Effective IPC requires constant action at all levels of the health system, including policymakers, facility managers, health workers and those who access health services. monitoring arrangements and post infection review process for MRSA It will apply to registered providers of all health and adult social care in England. al., Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis. The code now reflects the changes required to meet the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and the role of infection prevention (including cleanliness). The emphasis with a serious incident is to gather appropriate learning to reduce the likelihood of recurrence in future practice. News stories, speeches, letters and notices, Reports, analysis and official statistics, Data, Freedom of Information releases and corporate reports. When appropriate or where they exist, recognised definitions should be used. However, it may not be necessary to provide the level of detail that a healthcare setting would need. Refer also to CQC guidance on compliance with Regulation 12 (2)(i) on Safe Care and Treatment shared care. INDG163(rev4), Loveday HP, Wilson JA, Pratt RJ and others (2014), epic3: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Primary medical care practitioners are key providers of information to other health and adult social care providers and to public health authorities, both concerning individual users and community outbreaks. September, 2013. (Available at, Centers for Disease Control and Prevention. Dental practitioners should regularly obtain a medical history, which may assist in identifying some risk factors for infection. 0300 3038162 Page 3 of 34 Introduction - Your role in helping prevent the transmission of Infection Effective infection prevention and control practices are essential in ensuring service users who access health and social care services we deliver, receive safe and effective care. Health services primarily based in the local community, including community matrons, community nurses, GPs, pharmacists, dentists, optometrists, paramedics and podiatrists. The code recognises that many infections that arise in the community may not be related to the delivery of health or adult social care. Ensure that healthcare personnel adhere to recommended insertion and maintenance practices. 3.2 Service providers, where appropriate, should have in place a designated lead for antimicrobial stewardship responsible for developing, implementing and monitoring the organisations stewardship programme and reporting to the executive board or equivalent, where available. Ensure that staffing and resources do not prevent nurses, environmental staff, et. Primary medical care practitioner prescribing accounts for 80% of NHS antibiotic use and this antibiotic use must be both necessary and appropriate. Providers have a policy that describes the process in place to manage health and care worker health and wellbeing and obligations in relation to IPC (including cleanliness), control and management. Registered providers are free to decide to use alternative approaches but should be prepared to justify to the CQC how the chosen approach is equally effective or better in ensuring that the criteria are met. This could be the registered provider, registered manager or another member of staff. Staff should have access to appropriate occupational health advice. Link National infection prevention and control manual for England Summary CDC twenty four seven. Providers shouldnote that Regulation 15 is also relevant to IPC (including cleanliness) and that other provisions of the regulations may also apply. (Available at, Centers for Disease Control and Prevention. This applies to all health and adult social care. Ensure that supplies necessary for adherence to hand hygiene are readily accessible in all areas where patient care is being delivered. Themes relevant to the provision of information include: Materials from global, national or local awareness campaigns could be used to develop information on appropriate principles of IPC (including cleanliness), including hand hygiene, respiratory hygiene and action to promote safe, effective and appropriate use of antimicrobials to reduce risk of developing antimicrobial resistance. The One & Only Campaign injection safety training materials. Workplace (Health, Safety and Welfare) Regulations 1992. The CQC can prosecute a provider that breaches any part of Regulation 12(2)(h) if a failure to meet the regulation results in a risk of exposure to significant harm or avoidable harm to a person using the service, or if a person using the service is exposed to a significant risk of harm. It is about people and their . The CQC website provides further information about how the CQC assesses registered providers and what action it can take if a registered provider does not comply with the regulations. Such an approach could be implemented facility-wide or targeted toward higher risk areas (e.g., emergency departments, urgent care, units experiencing an outbreak) based on a facility risk assessment. This guidance is contained in the CQC Guidance for providers on meeting the regulations. 