Survey of health and social care setting food businesses on implementation of the FSA Listeriosis Guidance

Following the 2019 listeriosis outbreak in hospitals in England, the Food Standards Agency (FSA) committed to reviewing its guidance ‘Reducing the risk of vulnerable groups contracting listeriosis’ (2016). The FSA commissioned research to measure awareness, implementation and perceived effectiveness of the guidance, including barriers to implementing the guidance in full.  

This report covers findings from 39 respondents within NHS Trusts and 445 from Health and Social Care (HSC) (non- NHS Trust) settings, such as nursing homes, home care service providers and hospices, in England, Wales and Northern Ireland. Findings from the NHS Trust survey are reported in their own chapter and their own section of this executive summary.

HSC (Non-NHS Trust) Settings

Awareness and usage of the guidance

Most settings - 63% - had some knowledge of the guidance. However, 36% did not know anything about the guidance or were not aware of it.

Most settings stated that they trained kitchen staff (57%), nurses, midwives or carers (55%) and management personnel (52%) in controlling the risk of Listeria monocytogenes (referred to as Listeria or L. monocytogenes in the reminder of this report). Fewer stated that they trained staff who sell or serve food as their main role (35%) or non-catering staff, such as maintenance or reception staff (19%).  

Implementing good practice and the barriers to this

Generally, settings found the good practice outlined in the control of contamination section of the guidance (around personal hygiene, washing fruit, cleaning of food preparation areas and access to kitchens) to be easy to implement. 71%-81% reported that they found each area of recommended good practice ‘very easy’ to implement. Good practice in ‘controlling access to kitchens/pantries’ was considered most difficult to implement, with 6% of settings finding it difficult, rising to 11% in community care settings. 

Among settings that found any good practice difficult to implement, a lack of control over the kitchen area was the most frequently mentioned difficulty (44%), followed by 30% of settings who found it challenging to implement good practice in clients’ homes or residents’ rooms.

In terms of controlling the growth of Listeria, only half of settings felt that ‘ensuring packed lunches for patients going home or off-site, including advice on how quickly any ready-to-eat food should be eaten’ was very easy, while 5% thought it was very or fairly difficult. There were similar levels of perceived difficulty (3-5%) for ensuring chilled ready-to-eat food was kept at 5°C or below from delivery to service, time and temperature control during food service and temperature monitoring of fridges in residents’ rooms. 

When asked why implementing good practice around control of growth was difficult, lack of control over when food was consumed was the most common barrier faced by settings, with almost two in five (39%) reporting this.

Settings generally found good practice relating to management controls less easy to implement, compared to practice in the ‘control of contamination’ and ‘control of growth’ sections of the guidance.  For example, 41% found it very easy to include food safety requirements in contracts for on-site retailers or contracted caterers.

Areas which settings found more difficult were the labelling and refrigeration of food brought in by visitors / patients / residents / customers (8% found this very or fairly difficult), as well as the collecting of feedback from patients / residents / customers (12%). The most difficult area of Listeria control was the carrying out of unannounced visits to suppliers every 6-12 months to check food safety - while 35% of respondents found this very easy, 23% found it very or fairly difficult.

When asked about the reasons why good practice in management controls were difficult, 38% of settings reported residents’ lack of comprehension of the risks. This includes the challenge of collecting feedback from, and communicating risks to, patients with dementia or learning difficulties.

Controlling the risk of Listeria

Almost all settings (98%) agreed that ‘food safety controls on site are effective in stopping cross-contamination of food with Listeria’. In a separate question, 54% reported being fully aware of the risks associated with chilled ready-to-eat foods and Listeria. 

Over half (56%) of all settings reported that the maximum temperature that chilled ready-to-eat foods reached, from supply of chilled ingredients until the point of sale or service, was 5°C, which is in line with the FSA good practice guidelines. Just under a half (46%) of all settings reported that the maximum temperature that chilled ready-to-eat foods reached during storage in areas for patients or residents was 5°C, again in line with FSA good practice. Food reaching a temperature of 8°C for over four hours at any point in the supply of ingredients to point of sale / service was reported by 1% of settings, and by 2% of settings during storage in areas for patients / residents. 

Only 54% of settings agreed that they carry out regular sampling for Listeria. 29% disagreed. There was also disagreement by 14% that the maximum shelf-life for ready-to-eat sandwiches sold or distributed on site was day of production plus 2 days.

Just over three-quarters (77%) of all settings have a food safety management system (FSMS) based on hazard analysis critical control point (HACCP) principles. Just over one in ten (13%) did not have such a system in place and a further 10% were unsure whether they did or not. However, it should be noted that settings may have said ‘no’ as they are unfamiliar with the term HACCP but use guidance that ensures practice is based on these principles. Community care settings were more likely to report that they did not have an FSMS in place based on HACCP principles (45% vs. 5% of healthcare and 5% of social care settings).  

Perceptions of the guidance

Ninety-five per cent of settings who were aware of the guidance felt it was effective in reducing the risk of vulnerable groups contracting listeriosis. Just a small proportion (3%) thought it was not effective. Similarly, 92% of settings who were aware of the guidance claimed that the guidance clearly distinguishes between legal requirements and good practice. 

Parts of the guidance which were mentioned by settings as being useful in reducing the risk of listeriosis in their setting included information around temperature control and fridges (cited by 14% of all settings aware of the guidance), checklists for preventative practice (12%), information on cross-contamination / infection control (8%) and content on cleaning standards (8%). 

Suggestions for improvements to the guidance included that it be made easier to read (11%), be updated more often (5%) or be made more accessible (4%). Beyond improving the text itself, there was also some call for raising awareness of the guidance (4%).

Differences by setting type

Healthcare settings were more likely than social care or community care settings to know a lot about the guidance and to be fully aware of the risks associated with chilled ready-to-eat food and Listeria. They were also more likely to find many areas of good practice easier to implement. Community care settings, by contrast, were more likely than both healthcare and social care settings to feel that a number of areas of the guidance were difficult to implement.

Local Authority and Primary Authority (PA) relationships in England and Wales

Fifty per cent of settings in England and Wales reported they were registered with their local authority but did not have a PA relationship, whilst 18% reported they were registered with their local authority and had a PA relationship and 13% reported that they did not know. However, 20% of settings reported that they were not registered at all with their local authority. 

The 20% of health and social care settings who reported not being registered with their local authority were compared with the Food Hygiene Rating Scheme (FHRS) listings to ensure the reliability of this unexpected finding. However, the results of this investigation were inconclusive. 

NHS Trusts findings

Ninety-two per cent of NHS Trusts said their settings were using the FSA guidance on listeriosis before taking part in the survey, with 3% reporting they were not using the guidance and 5% unsure. 97% of NHS Trusts said their kitchen staff had received training about how to control the risk of Listeria. 89% reported that their service and food retail staff had received the same training. However, fewer Trusts (55%) had trained ward staff.

Around four in five Trusts reported having fully implemented the good practice outlined in the guidance with regards to control of contamination (82%), with slightly fewer having fully implemented good practice in terms of control of growth and management controls (73% each).  

The NHS survey asked Trusts to consider barriers which made it difficult for them to implement the FSA guidance in full. From a prompted list, almost a third (31%) of settings agreed they had a lack of control over food service, a quarter (25%) felt they had a lack of control over their supply chains and just over one-fifth felt that their high staff turnover (22%) or lack of control over food storage (22%) were barriers to implementing the FSA guidance.

Over eight in ten (84%) agreed that ‘cleaning of all food contact surfaces controlled the risk of L. monocytogenes effectively in the Trust’. There were also high levels of agreement with regards to food safety in the Trust being effective in stopping cross-contamination of food with Listeria, with 97% agreeing with this statement.

Around seven in ten (71%) reported that the maximum temperature that chilled ready-to-eat foods reached, from supply of chilled ingredients until the point of sale or service, was 5°C, which is in line with the FSA good practice guidelines. Over half (57%) reported that the maximum temperature foods reached was 5°C during storage in areas for patients or residents. 

Nearly all NHS Trusts (97%) reported having a food safety management system based on HACCP principles. Agreement was high among Trusts with regards to monitoring and recording throughout the cold chain, with 95% agreeing with this statement. Around eight in ten NHS Trusts (79%) agreed that the maximum shelf-life for ready-to-eat sandwiches sold or distributed in the Trust was day of production plus two days, whilst 13% disagreed with this statement. 51% agreed that their Trust carried out regular sampling for L. monocytogenes compared to 38% who disagreed. 

NHS Trusts generally found the guidance to be clear and informative. However further guidance was asked for on food being brought into the premises by relatives and on what was an acceptable standard of cleaning to ensure control of contamination.

Three Trusts wanted further training to be provided to nursing staff. While they were confident that their catering teams were well trained, these Trusts felt that training amongst their nursing staff could be strengthened.

Background and objectives

Food safety is a crucial component of protecting the wellbeing of those in the care of health and social care organisations. Incidents, such as the 2019 listeriosis outbreak associated with pre-packed sandwiches supplied to hospitals in England, from which seven patients died of listeriosis, underline the risk of the disease and the serious consequences that a breach in standards can have.

