Standards › Standard 2B › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · ENV-SOP-002 · Version 1.1 · Approved by the ASF Expert Committee
Supports: 2B.5
At a glance
- Clean shared clinical and waiting areas on the schedule for each area.
- Clean high-touch surfaces at least daily, and more often where the risk is higher (EC).
- Record each clean on the schedule sheet with initials.
- Check cleanliness each month with a test or audit, not only by looking.
- Act on any area that fails the audit the same week.
- Stop and get help straight away if: an area is visibly soiled with body fluids or the cleaning supplies are unavailable.
1. Purpose
To keep shared clinical and waiting areas clean through a documented schedule, and to check cleanliness by more than a visual check [EC].
2. Scope
| Applies to | Cleaning staff, ward and department staff, and the facilities manager |
| Locations | Shared clinical areas, corridors, waiting rooms and toilets at the facility |
| When | On the schedule for each area, and after any spill |
| Does not apply to | Detailed toilet and bathroom cleaning, covered by the cleaning SOP for each area (SOP-015) |
3. Definitions
| Term | Meaning |
|---|---|
| High-touch surface | A surface touched often by hands, such as handles, rails, chairs and switches |
| Cleanliness audit | A check of cleanliness using a test (for example, an ATP test or a standard swab) and a visual check |
| Schedule | The document setting the frequency and method for each area |
4. Background
Shared areas carry the most contact between patients, visitors and staff. A visual check misses contamination that a test would find. Criterion 2B.5 asks for a schedule and verification beyond sight.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Facilities manager | Owns the schedule; runs the audit; acts on failures | Facilities management |
| Cleaning lead | Runs the daily cleaning; records; trains cleaners | Cleaning management |
| Cleaners | Clean to the schedule and method; record each clean | Training in method and products |
| Infection prevention lead | Advises on methods and high-risk areas | Infection prevention |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Cleaning schedule for each area | Current; frequency and method stated | Posted in the area |
| Approved disinfectant and detergent | Product and dilution per the product label | In date; labelled |
| Colour-coded cloths and mops | Colours set by the cleaning SOP | Clean and in use correctly |
| Audit kit (test or swab) | As the audit method requires | In date |
7. Safety
- Use the product dilution on the label. More concentrate is not better.
- Wear gloves and eye protection when using disinfectant.
- Do not mix products.
8. Before you start
- Check the cleaning schedule for the area.
- Check supplies are in stock.
9. Procedure
Step 1. Clean to the schedule.
- Clean the area at the frequency on the schedule.
- Clean from clean to dirty and from high to low.
- Clean high-touch surfaces with the approved product, and allow the contact time on the label.
Key point: The contact time is what kills the organisms. Wiping quickly does not disinfect.
Step 2. Use colour coding.
- Use the colour-coded cloth for each area, and do not move a cloth between areas.
- Change the cloth when it is dirty.
Key point: Colour-coding stops cross-contamination.
Step 3. Record each clean.
- Initial and time the schedule sheet for each area when cleaned.
- Record any problem and report it to the cleaning lead.
Key point: A record that is not made did not happen.
Step 4. Audit monthly.
- Select at least 10 surfaces per area at random each month.
- Test each surface by the audit method, and record pass or fail against the threshold set (EC).
- Record the result on ENV-FRM-002.
Key point: The test shows the actual state of the area. A pass by eye can still be a fail.
Step 5. Act on failures.
- Re-clean the failed area the same shift.
- Retest the failed surfaces within 24 hours.
- Find the reason: the method, the product, the frequency or the staffing. Change it.
Key point: A failure that is only re-cleaned will fail again.
10. Decision points
- If a surface fails the test twice in a month, the cleaning lead reviews the method and the staffing for that area.
11. Special situations
| Situation | Action |
|---|---|
| Spill of body fluids | Clean at once using the spill procedure and the infection prevention lead’s product list. |
12. Escalation
- Repeated audit failures go to the facilities manager and infection prevention lead.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Scheduled cleans recorded | 100% | Daily check | Cleaning lead | Correct the same shift |
| Audited surfaces passing the threshold (3 months) | Set by committee (EC) | Monthly | Facilities manager | Re-clean and retest within 24 hours |
| Areas audited each month | 100% | Monthly | Facilities manager | Escalate to chief executive |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Cleaning schedule sheet | Area file | 3 months on site, then archived for the period set by the facility’s records policy years |
| ENV-FRM-002 Cleanliness Audit Record | Facilities file | the period set by the facility’s records policy years |
15. Training
- Cleaners are trained in method, colour coding, contact times and product safety at induction and yearly (EC).
- Ward staff are briefed on what they must report.
16. Related documents
| ID | Title | Use |
|---|---|---|
| ENV-FRM-002 | Cleanliness Audit Record | Used in step 4 |
| SOP-015 | Cleaning and Disinfection Procedure (generic) | Basis for methods |
| SOP-037 | Infection Prevention and Control Procedure (generic) | Hand hygiene |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | ASF Expert Committee consensus. Cleaning frequency and audit threshold to be set and checked against national infection control guidance. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | Approved by the ASF Expert Committee |
| 1.1 | the date of approval | Internal quality review: corrected cross-references, status wording and document control | Approved by the ASF Expert Committee |
E-learning for this document
- Environment & Shared Spaces (H-03)
- Environmental Hygiene Standards for ASF Accreditation (HYG-01)
- Linen, Laundry & Housekeeping Standards (HYG-02)
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)