3.1 Systems should be in place to manage and monitor the use of antimicrobials to ensure inappropriate and harmful use is minimised and service users with severe infections, such as sepsis, are treated promptly with suitable antimicrobial(s). Infection control e-learning course | SCIE - Social Care Institute for Guidelines for Preventing Healthcare-associated Pneumonia, 2003 Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. All registered providers will need to have adequate systems for IPC (including cleanliness) as stated in the code (see part 2), if they are to comply with the law; but because of the wide range of services provided by all registered providers, the code will be applied in a proportionate way. Find out about the Energy Bills Support Scheme, Health and Social Care Act 2008: code of practice on the prevention and control of infections, Appendix A: examples of interpretation for adult social care, Appendix B: examples of interpretation for primary care dental practices, Appendix C: examples of interpretation for primary medical care, nationalarchives.gov.uk/doc/open-government-licence/version/3, Regulations for Service Providers and Managers Care Quality Commission 2022, Health Protection (Notifications) Regulations 2010, decontamination self-assessment dental audit tool, national dental antimicrobial stewardship toolkit, Everyone counts: planning for patients 2014/15 to 2018/19, Prevention and control of infections in care homes: an informative resource, Prevention and control of infection in care homes: summary for staff, Guidance for providers on meeting the regulations, Infection prevention and control in care homes, Infection prevention and control: resource for adult social care, Care homes: infection prevention and control, National infection prevention and control manual for England, Leadership and worker involvement toolkit, Start smart then focus: antimicrobial stewardship toolkit for English hospitals, Infection prevention and control: Quality statement 1: antimicrobial stewardship, Summary of antimicrobial prescribing guidance managing common infections, Antimicrobial prescribing and stewardship competences, Tackling antimicrobial resistance 2019 to 2024: the UKs 5-year national action plan, English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) reports, Scottish Reduction in Antimicrobial Prescribing (ScRAP) Programme, Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use (, Pneumonia (community-acquired): antimicrobial prescribing, Pneumonia (hospital-acquired): antimicrobial prescribing, Summary of antimicrobial prescribing guidance: managing common infections, WHO strategic priorities on antimicrobial resistance: preserving antimicrobials for today and tomorrow, Pneumonia in adults: diagnosis and management, Antimicrobial prescribing in dentistry good practice guidelines, 3rd Edition, Patient group directions: who can use them, WHO policy guidance on integrated antimicrobial stewardship activities, The UKs 20-year vision for antimicrobial resistance, Local self-assessment dental audit tool and supporting documents for assessing implementation of, Antibiotic prescribing in primary care UTI audit for people with catheters, Dental record keeping standards: a consensus approach, Antibiotic prescribing audit tool for dentists, Managing infection risks when handling the deceased, Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes, epic3: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England, Infection prevention and control of healthcare-associated infections in primary and community care, Patient experience in adult NHS services: improving the experience of care for people using adult NHS services, Personal assistants and the Care Quality Commission, Infection prevention and control commissioning toolkit: guidance and information for nursing and commissioning staff in England, Risks arising from breakdown and failure to act on communication during handover at the time of discharge from secondary care, Keeping your online health and social care records safe and secure, Confidentiality: NHS Code of Practice (England), Working party guidance on the control of multi-resistant Acinetobacter outbreaks, Guidelines for the prevention and control of carbapenem-resistant Enterobacteriaceae, Acinetobacter baumannii and Pseudomonas aeruginosa in health care facilities, Patient safety alert addressing rising trends and outbreaks in carbapenemase-producing Enterobacteriaceae, Framework of actions to contain carbapenemase-producing Enterobacterales, A report on the management of diarrhoea in care homes: August 2010, Clostridioides difficile infection: antimicrobial prescribing (, Clostridioides difficile infection: updated guidance on management and treatment, Communicable disease outbreak management: operational guidance, Guidelines for the management of norovirus outbreaks in acute and community health and social care settings, Infection prevention and control: an outbreak information pack for care homes, Recommendations for the public health management of gastrointestinal infections 2019: principles and practice, Guidelines (2008) for the prophylaxis and treatment of methicillin-resistant Staphylococcus aureus (, Guidelines for the laboratory diagnosis and susceptibility testing of methicillin-resistant Staphylococcus aureus (, Joint Healthcare Infection Society (HIS) and Infection Prevention and Control (, Guidelines for the prophylaxis and treatment of, Treatment of methicillin-resistant Staphylococcus aureus (, Guidance on the diagnosis and management of PVL-associated Staphylococcus aureus infections (2nd edition), Guidelines for UK practice for the diagnosis and management of meticillin-resistant Staphylococcus aureus (, Immunisation against infectious disease (the Green Book), Minimise transmission risk of CJD and vCJD in healthcare settings, Management of Hazard Group 4 viral haemorrhagic fevers