Vulnerable consumers - whose immune systems are weakened in some way - are particularly susceptible to listeriosis and the disease has a high hospitalisation and fatality rate, compared to infections with other bacterial pathogens.

The bacterium which causes listeriosis, Listeria monocytogenes, is acutely challenging to control as it has the potential to grow at low temperatures and can survive freezing. As such, L. monocytogenes must be controlled in any health or social care (HSC) organisation that provides chilled ready-to-eat food for vulnerable groups. The Food Standards Agency (FSA) guidance on ‘Reducing the risk of vulnerable groups contracting listeriosis’ concentrates on preventing the spread of listeriosis,  from preparation to consumption, in chilled ready-to-eat food. 

The review set up following the 2019 listeriosis outbreak - the Independent Review of NHS Hospital Food, contained recommendations on food safety for NHS trusts to take on board. The FSA also committed to assess its own guidance in response to the 2019 outbreak. Social research was commissioned as part of the FSA’s response. 

This report covers findings from 39 respondents within NHS Trusts and 445 from Health and Social Care (HSC) (non- NHS Trust) settings, such as nursing homes, home care service providers and hospices, in England, Wales and Northern Ireland.  

The research objectives for the surveys of health and social care settings and NHS Trusts were to:

• Measure awareness of the FSA guidance on listeriosis 
  Find out how well the FSA guidance on listeriosis is implemented 
  Understand barriers to implementing the guidance in full
  Understand good practice in implementing the guidance
  Understand HSC stakeholders’ perceptions of the effectiveness and suitability of the guidance

Methodology

Survey of NHS Trusts

An FSA online survey was sent to all NHS Trusts in England, Wales and Northern Ireland between 22nd November and 17th December 2021 and 39 responses were received.  In the vast majority of cases, the survey was completed by the catering manager (who was responsible for food safety).  

Data weighting – which can be used to ensure survey findings are representative of the wider population – was not applied in this case due to the relatively low numbers of Trusts completing the survey (any weighting would further reduce the effective sample size).

Survey of other HSC settings (non-NHS Trusts)

IFF Research carried out a separate survey of 445 HSC settings across England, Wales and Northern Ireland by telephone. An online survey option was also provided, but all surveys were completed via phone. Fieldwork took place between 16th August and 14th September 2022.  The breakdown of interviews achieved across the three countries is shown in Table 2.1.

Table 2.1 Table showing the breakdown of interviews achieved across each country

Country	Number of interviews
England	410
Wales	20
Northern Ireland	15

IFF Research interviewed the person with overall responsibility for food safety at the HSC (non-NHS Trust) settings - this was often the general manager. To ensure all settings spoken to were in scope, interviewees were asked to confirm that chilled ready-to-eat food was available at their site before proceeding with the rest of the survey. Potential interviewees at residential care establishments, private hospitals, and day procedure units were also asked to confirm whether vulnerable consumers were present. 

HSC (non-NHS Trust) settings were categorised as social care, community care, or healthcare settings, shown in bold in Table 2.2, with the types of settings falling into each category listed under each heading. Two commercial meal providers to HSC (non-NHS Trust) settings were interviewed as part of the research, but the results are not presented in a separate category throughout the report, due to the low numbers. 

The final breakdown of interviews achieved (unweighted) was as follows:

Table 2.2 Table showing the breakdown of interviews achieved across each sector

Category	Number of interviews
Social Care	261
Nursing home	53
Residential care home	155
Day centre for the elderly or vulnerable	53
Community Care	116
Community meal provision (for example, meals on wheels)	20
Home case service providers	88
Assisted living development for the elderly	8
Healthcare	66
Hospice	33
Private hospital	32
Day procedure unit	1
Commercial meal provider to health and social care settings	2
Total	445

Data weighting was applied to the data to ensure results were, as far as possible, representative of all non-NHS Trust settings in scope of the research. Further detail on sampling, weighting and response rates can be found in the technical appendix.

As around three-quarters of the overall weighted total are social care settings (77%), the overall pattern of the data follows this category. 

Reporting conventions

Findings from the NHS Trust survey and HSC (non-NHS Trust) settings are not directly compared with each other within this report.  This is because any differences between the two would be unlikely to be statistically significant because of the small base size among NHS Trusts.  

The small numbers of NHS Trusts completing the survey also means that no sub-group analysis has been conducted on the NHS Trust data.  

All differences stated in this report between sub-groups of the HSC (non-NHS Trust) survey are statistically significant at the 95% confidence level.  

For analysis purposes, the nine main HSC (non-NHS Trust) setting types included in the initial sample frame have been grouped into three categories – social care, healthcare and community care (see Table 2.2).  
Where the report refers to HSC settings, this covers all three categories but excludes NHS Trusts.

Throughout this report, analysis has been conducted comparing HSC (non-NHS Trust) settings that have a PA relationship with a local authority with those who do not. This analysis applies to settings based in England and Wales only. The Primary Authority Scheme does not extend to food safety in Northern Ireland therefore a PA relationship with a local authority is not available.

Where figures do not add to 100% exactly, this is typically a result of rounding.  In some cases, ‘don’t know’ responses or answer options with low response levels are not shown. This is stated where it occurs.
‘Not applicable’ responses have been excluded from the figures for some questions among HSC (non-NHS Trust) settings (reporting of NHS Trust data is not affected). Again, where this is the case, it is stated that Community care settings were generally more likely to record N/A responses to questions about good practice in the FSA guidance. This may be due to the different circumstances in which they work (for example, they are more likely to work in customers’ own homes).
 

This chapter covers knowledge of the FSA guidance on ‘Reducing the Risk of Vulnerable Groups Contracting Listeriosis’ and training on controlling the risk of listeriosis. 

Only HSC (non-NHS Trust) settings’ responses are reported in this chapter. NHS Trust findings are reported in chapter 7.

Knowledge of the FSA guidance on listeriosis

Most settings - 63% - had some knowledge of the guidance. This includes 23% who knew a lot about the guidance and 41% who knew a little about it. However, 36% did not know anything about the guidance including 13% who had never heard of the guidance. 

Figure 3.1 Knowledge of the FSA guidance on listeriosis

Reported knowledge was higher among some groups than others. By staff type, catering managers were the most likely to know about the guidance (79% knew a lot or a little vs. 63% overall). Administrative staff, e.g., admin or office managers, were the least likely to know about it, with 27% reporting never having heard of the guidance, compared to 13% overall. 

Healthcare settings were more likely than average to know a lot about the FSA guidance on listeriosis (35% vs. 23% of all settings). 

Settings that had a primary authority (PA) relationship with a local authority were also more likely to know a lot about the guidance (32% vs. 21% who do not have a PA relationship). They were also less likely to have never heard of the guidance (3% vs. 15% of those who do not have a PA relationship). 
 

Training provided

All settings were asked who received training on how to control the risk of L. monocytogenes. As seen in Figure 3.2, most train kitchen staff (57%), nurses, midwives or carers (55%) and management personnel (52%). It should be noted that not all HSC settings have kitchen staff. Fewer train staff who sell or serve food as their main role (35%). Less than a fifth (19%) of non-catering staff such as maintenance or reception staff were trained. Around one in six (17%) said they trained all their staff on how to control the risk of L. monocytogenes.

Figure 3.2 Training provided on controlling the risk of listeriosis

As shown in Figure 3.3, healthcare settings were more likely to report training several types of staff in controlling the risk of listeriosis: 

• For kitchen staff, 89% of healthcare settings said their kitchen staff received training vs. 65% of social care and 23% of community care settings
• For staff who sell or serve food as their main role, 51% vs. 38% social care and 24% community care
• For volunteers, 23% vs. 3% social care and 5% community care.

Social care settings were the most likely to say that ‘all staff’ on their site received training, compared to other settings (19% vs. 5% in healthcare and 10% in community care). With this taken into account, there are a few differences between the three settings in terms of which staff they train. 

Community care settings were least likely to train kitchen staff (23% vs. 65% in social care and 89% in healthcare). The same is true of staff who sell or serve food as their main role (24% vs. 38% and 51% respectively). This is likely to reflect the nature of the work in these settings. Community care settings are less likely to employ staff in these roles. Community care staff are more likely to prepare food they have purchased from a supermarket in clients’ homes than staff in other settings.

Within social care settings, nursing homes were less likely to train their management staff compared to residential care homes and day centres (31% vs. 50% and 52% respectively). Very few day centres trained non-catering staff (3%), significantly lower than in nursing homes (22%) and residential care homes (18%).

Settings that had a PA relationship with a local authority were more likely to train their kitchen staff than those without such a relationship (68% vs. 54%).  

