches are
not brought in for patients.
2.6 Takeaway meals
Takeaway meals delivered direct to the patient are permitted unless the patient requires
a ‘neutropenic diet’; the responsibility for the safety of these products is with the
takeaway provider. These products must not be reheated in the ward areas.
3.0 Microwaves
Only commercial microwaves should be used (1000kw or over) these are separate and
different to the steamplicity regen microwaves.
Microwaves must only be used for re-heating food and not for cooking.
All staff that uses the microwaves must have adequately instruction on the programming
and operating the specific microwave, and printed instructions should be provided for the
use of the microwave.
Instructions on using the microwave to include the following:
Types of food to be placed in the microwave

Length of time required for heating food
Length of standing time required (period of time after heating to allow an even
distribution of heat throughout the food)
document.
Operating instructions microwave specific
Safety instructions
Care and maintenance of the Microwaves.
Nursing staff must take responsibility for cleaning the microwave after they have used it.
4.0 Hygiene
Utensils should be clean and the food prepared on a clean (sanitised) surface.
Hands should be thoroughly washed and dried before and after handling food.
It is the responsibility of the person preparing the food to clean work surfaces, crockery
and utensils and microwave following the food preparation.
5.0 Food Handlers

All non catering food handlers must complete food hygiene training See Food hygiene
policy1.4 page 5 and Appendix B page 7.
A ‘food handler’ is a person who handles or prepares food whether open (unwrapped) or
packaged. Food includes drinks and ice.
All staff working in a food handling area must wear suitable protective clothing i.e. white
aprons and gloves.
People working in food handling areas must also practice good personal and hand
hygiene. This includes:
Ensuring they have clean hands when handling food.

White aprons must be worn as per trust policy when preparing and distributing food.
No eating or drinking whilst handling food.
document.
Patients own food reheating chart.
Date Patient Description of food Duration of Temperature Action taken if not above 83C Signature
name reheated reheating when probed
This form must be kept for a minimum of seven days from the date of last entry.
This form must be accessible to infection prevention at all times to facilitate investigation into potential food poisoning outbreaks.

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Food Hygiene Policy

Date of Ratification (Category 1 28th August 2013

Equality Impact Assessments completed June 2010

1.3 Purpose – outline objectives and intended outcomes 5

1.4 Definitions – if necessary 5

High & low risk Low risk food

▪ The Food Safety Act 1990

A HACCP plan for the Trust is detailed in Appendix B.

The objectives of this policy are to:

Provide specific food hygiene guidance to be followed by food handlers.

‘Low risk food’ is defined as foods which:

 will not support the multiplication of micro-organisms, or

‘Appropriate training’ for food handlers is as stipulated in the Industry Guide to

2 Related Trust Policies

▪ Outbreak of Infection Policy

3 Roles and responsibilities

 The Chief Executive holds ultimate responsibility for implementation of this

 Director of Nursing and Organisational Development holds delegated

Contracted caterers and food retailers are responsible for:

o Promptly informing the Trust of visits from local Environmental Health

o Ensure that recommendations made by pest control contractors are actioned,

o Informing the Trust (Environment Team and Infection Prevention Team) of

The Environment Team is responsible for:

o In consultation with the Infection Prevention Team, handling any food

The Infection Prevention Team is responsible for:

o In consultation with the Environmental Monitoring Team, for liaising with

o In consultation with the Environmental MonitoringTeam are responsible for

o In consultation with the Environmental Monitoring Team, handling any food

o In consultation with the Environmental Monitoring Team, liaising with

Care Group Manager for Non Clinical Support is responsible for:

o Managing the Trust catering and food retail contracts.

o Liaising with the Infection Prevention Team and Environmental

o Reporting regularly to the Infection Prevention Committee on food safety

o Ensuring a response within agreed Service Level Agreements, to defects

Ward and Department Managers are responsible for:

o Staff working in their ward or department are appropriately trained and/or

Consultant Medical Staff are responsible for:

Divisional and Care Group Management Teams are responsible for:

o Monitoring implementation of this policy and for ensuring action is taken if

Divisional Director of Operations, Division C is responsible for:

o Adhering to this Food Hygiene Policy

Regardless of charitable or commercial status, all organisations involved with

5 Implementation (including training and dissemination)

▪ Staff net announcement

6 Process for Monitoring Compliance/Effectiveness

Processes in place in order to monitor and verify this policy include:

Environmental Health Practitioner reports:

 Reports to Infection Prevention Committee on food safety within the Trust,

▪ Patient feedback/customer satisfaction:

TEC and Trust Board

Infection Prevention Division C Governance

7 Arrangements for review of the policy

Industry Guide to Good Practice – Catering Guide

Purchase and delivery

Refrigerated & frozen storage

If refrigerator or freezer temperatures are unsatisfactory the person checking the

Storage of food brought in to hospital

cooked meats & meat products

Food brought in by staff