and similar human infectious diseases of high consequence, Viral haemorrhagic fevers: origins, reservoirs, transmission and guidelines, Ebola virus disease: clinical management and guidance, Decontamination in primary care dental practices (, Managing medical devices: guidance for health and social care organisations, Decontamination of surgical instruments ((, elearning for healthcare: Infection Prevention and Control Level 1, elearning for healthcare: Infection Prevention and Control Level 2, Urinary catheterisation: management, care and prevention of infection, Infectious diseases: detailed information A to Z pathogens list, Clostridium difficile infection: how to deal with the problem, HBN 00-09: Infection control in the built environment, HBN 26: Facilities for surgical procedures: volume 1, HBN 00-10: Design for flooring, walls, ceilings, sanitary ware and windows, BS 8580-2:2022 Water quality. Am J Infect Control. Primary dental care practices may not need to supply the full range of information suggested. These additions were presented to HICPAC at the November 3, 2022 meeting. Policies should be in place for handling devices for single use only. Preventing Infections in Multiple Healthcare Settings | National Consult and adhere to manufacturers instructions for reprocessing. (Available at, Sehulster L, Chin RY, Healthcare Infection Control Practices Advisory Committee. Early and prompt removal of invasive devices should be part of the plan of care and included in regular assessment. Ensure that healthcare personnel either receive immunizations or have documented evidence of immunity against vaccine-preventable diseases as recommended by the CDC, CDCs Advisory Committee on Immunization Practices (ACIP) and required by federal, state or local authorities. 2.1 To minimise the risk of infection, a registered provider should ensure that: 2.2 The environment means the totality of a service users surroundings when in care premises or transported in a vehicle. Provides specialist local support to prevent and reduce the impact of infectious diseases, chemical and radiation hazards and major emergencies. These should feature a trend analysis for infections, antimicrobial resistance, antimicrobial prescribing and compliance, with quarterly reporting to the NHS board or registered provider by clinical directors and matrons (including nurses who do not hold the specific title of matron but who operate at a similar level of seniority and who have control over similar aspects of the service user or the service users environment). Primary medical care facilities do not require dedicated isolation treatment rooms but are expected to implement reasonable precautions when a service user is suspected or known to have a transmissible infection. So, by following the code, registered providers will be able to show that they meet the regulation on IPC (including cleanliness). This publication replaces the previous Health and Social Care Act 2008: Code of Practice document for health and adult social care on the prevention and control of infections and related guidance. Practices can use risk assessment processes to identify staff who may be at higher risk of transmitting or developing an infection. Do not wash gloves for the purpose of reuse. This unit aims to enable learners to gain an understanding of the importance of infection prevention and control in health and social care settings. (Available at, U.S. Public Health Service Working Group on Occupational Postexposure Prophylaxis, Kuhar DT, Henderson DK, et. An advocate is someone who speaks on behalf of another; or it can have special meaning derived from the Mental Health Act 1983 (amended 2007) and Mental Capacity Act 2005 and Care Act 2014. Commissioners may require providers to demonstrate active management of the NHS PAM as part of clinical service contracts. That they have and adhere to policies designed for the individuals care, and provider organisations that will help to prevent and control infections. Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. Prevention Strategies for Seasons Influenza in Healthcare Settings. 3.3 Providers should develop a local antimicrobial stewardship policy and local infection management guidelines drawing on national guidance (including from NICE), the British National Formulary and UK Health Security Agency (UKHSA) that takes account of local antimicrobial resistance patterns. The policy should refer to the latest guidance from the Advisory Committee on Dangerous Pathogens (ACDP) and the Control of Substances Hazardous to Health Regulations 2002 and make provision for: In cases of acquired carbapenemase-producing Gram-negative bacteria, including carbapenemase-producing Enterobacterales (CPE), the policy should make provision for: This should take account of local epidemiology and risk assessment of the environment, infection and service. Because of the wide range of services provided by all registered providers, the code will be applied in a proportionate way. 6.2 The registered provider should include IPC (including cleanliness) in all job descriptions. Information on policy should be included in IPC training programmes for all relevant staff groups. An annual IPC statement should be prepared and kept on record for anyone who wishes to see it, including service users and regulatory authorities. Helping to prevent infection | Quick guides to social care topics This guidance applies from 4 April 2022. 