Figure 3.3 Training provided on controlling the risk of listeriosis by setting type

23% of settings facing difficulties implementing good practice in management controls reported lack of control over their supply chain. The FSA guidance on ‘Reducing the Risk of Vulnerable Groups Contracting Listeriosis’ indicates good practice in control of contamination, control of growth and management controls. Good practice goes beyond what is legally required. This chapter looks at good practice in health and social care settings.  It examines how easy or difficult settings found it to implement good practice and, where difficult, why this was the case. 

Please note that the survey asked about ‘best practice’. We do not believe this impacted the findings presented here as the two terms are very similar and settings are likely to have understood them in the same way.

Only HSC (non-NHS Trust) settings’ responses are reported in this chapter. NHS Trust findings are reported in Chapter 7.

Control of contamination

The effective management of cross-contamination is an essential food safety control for Listeria. Generally, settings found the good practice outlined in the control of contamination section to be easy to implement.  The focus here is on those who found good practice ‘very easy’ to implement.  This is because, even where settings found measures ‘fairly easy’ to implement, this still suggests that they might be facing some barriers to doing so.  81% found it ‘very easy’ to wash fruit before serving, 76% found the ‘cleaning and disinfection of food preparation areas’ very easy and 71% found it very easy to implement good practice around personal hygiene and to control access to kitchens/pantries. 

Good practice in ‘controlling access to kitchens/pantries’ was most difficult to implement for all settings. 6% of settings reported finding it difficult.

Figure 4.1 How easy or difficult settings found it to implement good practice in the following control of contamination areas

Healthcare settings were most likely to find it very easy to implement good practice around:

• Personal hygiene (91% vs. 72% social care and 64% community care)
• Cleaning and disinfection of food preparation areas (92% vs. 79% social care and 63% community care)
• Wash fruit before serving (92% vs. 82% of social care vs. 78% community care

Community care settings were least likely to find it very easy to control access to kitchens/pantries (77% of healthcare settings and 73% of social care vs. 61% community care).

Community care settings were also more likely to say that each of the following areas was fairly or very difficult to implement:

• Personal hygiene (6% vs. 3% of all settings)
  Cleaning and disinfection of food preparation areas (7% vs. 0% of healthcare and 0% of social care settings)
  Wash fruit before serving (2% vs. less than 1% of all settings)
  Control access to kitchens/pantries (11% vs. 6% of all settings)

Barriers to implementing good practice

We asked settings that found at least one of the areas of good practice mentioned above difficult to implement, why they found them difficult to implement. A lack of control over the kitchen area was the most frequently mentioned barrier to implementation (44%), followed by 30% of settings finding it challenging to implement control of contamination good practice guidance in clients’ homes or residents’ rooms. The latter challenge was only mentioned by community care settings. Figure 4.2 lists the most common barriers settings faced relating to control of contamination good practice.

“Everyone has access to the [kitchen] area, if it was just staff it would have been easier, however, service users also have access so it is difficult to handle.” - Residential care home

Figure 4.2: Barriers to implementing good practice: Control of contamination

Control of growth

As stated in the guidance, it is important to minimise growth of Listeria in chilled ready-to-eat foods, to prevent the bacteria from reaching levels likely to be harmful to the health of vulnerable groups. Settings generally found the good practice in the ‘control of growth’ section of the document to be very easy to implement:

• 79% found it very easy to implement shelf-life controls e.g., checking use-by dates and rotating stock, 
• 76% found temperature monitoring of fridges in residents’ rooms, kitchenettes or pantries very easy,  
• 74% found it very easy to ensure that chilled ready-to-eat food is kept at 5°C or below, from delivery to service, 
• 71% found time and temperature control during food service to be very easy. 

Only 50% reported finding it very easy to ensure that ‘packed lunches for patients going home or off-site, including advice on how quickly any ready-to-eat food should be eaten’, 41% reported that this was fairly easy. 

Only 1% of settings found shelf-life controls difficult to implement, with 3-5% finding each of the other areas difficult.

Figure 4.3: How easy or difficult settings found it to implement good practice in the following control of growth areas

As with control of contamination areas of good practice, community care settings were consistently less likely to find areas of control of growth good practice ‘very easy to implement’. Community care settings were also more likely to find each area fairly or very difficult to implement, except for good practice around packed lunches.

Healthcare settings were more likely than social care settings to find the following very easy to implement:

• Ensuring chilled ready-to-eat food is kept at 5°C or below from delivery to service (95% healthcare vs. 78% social care)
• Time and temperature control during food service, ensuring ready-to-eat foods are eaten as soon as possible (86% vs. 75%)
• Shelf-life controls e.g., checking use-by dates and rotating stock (91% vs. 82%)
• Ensuring packed lunches for patients going home or off-site including advice on how quickly any ready-to-eat food should be eaten (77% vs. 50%).

Within social care settings, residential care homes were more likely than day centres to find it very easy to implement good practice around residents’ fridges (84% residential care homes vs. 68% day centres). 

Barriers to implementing good practice

When asked why implementing good practice around control of growth was difficult, lack of control over when food is consumed was the most common barrier faced by settings, with 39% reporting this. Just under a third (32%) mentioned how challenging the good practice guidance was to implement in clients’ homes/residents’ rooms.

“We work in customers own homes, so we're not there all the time to monitor them. Sometimes we prepare their food, but then aren't also/still there when they consume it.” - Home care provider

"Because the rooms of residents are independent and treated as a private residence, no jurisdiction.” - Residential care home 

Figure 4.4: Barriers to implementing good practice: Control of growth

Management controls

Settings generally found good practice relating to management controls less easy to implement, compared to practice in the ‘control of contamination’ and ‘control of growth’ sections.

Almost three quarters (73%) of settings found it very easy to have clearly documented guidance on roles and responsibilities for all staff. 63% found it very easy to label and refrigerate food brought in by visitors or patients. At least half of respondents found it very easy to: 
train staff in Listeria control procedures (58%) 

• use assessed suppliers, covering each stage of the supply chain (58%) 
• to use specifications describing food safety standards expected of suppliers (53%), and 
• to collect feedback from patients, residents or customers including incident and complaint monitoring (51%). 

Slightly fewer settings found it very easy to include food safety requirements in contracts for on-site retailers or contract caterers (41%), or to check food safety at suppliers by carrying out unannounced visits to them every 6-12 months (35%). 

The proportion of settings finding it difficult to implement good practice in management controls was typically 5% or less, there were higher levels of difficulty for:

• Labelling and refrigeration of food brought in by visitors / patients / residents / customers (8%)
• Collecting feedback from patients / residents / customers (12%)
• Carrying out unannounced visits to suppliers (23%)

Figure 4.5: How easy or difficult settings found it to implement good practice in the following management control areas

Community care settings were most likely to find it very or fairly difficult to: 

• Label and refrigerate food brought in by visitors / patients / residents / customers (23% vs. 6% healthcare and 5% social care).  
• Use assessed suppliers, covering each stage of the supply chain (14% vs. 4% social care, 0% healthcare).

Social care settings were more likely to report that collecting feedback from patients / residents / customers was difficult (14% vs. 3% of healthcare and community care settings).

Barriers to implementing good practice

When asked about the reasons why good practice in management controls was difficult, 38% of settings reported residents’ lack of comprehension of the risks as the main barrier to implementing good practice.

The settings interviewed include those supporting patients with dementia or learning difficulties. 

“Patients' lack of communication skills/being non-verbal, having difficulty communicating their concerns and complaints.” - Day centre

23% of settings facing difficulties implementing good practice in management controls reported lack of control over their supply chain.  

"Sometimes the quality of what is expected to be delivered isn’t good like milk may expire in 2 days. There can also be stock problems as we can’t get fresh food delivered so we have to go the local shop instead." - Nursing home

Others (16% in total) mentioned the operational (i.e., time and resource) pressures involved in maintaining compliance. 

"Because the main thing is we got a small number of catering staff that is fairly difficult to enable your staff to visit these sites because of time and distance factors.” - Residential care home

An overview of the difficulties reported is shown in Figure 4.6.

Figure 4.6: Barriers to implementing good practice: Management controls

Other difficulties faced

All HSC settings were asked whether they faced any difficulties in meeting the good practice guidance other than those they may have already mentioned. 

Figure 4.7: Other barriers faced by settings

Healthcare settings were more likely (91%) to have no other difficulties to mention than social care (80%) and community care (72%) settings. 

Where settings had further comments to make in terms of difficulties they faced implementing the good practice guidance, it was most common to cite a lack of comprehension from clients (5%), followed by ensuring all staff are properly trained, and meeting compliance requirements (4%).  

"New starters take a while to understand procedures, need to be patient and monitor them at first." - Home care and help services provider

Other comments covered insufficient knowledge of the guidance and challenges around it being difficult to implement, monitor or enforce in residents’ rooms / communal kitchens.  

"The guidance is quite hard to difficult to interpret. The way I read it might be differently understood by another person. The information can become unclear and you have several hundreds of staff to get the message across." - Meals on Wheels provider

"If people don't want to throw away their own food it is reported and documented by us but, ultimately, that is the limit of what we can do." - Home care provider
 

This chapter details awareness of the risk of listeriosis, among HSC (non-NHS Trust) settings. It also covers the extent to which these settings implement the FSA guidance in three areas: control of contamination, control of growth, and management controls.

