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Estates, Facilities and Capital Services
Quality Assurance Manager
Facilities Manager
Director of Estates, Facilities & Capital Services
01 January 2006
22 April 2013
22 February 2016


1.1 To ensure the safe and hygienic provision of foodstuffs to patients, staff and visitors.

1.2 To ensure that all processes and systems of work follow current legislation: Food Safety Act 1990; Food Safety Regulations 1995; Food Temperature Regulations 1995.

1.3 To ensure hygiene of food premises, equipment and personnel.



2.1 All areas where food preparation and food service is provided for staff, patients and visitors in NHS Fife Hospitals.

2.2 Production kitchens, finishing kitchens, food preparation areas, ward kitchens, pantries, serveries, dining rooms, patient related kitchens, staff rooms, and food storage areas in NHS Fife Hospitals.


3.1 The Head of Department/Charge Nurse has overall responsibility for all staff within their remit and must ensure that all staff adhere to all departmental procedures.

3.2 Individual staff are required by law to notify their line manager if they are suffering from any illnesses.  Food-handlers suffering from diarrhoea and/or vomiting, symptoms of food borne infection (eg nausea, abdominal pain or fever), heavy colds, skin infections including sore and discharging lesions, or any notifiable disease must inform their line manager, and should not participate in any food handling duties until advice has been sought from Occupational Health or Control of Infection Team.

3.3 Food handlers must keep themselves clean and wear suitable clean and protective clothing.  At ward level white plastic aprons should be worn by food handlers.  These aprons must be discarded on completion of food handling duties.

3.4 Hands should be washed before and after the handling and serving of food, following appropriate hand washing techniques. 

3.5 Cuts should be covered with a suitable waterproof plaster (preferably blue in colour).

3.6 The Head of Department/Charge Nurse must ensure that control measures, departmental regulations, and procedures are in place which adhere to current legislation and comply with the Food Safety Act 1990. Training and advice are provided by the Facilities Departments for this.

3.7 The Head of Department/Charge Nurse must comply with the Food Safety Act 1990 and ensure that all food handlers, catering and clinical, are trained in food hygiene to a level appropriate to their job.  Advice on training is available from the Catering Manager.

3.8 The Head of Department/Charge Nurse will be responsible for ensuring that all staff apply safe food handling practices.  Advice on training is available from the Catering Manager.

3.9 The Charge Nurse will ensure that a system is in place to check and record the ward refrigerator temperature (1 – below 5°C) twice per day, and that outdated foodstuffs are discarded (ref Appendix 2).

3.10 The Head of Department/Charge Nurse will ensure that all foods in their areas are dated, labelled, and that stock is rotated and that food requiring refrigeration is not held for any extended period at ambient temperatures.

3.11 Patients and visitors should not be involved in the preparation and service of food and beverages unless authorised by Head of Department/Charge Nurse.  A disclaimer must be signed if high risk food is prepared (ref Appendix 3) and temperatures must be taken and recorded (ref appendix 1).  Advice can be obtained from the Catering Manager.

3.12 The Catering/Quality Assurance/ICT staff will check periodically on the content of ward refrigerators, and will discard any outdated foodstuffs found within the refrigerator.  The Head of Department/Charge Nurse will be notified if any outdated foodstuffs are found.

3.13 The Head of Department/Charge Nurse will ensure that a system is in place to report to the Estates Department, any defects or damage to the fixtures, fabric and equipment within the ward servery/kitchen.

3.14 The Head of Department/Charge Nurse will ensure that a system is in place to report to the Catering Department, any temperature problems with the patient meal service immediately.  Heated food trolleys should be plugged in on arrival at ward level, any food trolley that is not holding the temperature should be reported immediately to the Catering Department.

3.15 Domestic/Nursing Staff who participate in food handling must not carry out sanitary duties prior to food service.

3.16 Food waste and refuse must not be allowed to accumulate in food rooms.

3.17 If a patient is unavailable or unable to eat when the meal is delivered, then the meal should not be retained at ward level.  The Catering Department should be contacted when the patient requires a meal.  Only date stamped items may be retained and stored under refrigeration, eg sandwiches, yoghurts.


4.1 All food handlers on induction training should be provided with information on Food and Personal Hygiene.

4.2 All wards are issued with a local A – Z Catering Booklet, available from the Catering Manager.

4.3 It is the responsibility of each Catering Manager to ensure that they have documented evidence of food safety, especially HACCP, to demonstrate to visiting EHOs that procedures are being followed.  This will include:

4.3.1 Flow charts to show the product from purchase, through receipt, storage, preparation, cooking and service.

4.3.2 Time/temperature graphs to record temperature of product from raw stage on delivery to temperature on service.

4.3.3 Temperature control sheets to record food temperatures at the beginning and throughout service period.

4.3.4 Ward temperature charts to record temperatures of food at delivery point when it is a bulk service (Patients trayed meals should be delivered to patients by nursing staff as soon as they arrive on the ward, tray lids should not be lifted by nursing staff prior to service).

4.3.5 Cleaning schedules to provide evidence of the cleaning system.

4.3.6 Training records to provide evidence of staff training.

4.3.7 Risk assessments to adhere to Divisional regulations and highlight high risk areas.

4.4 Cleaning: All food premises and equipment must be cleaned safely and hygienically.

4.4.1 All spillage must be wiped up immediately.

4.4.2 The Head of Department must ensure that each Catering Unit has Cleaning Schedules, and that they are in place.

4.4.3 Checklists and rotas must be adhered to, and a system put in place to assure safe cleaning.

4.5 Cleaning in the Ward Kitchen: General cleaning is the responsibility of the Domestic Services Manager, however, all food handlers should adopt a “clean as you go” policy.

4.5.1 Crockery and cutlery must be hand washed in hot water with a bactericidal detergent then rinsed thoroughly in hot water; or

4.5.2 Rinsed to remove food debris and then washed in a mechanical dishwasher.

4.5.3 All crockery and cutlery should be dried using paper roll which should be discarded after use.  All equipment should be stored dry.

4.5.4 Food waste should be returned as per local policy A – Z procedure.

4.6 Pest Control: Any sightings of insects or vermin should be notified to the Estates Department.

4.7 Under the Food Safety regulations 1995 NHS Fife Hospitals must ensure that Food Preparation Areas adhere to the following:

4.7.1 Premises are kept clean and well maintained.

4.7.2 Washing and hand washing facilities are provided.

4.7.3 Adequate services are provided eg water, drainage, lighting, ventilation.

4.7.4 Staff training is provided at all levels.

4.7.5 HACCP procedures are in place and relevant documentation is kept up to date.

4.7.6 Under Food Temperature Regulations 1995, NHS Fife must ensure that:

  • chilled perishable items are stored at the correct temperatures
  • hot food is kept at or above 63°
  • cold food is kept below 5°C
  •  reheated food is heated to above 82°C


5.1 Assessment is built into the Operational System.


GP/E8-1 Appendix 1 Control Re-Heat Procedures for Commercially Produced Food Products.
GP/E8-1 Appendix 2 Ward Refrigerator Temperature Record
GP/E8-1 Appendix 3 Disclaimer Form.  


Food Safety regulations 1995
Food Temperature Regulations 1995