8.1 A registered provider should ensure that laboratories that are used to provide testing services, in connection with arrangements for IPC, have appropriate protocols in place. Appropriate antimicrobial use and stewardship to optimise outcomes and to reduce the risk of adverse events and antimicrobial resistance. 10.1 Registered providers should note that this criterion also covers health and care worker education and training in policies and procedures to reduce the risk of occupational infection. The committee should report antimicrobial stewardship activities, antimicrobial prescribing trends (this should include appropriate peer comparison data) to the trust board via the organisations DIPC, or the designated lead for antimicrobial stewardship. This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. The CQC has published guidance for providers on meeting the requirements of the regulations, including the enforcement policy, and will use these documents in conjunction with this code of practice and related guidance when judging compliance. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Health and social care staff must know how to recognise the signs of infection, including atypical presentations, and know how to seek prompt medical advice so that diagnostic tests and antimicrobial therapy (if required) can be used optimally. Parts 3 and 4 of this document will help registered providers interpret the criteria and develop their own risk assessments. Use aseptic technique when preparing and administering medications, Disinfect the access diaphragms of medication vials before inserting a device into the vial. You can change your cookie settings at any time. Sufficient numbers of staff with suitable training should be available. Infection prevention and control is the discipline concerned with preventing healthcare-associated infections; a practical rather than academic sub-discipline of epidemiology.In Northern Europe, infection prevention and control is expanded from healthcare into a component in public health, known as "infection protection" (smittevern, smittskydd, Infektionsschutz in the local languages). 5f. Infection prevention and control is a clinical and public health specialty that is based on a scientific approach, providing practical solutions grounded in infectious diseases, epidemiology, social The term independent-sector ambulance provider covers triage, medical or clinical advice provided remotely, face-to-face treatment and transport services. There should be a policy concerning the appropriate provision and maintenance of isolation facilities. Independent consumer champion that gathers and represents the publics views on health and social care services in England. To help us improve GOV.UK, wed like to know more about your visit today. When space permits, separate patients with respiratory symptoms from others as soon as possible (e.g., during triage or upon entry into the facility). Antimicrobial prescribing should follow local policies and national guidance such as NICE managing common infections, guidance for primary care and TARGET antibiotics toolkit. (2) Without limiting paragraph (1), the things that a registered person must do to comply with that paragraph include: 15. Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients. 7.3 Policies should be in place for the allocation of appropriate isolation facilities based on service user needs and local risk assessment. Effective IPC can help reduce the risk of infection and ensure the safety of people receiving care, staff and visitors. However, the relative impact of different factors will vary for different organisations. Infection prevention and control (IPC) is critical to keeping people safe when they are receiving health and social care. This document builds on the previous H&SCA 2008 code of practice for health and adult social care on the prevention and control of infections and related guidance. For example, in an acute hospital setting there is a greater risk to service users of infection and therefore the registered provider will need to comply with most aspects of the compliance criteria. Part 2 (The code) details the criteria against which the registered provider will be judged on how it complies with the registration requirements for IPC (including cleanliness). This includes assessing the risk of, and preventing, detecting and controlling the spread of, infections, including those that are healthcare associated. Refer also to section on Regulation 15 on premises and equipment, contained in the CQC guidance for providers on meeting the regulations. Primary medical care practices should make information available about their approach to prevention and control of infection, staff roles and responsibilities, and who people should contact where there are concerns about prevention and control of infection. Readers will note that only paragraphs in part 3 of this document have been numbered, as these particular sections are likely to be specifically referenced by the CQC in ensuring compliance with the regulations. The assessment could include consideration of the need for special ventilated isolation facilities, management of appropriate PPE, bare below the elbows (BBE) protocols, waste management strategies, impact of social isolation assessments, and the monitoring of service users. Providers of regulated activities need to recognise that effective management of IPC is an important service-user safety issue. This could be the registered provider, registered manager or another member of staff. IPC is integral to quality health and social care delivery The principle of proportionality extends throughout this guidance and the level of detail and complexity for each policy will depend on local risk assessments. There are formal and informal advocates, and these can be: individuals acting informally (carers, relatives, partners, neighbours or friends, staff); those prescribed by legislation, such as independent mental health advocates and independent mental capacity advocates; or those provided by schemes run by local authorities, the NHS and charities. 