Awareness of the risk of Listeria

The vast majority of all settings were aware of at least some of the risks associated with chilled ready-to-eat foods from Listeria. Over half (54%) were fully aware of the risks, whilst 36% were aware of some of the risks, 7% knew little and 2% knew nothing about the risks.

Figure 5.1: Awareness of the risks associated with chilled ready-to-eat foods and Listeria

Healthcare settings were more likely to be fully aware of the risks (73% vs. 54% overall). Social care settings were more likely to know little about the risks (9% compared to 3% of healthcare and community care settings).

Settings that had a PA relationship with a local authority were more likely to be fully aware of the risks, compared to those who do not (70% vs. 51%). 

Implementing practice to control contamination

Almost all settings agreed that the cleaning of all food contact surfaces at their site controlled the risk of L. monocytogenes (98%), with 70% strongly agreeing. Similarly, the vast majority (98%) agreed that food safety controls on site were effective in stopping cross-contamination of food with Listeria, with 72% strongly agreeing.  

Figure 5.2: Extent to which settings agree with the statements relating to the control of growth

Social care settings were more likely than average to strongly agree that the cleaning of all food surfaces at their site controlled the risk of Listeria (73%) while community care settings were less likely to (61%).  Healthcare and social care settings were both more likely than community care to strongly agree that food safety controls on site were effective in stopping cross-contamination (77% and 79% vs. 56%).

Within social care settings, nursing homes (84%) were more likely than residential care homes (70%) and day centres for the elderly or vulnerable (65%) to strongly agree that cleaning of all food contact surfaces on the site controlled the risk of L. monocytogenes. Day care centres were less likely to strongly agree that food safety controls on site were effective in stopping cross-contamination of food with Listeria (64% compared to 77% of residential care homes and 80% of nursing homes).

Implementing practice to control growth

Temperature control of chilled ready-to-eat foods from supply to point of service on site

All settings were asked questions about temperature control. The FSA guidance states that “It is good practice for healthcare/social care organisations to maintain their cold chain of chilled ready-to-eat food at 5°C or below from delivery through to service”’. 56% of all settings reported that the maximum temperature that chilled ready-to-eat foods reached, from supply of chilled ingredients until the point of sale or service, was 5°C. However, 16% reported that the maximum temperature reached was 8°C, which is the legal requirement. Just under a quarter (23%) did not know the answer to this question. 

As can be seen in Figure 5.2, healthcare and social care settings were more likely to follow good practice, reporting that the maximum temperature that chilled ready-to-eat foods reached was 5°C (68% and 57% respectively vs. 50% of community care settings). Community care settings were most likely to answer ‘Don’t know’.

One per cent of settings reported reaching temperatures over 8°C for more than four hours. All of these settings were residential care homes.

Figure 5.3 Maximum temperature that chilled ready-to-eat foods can reach from supply chain of chilled food ingredients to point of service

Temperature control of chilled ready-to-eat foods during storage on site

The FSA guidance on temperature control during food service to the patient/resident states that it is good practice to “Hold chilled ready-to-eat foods transported to the service point in chilled equipment at 5°C or less or transfer to appropriate refrigeration at ward/pantry”. 

Just under half (46%) of all settings reported that the maximum temperature that chilled ready-to-eat foods reached during storage in areas for patients or residents was 5°C, which is in line with the FSA good practice.

Around one-fifth (21%) reported that the maximum temperature was 8°C. Just over a quarter (26%) did not know.

Two per cent of all settings reported that chilled ready-to-eat foods reached temperatures over 8°C for more than four hours. This represents 4% of community care settings and 2% of social care settings.

As can be seen in Figure 5.4, healthcare and social care settings were more likely to follow good practice, reporting that the maximum temperature that chilled ready-to-eat foods reached during storage in areas for patients or residents was 5°C (64% and 50% respectively vs. 32% community care settings). Community care settings were more likely to say ‘don’t know’ (43% vs. 23% social care and 15% healthcare).

Figure 5.4: Maximum temperature that chilled ready-to-eat foods reach during storage in areas for patients or residents

 

Further practice around the control of growth

Respondents were also asked to what extent they agree or disagree with three statements in relation to their own site:

• Across the site, we monitor and record temperatures throughout the cold chain, consistently and accurately.
• The maximum shelf-life for ready-to-eat sandwiches sold or distributed on site is day of production plus 2 days.
• Across the site, we carry out regular sampling for Listeria to verify compliance with microbiological criteria regulations.

Almost all (98%) settings agreed that across their site temperatures were monitored and recorded throughout the cold chain, consistently and accurately, with 68% strongly agreeing. There were also a high proportion of settings (80%) who could agree that the maximum shelf-life for ready-to-eat sandwiches sold or distributed on their site was day of production plus two days, although 14% disagreed. Only 54% of settings agreed that they carried out regular sampling for Listeria and 29% disagreed.

Figure 5.5: Extent to which settings agree with the statements relating to control of growth

Healthcare settings were significantly more likely (64%) to strongly agree that the maximum shelf-life for ready-to-eat sandwiches was the day of production plus two days, than social care (47%) and community care (36%) settings. Community care settings were less likely to agree with the two statements relating to monitoring the cold chain (86% vs. 98% overall).

Settings with a PA relationship were more likely to agree that they carried out regular sampling (70% vs. 50% without). Settings registered with a local authority agreed more frequently than those reporting to not be registered (58% vs. 45% without).

Implementation of management controls

Whether HSC settings have food safety management systems based on HACCP principles

Just over three-quarters (77%) of all settings reported having a food safety management system based on HACCP principles in place. 13% reported not having such a system in place and a further 10% were unsure. However, settings may have been unfamiliar with the HACCP terminology, but they still followed guidance based on HACCP principles, e.g., the Safer Food, Better Business resource pack.

Figure 5.6: Whether settings have food safety management systems based on HACCP principles in place

As seen in Figure 5.6, community care settings were much more likely to report not having a food safety management system based on HACCP principles in place (45% vs. 5% of healthcare and social care settings). 

Within social care settings, both nursing homes and residential care homes were more likely to have a food safety management system based on HACCP principles compared to day centres for the elderly or vulnerable (87% and 88% respectively vs. 64%). 

Settings that had a PA relationship were more likely to have a food safety management system based on HACCP principles in place, compared to those without a PA (91% vs. 74% without). 

Further practice around management systems and overall risk monitoring/controls

Respondents were asked about three statements on their food management systems. There were similar levels of agreement on all three statements: 

• ‘the site's food safety management system covers all food pathways’ (92% agreed).
• ‘across the site, we monitor and record the performance of all our controls for L. monocytogenes effectively and take effective action when required as a result’ (91% agreed).
• ‘across the site, we ensure that the risk of L. monocytogenes is controlled effectively in the whole supply chain’ (91% agreed).

Between 3-4% disagreed with each of the statements.

Figure 5.7: Extent to which settings agree with the statements relating to management controls

Community care settings were significantly less likely to agree that their food safety management system covered all food pathways than social care and healthcare settings (79% vs 95% and 94% respectively). They were also more likely not to know about this statement than social care settings (12% vs. 3%).

Within social care settings, nursing homes and residential care homes (95% and 92% respectively) were both more likely to agree that ‘they control for Listeria effectively and take effective action when required as a result’ than day centres for the elderly or vulnerable (82%). Nursing homes were also more likely than day centres to agree that the risk of Listeria was controlled effectively in the whole supply chain (95% vs. 80%). 

This chapter details perceptions of the FSA guidance on ‘Reducing the Risk of Vulnerable Groups Contracting Listeriosis’ among HSC (non-NHS Trust) settings. It reports the perceptions of those aware of the guidance, who were able to give an informed view. Participants were asked about the effectiveness of the guidance, which parts are most useful, and how the guidance could be improved.

Perceived effectiveness

95% of all health and social care settings aware of the guidance felt the FSA guidance was effective in reducing the risk of vulnerable groups contracting listeriosis. 70% reported that it was very effective. Only 3% of settings perceived the guidance to be ineffective, with the remaining 3% unsure.

Social care settings and healthcare settings were significantly more likely to perceive the guidance to be effective than community care settings (97% and 95% vs 88% respectively).

95% of all health and social care settings aware of the guidance felt the FSA guidance was effective in reducing the risk of vulnerable groups contracting listeriosis. 70% reported that it was very effective. Only 3% of settings perceived the guidance to be ineffective, with the remaining 3% unsure.
Social care settings and healthcare settings were significantly more likely to perceive the guidance to be effective than community care settings (97% and 95% vs 88% respectively).

Figure 6.1: Effectiveness of the guidance in reducing the risk of vulnerable groups contracting Listeriosis

Perceived clarity

92% of settings aware of the guidance felt that the guidance clearly distinguished between legal requirements and good practice. Only 1% reported that the distinction was not very or not at all clear. 