1.7 The IPC (including cleanliness) programme should: 1.8 An IPC (including cleanliness) infrastructure should encompass the below. Infection prevention and control are essential to prevent the spread of coronavirus (COVID-19). Infection prevention and control: resource for adult social care The primary care clinician/GP may wish to draw on local expertise in IPC, infection management and/or health protection. In most cases further action will not be needed. Free! Maintain separation between clean and soiled equipment to prevent cross contamination. Health and Social Care Act 2008: code of practice on the prevention and Use respiratory hygiene and cough etiquette to reduce the transmission of respiratory infections within the facility. A registered provider may be able to demonstrate that it meets the registration requirement regulation in a different way (equivalent or better) from that described in the code. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. This is a form of management to reduce the likelihood of infection after potential exposure, for example to blood-borne viruses. Environmental Cleaning and Disinfection. Jensen PA, Lambert LA, Iademarco MF, Ridzon R. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Healthcare Infection Control Practices Advisory Committee. It is about people and their behaviour in context and the book therefore explores . When information from manufacturers is limited regarding selection and use of agents for specific microorganisms, environmental surfaces or equipment, facility policies regarding cleaning and disinfecting should be guided by the best available evidence and careful consideration of the risks and benefits of the available options. Parts 3 and 4 of this document will help registered providers interpret the criteria and develop their own risk assessments. Use fluid infusion or administration sets (e.g., intravenous tubing) for one patient only, Dedicate multidose vials to a single patient whenever possible. A system for informing third parties that a process of due diligence is in place to assure safety and quality exists within that setting. Guidance tables can be found in a separate document - Guidance tables for H&SCA code of practice on IPC. Do not use the same gown or pair of gloves for care of more than one patient. Such records should be kept, as part of confidential staff occupational health records, including where vaccination has been offered and refused, the principles and practice of prevention of infection are included in induction and training programmes for new and existing staff, including occupational exposure to infections, such as sharps injury and appropriate respiratory protective equipment, for example FIT testing, the responsibilities of each member of staff for, risk-based screening for communicable diseases, and assessment of immunity to infection should be part of the recruitment process offer of relevant immunisations, arrangements for regularly reviewing the immunisation status of health and social care workers and providing vaccinations to staff as necessary in line with Immunisation against infectious disease (the Green Book) and other guidance from, having arrangements for identifying and managing health and social care staff infected or potentially infected with hepatitis B or C or HIV and advising about fitness for work and monitoring as necessary, liaising with the UK Advisory Panel for Healthcare Workers Infected with Bloodborne Viruses when advice is needed on procedures that may be carried out by, a timely risk assessment and appropriate referral after accidental occupational exposure to blood and body fluids, management of occupational exposure to infection, which may include provision for emergency and out-of-hours treatment, possibly in conjunction with accident and emergency services and on-call, this should include a specific risk assessment following a blood exposure incident, policies, procedures and guidance, and information on how they will be kept up to date and monitored to make sure they are effective and followed, initial and ongoing training that staff will receive, a record of the names and contact details of health practitioners who can provide advice. Appropriate information should be held in the practice patient summary record. make the registration requirements relating to, provide information for people who use the services of a registered provider, provide information for commissioners of services on what they should expect of their providers, provide information for the general public, the registered provider has arrangements in place to minimise the risks of infection; there is a clear governance structure and accountability that identifies a lead for, there are mechanisms in place by which the registered provider can ensure that sufficient resources are available to secure effective, these should include the implementation of an, all staff receive suitable and sufficient, systems are in place for service users and staff to raise concerns and to receive feedback, assurances