Figure 6.2: How clearly the guidance distinguishes between legal requirements and good practice

Social care settings were significantly more likely (95%) than community care (79%) and healthcare settings (83%) to say that the guidance clearly distinguished between legal requirements and good practice. Correspondingly, social care settings were less likely to report that the guidance did not distinguish clearly. (Less than 1% of social care settings said that the guidance was not very or not at all clear, compared to 4% of community care and 9% of healthcare settings.) 

Settings with a PA relationship were more likely to report that the guidance clearly distinguished between legal requirements and good practice (99% vs. 91% that do not have this relationship). 

Most useful parts of the guidance

The parts of the guidance mentioned as being most useful in reducing the risk of listeriosis included temperature control and fridges (cited by 14% of all settings aware of the guidance), checklists for preventative practice (12%), information on cross-contamination / infection control (8%), and content on cleaning standards (8%). Four percent also commented on the clear, concise, and beneficial nature of the material.

“The good practice part stands out as it provides examples of the food pathways and defines vulnerable groups. Initially I wasn't sure that our service users were vulnerable." - Day Centre

“The fact that Listeria isn't always easily detectable is a point worth raising and is worth bearing in mind.” - Private hospital

Figure 6.3: Parts of the guidance found most useful in reducing the risk of listeriosis

How the guidance can be improved

As shown in Figure 6.4, while most settings were unsure what could improve the guidance (53%) or felt that no improvements were necessary (16%), others would appreciate the guidance being easier to read (11%), updated more often (5%), or being made more accessible (4%).  

“An "easy read version" that's more accessible." - Residential care home

"An easy read leaflet, but also for that leaflet to be available in different languages as English is not everyone's first language…” - Hospice

"Presenting it in an "Easy Read" format, minimising jargon, using pictures." - Private hospital

Beyond improving the text itself, there was also some calls for publicising the information or raising awareness (by 4%) or other actions, such as providing more support or training or compliance testing (4%).

“Make it more well known, I don’t even know much about it, increase public awareness” - Residential care home

"More regular inspection… and regular training" - Nursing home

Figure 6.4: How all settings think the guidance can be improved

Healthcare settings were significantly more likely (12%) than social care settings (3%) to report that the information should be more accessible. Healthcare settings were also more likely to feel that the guidance could be improved by ensuring appropriate coverage of important aspects, e.g., disease control (10%), compared to all settings (2%). 

Settings without a PA relationship were more likely to say that they wanted the information to be easy to read than those with a PA relationship (13% vs. 3%). Those with a PA relationship were more likely to feel that no improvements were necessary (28% vs. 14% of those without a PA relationship).

Local authority and primary authority (PA) relationships in England and Wales

Health and social care settings within England and Wales were asked whether their site was registered as a food business operator with a local authority and/or if the business had a PA relationship. 

Fifty percent of settings in England and Wales reported they were only registered with their local authority.

Whilst 18% reported they were registered with their local authority and had a PA relationship, 13% reported that they did not know. However, 20% of settings reported that they were not registered at all with their local authority. 

The 20% of health and social care settings who reported not being registered with a local authority were compared with the Food Hygiene Rating Scheme (FHRS) listings to ensure the reliability of this unexpected finding. However, the results of this investigation were inconclusive. 

This concludes the report findings conducted by IFF Research on health and social care settings, other than NHS Trusts. The next chapter goes onto discuss the findings of the online survey of NHS Trusts carried out by the FSA. 
 

 

This chapter reports the findings of the separate online survey of NHS Trusts carried out by the FSA in 2021. It covers findings from 39 respondents within NHS Trusts in England, Wales and Northern Ireland. The survey asked about awareness, implementation and perceptions of the FSA guidance. 

Awareness and usage of the guidance

Usage of the guidance

In the NHS Trust Survey, participants were asked whether they were using the guidance prior to the survey.  92% of NHS Trusts said they had been using the FSA guidance on listeriosis before taking part in the survey, with 3% reporting they were not using the guidance and 5% unsure. 

Training provided

Nearly all Trusts (97%) said their kitchen staff had received training about how to control the risk of L. monocytogenes. Slightly fewer (89%) reported that their service and food retail staff had this training whilst 55% of ward staff received the same. 21% of volunteers received training.  

Figure 7.1: Training provided to NHS staff on controlling the risk of listeriosis

Implementing good practice and the barriers to implementation

Please note that the FSA guidance uses the term ‘good practice’ and the questionnaire asked about ‘best practice’. We do not believe this affects the survey findings as the two terms are very similar.

Extent to which good practice is implemented

82% of Trusts reported having fully implemented the good practice on control of contamination outlined in the guidance. Slightly fewer reported having implemented good practice on control of growth and management controls (73% each). The remainder of Trusts had implemented the guidance to some extent or were unsure. Only one Trust reported not having implemented good practice in terms of management controls. 

Figure 7.2: Extent to which NHS Trusts have fully implemented the sections of good practice

Barriers to implementation

The survey asked NHS Trusts to consider barriers which made it difficult for them to implement the FSA guidance in full. From a prompted list of barriers (including the option to provide a ‘other’ free text response), the most frequently selected barriers were: 

• a lack of control over food service - 31%
• a lack of control over their supply chains – 25%
• high staff turnover - 22%
• lack of control over food storage 22%. 

Key barriers mentioned are shown in Figure 7.3.  

Figure 7.3: Barriers faced by NHS Trusts in fully implementing the guidance

Implementing practice to control contamination

Among NHS Trusts, 84% agreed that ‘cleaning of all food contact surfaces controlled the risk of L. monocytogenes effectively in the Trust’, with 55% strongly agreeing. In total, 16% disagreed with this statement in relation to their Trust. 

There were also high levels of agreement with the statement that food safety controls in the Trust were effective in stopping cross-contamination of food with Listeria. 97% agreed, including 61% strongly agreeing.

Figure 7.4: Extent to which NHS Trusts agree with the statements relating to the control of contamination

Implementing practice to control growth

Temperature control

NHS Trusts were questioned about good practice in temperature control. The FSA guidance states that: “It is good practice for healthcare/social care organisations to maintain their cold chain of chilled ready-to-eat food at 5°C or below from delivery through to service”’. Among NHS Trusts, 71% answered that the maximum temperature was 5°C, with 26% reporting 8°C (the legal requirement). 

Additionally, the FSA Good Practice guidance on temperature control during food service to the patient/resident states: “Hold chilled ready-to-eat foods transported to the service point in chilled equipment at 5°C or less or transfer to appropriate refrigeration at ward/pantry”. Among NHS Trusts, 57% reported that the maximum temperature foods reached during service or storage on wards or other patient areas was 5°C. 24% reported that it was 8°C, with a further 11% reporting that the maximum temperature could go beyond 8°C for up to four hours. (Temperatures in excess of 8°C are acceptable for up to four hours).

Figure 7.5: Maximum temperatures that chilled ready-to-eat foods reach in the cold chain from supply of chilled ingredients to sale or service of the food

Figure 7.6: Maximum temperatures that chilled ready-to-eat foods reach during service or storage on wards or other patient areas

Further practice around the control of growth

Agreement was high among Trusts that accurate and consistent monitoring and recording of temperatures took place throughout the cold chain, with 95% in agreement. Around eight in ten NHS Trusts (79%) agreed that the maximum shelf-life for ready-to-eat sandwiches sold or distributed in the Trust was day of production plus two days. Only 13% disagreed with this statement (please note that this statement only had two options for NHS Trusts to choose from: ‘agree’ and disagree’, as opposed to the scale option provided elsewhere). The statement relating to regular sampling drew the lowest level of agreement, with 51% agreeing that their Trust carried out regular sampling for L. monocytogenes compared to 38% who disagreed. 

Figure 7.7: Extent to which NHS Trusts agree with the statements relating to control of growth

Implementation of management controls

Nearly all NHS Trusts (97%) reported having a food safety management system based on hazard analysis critical control point (HACCP) principles, with just one Trust unsure.

79% of Trusts agreed that the Trust's food safety management system covered all food pathways on their site(s). 89% agreed that they were monitoring and recording the performance of controls for L. monocytogenes effectively and took effective action when required, as a result. The same proportion agreed that ‘the risk of L. monocytogenes is controlled effectively in the whole supply chain, i.e., we ensure that there are effective safety controls in place at our suppliers and their suppliers’. 

Figure 7.8: Extent to which NHS Trusts agree with the statements relating to management controls

In terms of the legal requirements outlined in the guidance, 82% of NHS Trusts had fully implemented these with regards to control of contamination and management controls, with 77% of Trusts having done so for control of growth. The remainder of Trusts had implemented the guidance to some extent or were unsure. One Trust reported not having implemented the legal requirements in terms of management controls.  
 
Figure 7.9: Extent to which NHS Trusts have fully implemented the legal requirements of FSA guidance

NHS Trusts' view of the guidance

NHS Trusts were given the chance to comment about each chapter of the guidance in turn. As only a small proportion of respondents from NHS Trusts provided answers to these questions, this section is reported purely qualitatively and should not be interpreted as evidence of which views are typical across the sector. Reflecting on the comments provided by NHS Trusts across the chapters of the guidance, the most common view is that they found the guidance to be clear and informative. 

“The guidance is very specific and easy to follow.”

“Very clear and detailed.”

Two of the respondents asked for further guidance about food being brought into the premises by relatives. One described it as too “soft and fluffy in the way it advises”. Another reported that it would be helpful to have advice on how Trusts should approach allowing food to be brought from home for patients receiving end of life care. 

With regards to the effective cleaning and disinfection of surfaces, a couple of Trusts wanted clarity on what was an acceptable standard to ensure control of contamination.

“[In relation to Section two] …little more detail required. What are the chemicals known (base chemicals) that are effective against L. monocytogenes?  How often should air handling systems be cleaned?”

“Page 12 [on cleaning and disinfection] shouldn’t really give the impression that domestic grade equipment is ok to be used”

Lastly, while not strictly related to the contents of the guidance itself, three Trusts wanted further training to be provided to nursing staff. While they were confident that their catering teams were well trained, these Trusts felt that training amongst the nursing staff could be strengthened.

“…clinical staff control most of the time and don’t feel they adhere to guidance as much as catering staff. Whilst nursing do a basic food hygiene/safety course, I don't feel this covers all elements of this guidance.”

“While food safety training for catering staff as food handlers at CIEH level 2 is well established and embedded it is less so for other food handlers such as ward nursing staff…. Could routine awareness training be mandated for nursing staff who handle food during mealtime service?”

NHS Trusts’ registration status with local authorities and primary authority (PA) relationships

Almost all (97%) of NHS Trusts were registered with a local authority, while just under one in ten (29%) had a PA relationship on top of this.

Sampling

The HSC (non-NHS Trust) sample for the study was drawn from four sources: 

• Market Location provided settings in the social care category. This included nursing homes, day centres for the elderly/vulnerable, residential care homes, community meal provision (e.g., ‘meals on wheels’) and assisted living developments for the elderly. 
• Wilmington Healthcare supplied IFF Research with settings in the healthcare category; this consisted of hospices, private hospitals and day procedure units.
• As Market Location did not have enough community meal provision in their database to reach our quota target in this category, desk research was conducted in order to ‘top-up’ the sample. 
• IFF Research also utilised snowball sampling, asking those who completed the survey if they could give us contact details of the commercial meal providers they use. However, during fieldwork it became clear that very few HSC (non-NHS Trust) settings use outside caterers, with just 14 settings (3%) agreeing this was the case. With a number of interviewees providing details of the same meal provider, only a small fraction of the interviews in the study (two out of 445 completed interviews) are from commercial meal providers.

The sample was stratified by country and setting type to broadly reflect the underlying population, though some categories were overrepresented (such as healthcare settings and community meal provision) to give more robust base sizes for analysis. 

Questionnaire design

The questionnaire for HSC (non-NHS Trust) settings was designed by IFF Research and the FSA to best meet the research objectives.  It took the NHS survey as a basis, maintaining comparability where possible, but making refinements and additions where it was felt that this would collect more comprehensive or accurate data.  The performance of the questionnaire was monitored during the early part of the fieldwork period and a few small improvements made. 

Weighting

We used the amount of sample available from Market Location and Wilmington Healthcare in relevant categories as the most comprehensive available source of population data.  We then adjusted these figures to exclude the proportion of each sector which had been found to be out of scope of the survey either because the settings did not sell chilled ready-to-eat food or because the settings did not ever cater for vulnerable groups. 

The tables below show the proportions of each setting type we excluded from the scope of the research and the final unweighted and weighted proportions for each setting type (sample definition), and by country. 

As a note, we gave HSC (non-NHS Trust) settings the opportunity to tell us what kind of setting they are as part of the research. While we have used their self-definition for analysis purposes, the weighting was done based on the definition of their setting which was marked up on the sample records, as this felt the most directly comparable to the population data.

Table 8.1 Proportion of each setting that were excluded after being found to be out of scope

Setting type	Total number of settings who were asked screener questions	Number of settings who were excluded	Proportion of settings who were excluded
Antenatal clinic and/or centre	4	3	75%
Commercial meal provider	2	0	0%
Day and Care Centres	141	71	50%
Home Case and Help Services	146	67	46%
Home Care Service Providers	120	60	50%
Hospice	45	6	13%
Meals on Wheels	41	14	34%
Nursing Home	97	23	24%
Private hospital	60	18	30%
Residential Care establishments	158	53	34%
Rest and retirement homes			37%
Grand total	934	359	38%

Table 8.2. Unweighted and weighted proportions of completed interviews

Setting type	Proportion of completes: Unweighted %	Proportion of completes: Weighted %
Commercial meal provider	<1%	<1%
Day and Care Centres	11%	4%
Home Case and Help Services	12%	9%
Home Care Service Providers	9%	7%
Hospice	8%	1%
Meals on Wheels	4%	3%
Nursing Home	13%	17%
Private hospital	8%	1%
Residential Care establishments	19%	41%
Rest and retirement homes	15%	16%

Country

Country	Proportion of completes: Unweighted %	Proportion of completes: Weighted %
England	92%	93%
Wales	4%	5%
Northern Ireland	3%	2%

Response rates

A total of 3,761 HSC (non-NHS Trust) setting records were eligible to be contacted over the course of the survey. As listed in Table 8.1, 359 sites were found to be out of scope due to not having ready-to-eat food available or because they did not provide food to vulnerable groups. A further 2,634 records were out of scope for fieldwork. For example, 162 had unobtainable numbers or the site was closed. Table 8.2 breaks down those who could not be reached during the fieldwork period and are thus not included in response rate calculations, since no firm contact was made. 

This left 768 records in scope for fieldwork, of which 445 completed an interview. This equates to a response rate of 58%, as shown in Table 8.4.

Table 8.3. Setting outcomes of the total sample in scope of study

Setting outcomes	Total	Population in scope of study %
Total number of records in scope	3,402	100%
Setting not contacted	265	8%
Setting called but unable to reach target respondent	1,445	42%
Appointment made but not achieved during fieldwork period	595	17%
Unobtainable number/company closed	162	5%
Not available in fieldwork period/nobody at site available	65	2%
Out of quota - does not fit a category outlined in Table 2.1	107	3%

Table 8.4. Sample outcomes of the total sample in scope of fieldwork

Setting outcomes	Total	Population in scope of study %
Total number of records in scope of fieldwork	768	100%
Completes	445	58%
Refusals	273	36%
Breakdown during interview	6	1%
Preferred to complete online (but did not complete the survey)	44	6%

 

S Screener

Ask Telephonist

S1    Good morning / afternoon. My name is NAME and I'm calling from IFF Research. Please can I speak to NAME? [IF NO CONTACT INFO: Please can I speak to the owner or manager or the most senior person responsible for food safety at this site?]

ADD IF NECESSARY: We’re conducting a survey on behalf of the Food Standards Agency (FSA). This is exploring awareness of the FSA guidance on ‘Reducing the Risk of Vulnerable Groups Contracting Listeriosis’ within health and social care settings and understanding any challenges associated with implementing the guidance. 

IF WANT TO TRANSFER TO HEAD OFFICE OR ANOTHER BRANCH / SITE: We need to speak to someone based at this site, not at head office or another branch of your organisation. We are interested in activities at this location. Could I speak to the person at this site who would have the best overview of food safety issues?

Response	Number	Action
Transferred	1	Continue
Hard appointment	2	Make appointment
Soft appointment	3	Make appointment
Engaged	4	Call back
Refusal	5	Close
Refusal - company policy	6	Close
Refusal - taken part in recent survey	7	Close
Nobody at site able to answer questions	8	Close
Not available in deadline	9	Close
Fax line	10	Close
No reply/answer phone	11	Close
Residential number	12	Close
Dead line	13	Close
Company closed	14	Close
Request reassurance email	-	Collect email address then continue or make appointment (see appendix for email text)

Ask All

S2    NEW    Good morning / afternoon, my name is NAME, calling from IFF Research, an independent market research company, conducting a survey on behalf of the Food Standards Agency (FSA).

Can I first just check if chilled ready-to-eat food is available at your site?

IF NECESSARY: Examples of chilled ready-to-eat foods are sandwiches and fresh salads.
ADD IF HOMECARE: If you or your staff work in people’s own homes, please answer assuming that the home is the ‘site’ we are interested in.

IF NECESSARY: We’re conducting a survey on behalf of the Food Standards Agency (FSA).  This is exploring awareness of the FSA guidance on ‘Reducing the Risk of Vulnerable Groups Contracting Listeriosis’ within health and social care settings and understanding any challenges associated with implementing the guidance.
 

Response	Number	Action
Yes	1	Continue
No	2	Thank and close, if online. Unfortunately you are not eligible for this survey. Thank you for your time.
Don't know	3	Thank and close.