are in place to ensure that key policies and practices are being implemented, updated and adhered to appropriately, a decontamination lead is designated, where appropriate, a water safety group and water safety plan are in place, where appropriate, a ventilation/air safety group is in place, where appropriate, undertaken and recorded a comprehensive and dynamic assessment of infection risks to identify the potential and actual risks to the service user receiving care, identified and documented the steps that need to be taken to reduce or control those risks, including awareness of vaccination status, methods and interventions in place to monitor the risks of infection, to determine whether further steps are needed to reduce or control infection, provide oversight and assess assurance on, be responsible for leading the organisations, oversee infection prevention and control policies and work with, have the authority to challenge inappropriate practice and inappropriate antimicrobial prescribing decisions, have the authority to set and challenge standards of cleanliness, assess the impact of all existing and new policies on infections and make recommendations for change, be an integral member of the organisations clinical governance, patient safety teams, relevant structures, the lead will report directly to the registered provider, promote respectful challenge of inappropriate practice amongst all workers and have the authority to set and challenge standards of cleanliness, be an integral member of the organisations governance, and safety teams and structures where they exist, produce an annual statement with regard to compliance with practice on, review of trends (for example, monthly) and peer comparison of broad-spectrum and total antimicrobial prescribing, use of intravenous route of administration, treatment course length and audits of adherence to local/national guidelines for the management of common infections, annual patient led assessments of the care environment (PLACE) scores, contract performance measures where provision is in-house or outsourced, which will include cleanliness measures and issues of non-compliance and subsequent improvement actions, information taken from the organisations self-assessment using the NHS premises assurance model (NHS PAM) decisions, observations taken from board level or other staff, service users and family walk rounds, a review of mandatory and voluntary surveillance data, including antimicrobial resistance (drug-bug combinations), outbreaks and serious incidents, evidence of appropriate action taken to manage occurrences of infection or inappropriate prescribing of antimicrobials, including, where applicable, root cause analysis, with emphasis on lessons learnt and/or post infection review in adult social care, primary dental care and primary medical care independent healthcare providers and independent ambulance providers, evidence of appropriate action taken to prevent and manage infection, an audit programme to ensure that appropriate policies and measures have been developed and implemented, evidence that the annual statement from the service provider has been reviewed through the organisations governance structures and, where indicated, acted upon, regular review of antimicrobial prescribing decisions, set objectives that meet the needs of the organisation and ensure the safety of service users, health and social care workers and the public, identify agreed priorities for establishing an improvement plan, provide evidence that relevant policies have been effectively implemented, report progress against the objectives of the programme in the, antimicrobial pharmacists expertise (and/or with specialist training - in, other healthcare workers and appropriate administrative and analytical support, a specific individual has responsibility for oversight and management of cleaning, environmental services and decontamination of medical devices and equipment, the designated lead for cleaning is responsible for all aspects of cleaning services, from contract negotiation and service planning to delivery at the care level, there is collaboration with key stakeholders to ensure maintenance and cleaning is planned and implemented, in health and social care, all clinical and non-clinical staff have personal responsibility and accountability for maintaining a safe and clean care environment, the person in charge of any area has direct responsibility for ensuring that cleanliness standards are consistently maintained, all parts of the premises from which it provides care are suitable for the purpose, kept clean and maintained in good physical repair and condition, the cleaning arrangements detail the standards of cleanliness required as appropriate for the setting in each part of its premises and that a schedule of cleaning responsibility and frequency is available on request, there is adequate provision of suitable hand-washing facilities and products, there are effective arrangements for the appropriate cleaning of equipment that is used at the point of care, for example hoists, beds and commodes these should be incorporated within appropriate cleaning, disinfection and decontamination policies, for all healthcare settings, there are effective arrangements for the appropriate cleaning of equipment that is used at the point of care and which are based on the National Standards for Healthcare cleanliness responsibilities framework or equivalent standards and cleanliness charters.

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