This survey on behalf of the FSA is about exploring awareness of the FSA guidance on ‘Reducing the Risk of Vulnerable Groups Contracting Listeriosis’ within health and social care settings and understanding any challenges associated with implementing the guidance.

Please be assured that the responses you give will not be used to assess the food safety of your establishment. Your answers will only be used for the purpose of this research and all responses will be anonymised when reporting back to the FSA. 
The survey should take around 15 minutes. 

Would it be ok to run through this with you now? 

IF NECESSARY: We can provide a link for you to do the survey online in your own time if you prefer?

Response	Number	Action
Continue	1	Continue
Referred to someone else at establishment Name... Job title...	2	Transfer and re-introduce
Hard appointment	3	Make appointment
Soft appointment	4	Make appointment
Refusal	5	Thanks and close
Refusal - company policy	6	Thanks and close
Refusal - taken part in recent survey	7	Thanks and close
Not available in deadline	8	Thanks and close
Prefer to do online	9	Send email containing online survey link to respondent

ASK ALL

Throughout this survey, we will be asking about food safety practice at your ‘site’. By this, we mean the specific site where you work, rather than your organisation as a whole.

ADD IF HOMECARE: As a reminder, if you or your staff work in people’s own homes, please answer assuming that the home is the ‘site’ we are interested in.

S4    Which of these health and social care settings best describes your site? 

IF NECESSARY: If your site straddles more than one category, please choose the category your site most belongs to.

Read out. Single code. 

Response	Number	Details
Nursing home	1	-
Residential care home	2	-
Day centre for the elderly or vulnerable	3	-
Community meal provision (for example, meals on wheels)	4	-
Home care service provider	12	-
Assisted living development for the elderly	5	-
Hospice	6	-
Private hospital	7	-
Day procedure unit	8	-
Antenatal clinic or centre	9	-
Commercial meal provider to health and social care settings	10	-
None of these (specify site type)	11	THANK AND CLOSE BUT EXPLAIN WILL CHECK ELIGIBILITY AND MAY CALL BACK. IF ONLINE: Thank you. We will check to see if you are eligible for this survey. We will email you back if this is the case.

ASK RESIDENTIAL CARE ESTABLISHMENTS, PRIVATE HOSPITALS OR DAY PROCEDURE UNITS (S4=2, 7 OR 8)

S5A.    Do you ever have elderly residents or any whose immune systems may be weakened in some way, for example (but not limited to) pregnant women, people with diabetes, cancer patients or people struggling with addiction? 

SINGLE CODE. DO NOT READ OUT.
 

Response	Number	Action
Yes	1	Continue
No	2	Thank and close.
Don't know	3	Thank and close.

ASK ALL BASED IN WALES (COUNTRY=4)

S6    Would you prefer the [IF CATI: interview] [IF ONLINE: survey] to be carried out in Welsh or English?

SINGLE CODE. DO  NOT READ OUT.

Language	Number	Action
Welsh	1	“One of our Welsh speaking interviewers will call back in the next few days to make an appointment with you.” THANK AND CLOSE
English	2	Continue

ASK ALL
S7    [IF CATI: Before we begin the main survey, I need to read out a quick statement regarding GDPR legislation:] 

All information collected will be treated in the strictest confidence. You have the right to a copy of your data, to change your data or to withdraw from the research at any point until the final report has been written, If you’d like to do this, or find out more, you can consult our website at iffresearch.com/gdpr. 

[IF CATI: In order to guarantee this, and as part of our quality control procedures, all interviews are recorded. Is that OK?] 

DO NOT READ OUT. SINGLE CODE. 

Response	Number	Action
Yes - agree to continue	1	-
Refuse to continue	2	Thank and close.

Reassurances to use if necessary:

• IFF Research is an independent market research company, operating under the strict guidelines of the Market Research Society’s Code of Conduct. This means that anything you tell us will be treated in the strictest confidence, and none of your answers will be attributed to you unless you give explicit permission for us to do so. 
• the interview will take around 15 minutes to complete.
• please note that all data will be reported in aggregate form and your answers will not be reported to the Food Standards Agency in any way that would allow you to be identified. 
• if respondent wishes to confirm validity of survey or get more information about aims and objectives, they can contact:

A Awareness and usage of guidance

ASK ALL
A1    First, we’re going to ask about your general awareness of the FSA guidance on Reducing the Risk of Vulnerable Groups Contracting Listeriosis. 

Overall, how would you rate your knowledge of this FSA guidance?

IF NECESSARY: We are after your awareness of this specific guidance provided by the FSA on Listeriosis, rather than any other guidance you may have seen from the FSA.

SINGLE CODE. READ OUT SCALE

Response	Number	Details
I know a lot about it	1	-
I know a little about it	2	-
I am aware it exists but don't know anything about it	3	-
I have never heard of it	4	-
(FOR CATI: DO NOT READ OUT) Don't know	5	-

ASK ALL

A2    Across your [IF NOT HOMECARE: site / IF HOMECARE: organisation], who receives training about how to control the risk of Listeria monocytogenes? 
MULTICODE. PROMPT AS NECESSARY.

Response	Number	Details
Kitchen staff	1	-
Staff who sell or serve foo as their main role	2	-
Nurses, midwives or carers	3	-
Management personnel	4	-
Non-catering staff for example, maintenance or reception staff	5	-
Volunteers	6	-
Other (please specify)	7	-
None of these	8	Single code only
For CATI DO NOT READ OUT: Don't know	9	Single code only

B Barriers

ASK ALL

We will now ask about how easily different areas of the guidance can be implemented at your setting.  

Please remember that the survey is anonymous and do not hesitate to let us know about any challenges you may face – this is really useful for providing insight for the FSA’s review into where extra clarification or support may be needed.

B1    How easy or difficult is it for sites like yours to implement best practice in…?

READ OUT SCALE, REPEAT IF NECESSARY
 

Response	Very difficult	Fairly difficult	Fairly easy	Very easy	(FOR CATI DO NOT READ OUT: Don't know)	(FOR CATI: DO NOT READ OUT: Not applicable)
1 Personal Hygiene	1	2	3	4	5	6
2 Cleaning and disinfection of food preparation areas	1	2	3	4	5	6
3 Washing fruit before serving	1	2	3	4	5	6
4 Controlling access to kitchens/pantries	1	2	3	4	5	6

IF THEY FOUND ANY ASPECT OF CONTROL OF CONTAMINATION TO BE DIFFICULT [IF ANY B1_1 - 4=1 OR 2]. 

A1    You said you thought it would be difficult to implement best practice in:
 [INSERT AREAS FROM B1 WHERE CODES 1 OR 2 ARE SELECTED]

Why is this?

ONLINE ONLY: Please describe your difficulties in each area of best practice listed above.
PROBE FOR EACH BEST PRACTICE THAT THEY FIND DIFFICULT

Write in:

B3    How easy or difficult is it for sites like yours to implement best practice in…?
READ OUT SCALE, REPEAT IF NECESSARY

Response	Very difficult	Fairly difficult	Fairly easy	Very easy	(FOR CATI DO NOT READ OUT: Don't know)	(FOR CATI: DO NOT READ OUT: Not applicable)
1 Ensuring chilled Ready to Eat food is kept at 5c or below from delivery to service	1	2	3	4	5	6
2 Time and temperature control during food service, including ensuring ready-to-eat foods are eaten as soon as possible	1	2	3	4	5	6
3 Shelf life controls for example, checking use-by dates and rotating stock	1	2	3	4	5	6
4 Temperature monitoring of fridges in residents' rooms, kitchenettes, or pantries	1	2	3	4	5	6
5 Ensuring packed lunches for patients going home or off site including advice on how quickly any ready-to-eat food should be eaten	1	2	3	4	5	6

IF THEY FOUND ANY ASPECT OF CONTROL OF GROWTH TO BE DIFFICULT [IF ANY B3_1 - _5=1 OR 2]

B4    You said you thought it would be difficult to implement best practice in: [INSERT AREAS FROM B3 WHERE CODES 1 OR 2 ARE SELECTED]

Why is this?

ONLINE ONLY: Please describe your difficulties in each area of best practice listed above.
PROBE FOR EACH BEST PRACTICE THAT THEY FIND DIFFICULT

Write in:

B5    How easy or difficult is it for sites like yours to implement best practice in…?
READ OUT SCALE, REPEAT IF NECESSARY
 

Response	Very difficult	Fairly difficult	Fairly easy	Very easy	(FOR CATI DO NOT READ OUT: Don't know)	(FOR CATI: DO NOT READ OUT: Not applicable)
1 Having clear documented guidance on roles and responsibilities for all staff.	1	2	3	4	5	6
2 Training staff in listeria control procedures	1	2	3	4	5	6
3 Collecting feedback from patients, residents or customers including incident and complaint monitoring	1	2	3	4	5	6
4 Specifications describing food safety standards expected of suppliers	1	2	3	4	5	6
5 Using assessed suppliers, covering each stage of the supply chain.	1	2	3	4	5	6
6 Checking food safety at suppliers by carrying out unannounced visits to them every 6-12 months.	1	2	3	4	5	6
7 Including food safety requirements in contracts for on-site retailers or contract caterers	1	2	3	4	5	6
8 Labelling and refrigeration of food brought in by visitors or patients/residents/customers themselves	1	2	3	4	5	6

IF THEY FOUND ANY ASPECT OF MANAGEMENT CONTROLS TO BE DIFFICULT [B5_1-_8=1 OR 2]

B6    You said you thought it would be difficult to implement best practice in:
[INSERT AREAS FROM B5 WHERE CODES 1 OR 2 ARE SELECTED]
Why is this?

ONLINE ONLY: Please describe your difficulties in each area of best practice listed above.
PROBE FOR EACH BEST PRACTICE THAT THEY FIND DIFFICULT

Write in:

ASK ALL
A1  [IF NOTHING DIFFICULT: What difficulties, if any, do / IF ANYTHING DIFFICULT (IF B1_1 - 4=1 OR 2 OR B3_1 - _5=1 OR 2 OR B5_1-8=1 OR 2): Are there any other difficulties] you face in meeting the good practice guidance?  Please give as much detail as possible.

Write in:

C Implementation

ASK ALL
C1    How aware are you of the risks associated with chilled ready-to-eat foods and listeria?

SINGLE CODE. READ OUT SCALE

Responses	Number	Details
I am fully aware of the risks	1	-
I am aware of some of the risks	2	-
I know little about the risks	3	-
I know nothing about the risks	4	-
(FOR CATI: DO NOT READ OUT) Don't know	5	-

ASK ALL
C2    To what extent do you agree or disagree with the following statements in relation to your own site:
SINGLE CODE. READ OUT SCALE.
 

Response	Strongly agree	Agree	Disagree	Strongly disagree	(FOR CATI DO NOT READ OUT: Don't know)
1 Cleaning of all food contact surfaces on site controls the risk of Listeria monocytogenes	1	2	3	4	5
2 Food safety controls on site are effective in stopping cross-contamination of food with Listeria monocytogenes	1	2	3	4	5

ASK ALL

C3    What is the maximum temperature that chilled ready-to-eat foods reach from supply of chilled ingredients until the point of sale or service? 
SINGLE CODE. READ OUT.

Response	Number	Details
11	1	-
8°C	2	-
Over 8°C for up to 4 hours	3	-
Over 8°C for more than 4 hours	4	-
(FOR CATI DO NOT READ OUT) Don't know	5	-
(FOR CATO DO NOT READ OUT) Not applicable	6	-

ASK ALL

C4    What is the maximum temperature that chilled ready-to-eat foods reach during storage in areas for patients or residents, such as their rooms?
SINGLE CODE. READ OUT.

Response	Number	Details
5°C	1	-
8°C	2	-
Over 8°C for up to 4 hours	3	-
Over 8°C for more than 4 hours	4	-
(FOR CATI DO NOT READ OUT) Don't know	5	-
(FOR CATO DO NOT READ OUT) Not applicable	6	-

ASK ALL

C5    To what extent do you agree or disagree with the following statements in relation to your own site:
SINGLE CODE. READ OUT SCALE.

Response	Strongly agree	Agree	Disagree	Strongly disagree	(FOR CATI DO NOT READ OUT: Don't know)
1 The maximum shelf-life for ready-to-eat sandwiches sold or distributed on site is day of production plus 2 days unless shelf-life studies are provided	1	2	3	4	5
2 Across the site, we monitor and record temperatures throughout the cold chain, consistently and accurately	1	2	3	4	5
3 Across the site, we carry out regular sampling for Listeria monocytogenes to verify compliance with microbiological criteria regulations	1	2	3	4	5

ASK ALL

C6    Does your business have a food safety management system based on hazard analysis critical control point (HACCP) principles? 
SINGLE CODE. DO NOT READ OUT

Response	Number	Details
Yes	1	-
No	2	-
Don't know	3	-

ASK ALL

C7    Please rate to what extent you agree or disagree with the following statements in relation to your own site:
SINGLE CODE. READ OUT SCALE.

Response	Strongly agree	Agree	Disagree	Strongly disagree	(FOR CATI DO NOT READ OUT: Don't know)
1 The site’s food safety management system covers all food pathways e.g. on-site catering, retail, food prepared off-site, visitor supplied food	1	2	3	4	5
2 Across the site, we monitor and record the performance of all our controls for Listeria monocytogenes effectively and take effective action when required as a result	1	2	3	4	5
3 Across the site, we ensure that the risk of Listeria monocytogenes is controlled effectively in the whole supply chain, for example, we ensure that there are effective safety controls in place at our suppliers and their suppliers	1	2	3	4	5

D Perceptions of the guidance

ASK ALL

D1    How effective do you feel the FSA guidance is in reducing the risk of vulnerable groups contracting listeriosis?
SINGLE CODE. READ OUT SCALE.

Response	Number	Details
Very effective	1	-
Fairly effective	2	-
Not very effective	3	-
Not at all effective	4	-
IF CATI DO NOT READ OUT: Don't know	5	-

ASK ALL

D2    How clearly do you feel the FSA guidance distinguishes between legal requirements and best practice?
SINGLE CODE. READ OUT SCALE

Response	Number	Details
Very clearly	1	-
Fairly clearly	2	-
Not very clearly	3	-
Not at all clearly	4	-
IF CATI DO NOT READ OUT: Don't know	5	-

ASK ALL

D3    What parts of the guidance, if any, do you find most useful in reducing the risk of listeriosis on your site?
SINGLE CODE

Write in:

Response	Number	Details
Not useful at all	1	-
Don't know	2	-

D4 How, if at all, could the guidance be improved?

SINGLE CODE

Write in:

Response	Number	Details
Don't know	1	-
Refused	2	-

E Classification questions

SHOW TO ALL

Finally, we’d like to end by asking you a couple of questions about yourself and your site, to help us in our analysis. 
ASK ALL 

E1    What is your job title? 
SINGLE CODE

Write in:

Response	Number	Details
Don't know	1	-
Refused	2	-

IF IN ENGLAND OR WALES [COUNTRY =1 OR 3]

E2    Is your site registered as a food business operator with your local authority and/or does your business have a primary authority? 

IF NECESSARY: We are specifically interested in understanding whether you are registered as a food business operator. You may already be registered as a care operator with your local authority.

IF NECESSARY: Primary Authority was launched across England and Wales in 2009. It offers businesses an opportunity to form a legally recognised partnership with a local authority (the primary authority).

SINGLE CODE. READ OUT.

Response	Number	Details
Registered with local authority and have a primary authority relationship	1	-
Registered with local authority only	2	-
Not registered with local authority	3	-
(FOR CATI: DO NOT READ OUT) Don't know	4	-

IF IN NORTHERN IRELAND [COUNTRY = 2]

E3    Is your site registered as a food business operator with your local authority?
IF NECESSARY: We are specifically interested in understanding whether you are registered as a food business operator. You may already be registered as a care operator with your local authority.
SINGLE CODE. DO NOT READ OUT

Response	Number	Details
Yes. registered with local authority	1	-
No, not registered with local authority	2	-
(FOR CATI: DO NOT READ OUT) Don't know	3	-

F Thank and close

ASK ALL

F1    Thank you very much for your time today. Would you be willing for IFF to call you back regarding this particular study, if we need to clarify any information you provided? This would be before the end of the project, which is expected to be in October 2022. 
SINGLE CODE. DO NOT READ OUT.

Response	Number	Details
Yes	1	-
No	2	-

ASK ALL EXCEPT FOR COMMERCIAL MEAL PROVIDERS (S4 =/= 10)

F2 Do you sub-contract any of your catering to an outside organisation?
SINGLE CODE. DO NOT READ OUT.

Response	Number	Details
Yes	1	-
No	2	-

IF HAVE OUTSIDE CATERERS (F2=1)

F3    We would really like to include some outside caterers in the research.  To allow us to get in touch with them, would you be happy to share with us the organisation name, contact name if you have one, telephone number and email address? 

Details	Write in	Prefer not to say
Organisation name	-	1
Contact name	-	1
Email address	-	1
Telephone number	-	1

ASK COMMERCIAL MEAL PROVIDERS (S4 = 10)
F4    Would you be able to provide us with names of other commercial meal providers for health and social care settings? We’re looking to speak to more businesses like yours to ensure we capture a wide range of views.

Write in:

Refused 1

SAY TO ALL
Just to confirm, we’ll be keeping your details on file for up to 6 months. If you’d like a copy of your data, to change your data or for your data to be deleted then please get in contact with 
You also have the right to lodge a complaint with the Information Commissioners Office (ICO) and you can do so by calling their helpline on 0303 123 1113.

Thanks respondent and close interview. 

 

Section 1 – Your role

1.    Please select the best description of your role.

• Food handler (for example, catering, food service, food retail)
• Catering manager (responsible for food safety)
• Clinical staff (for example, nurse, doctor)
• Other staff (for example, porter, security, reception)
• Administrator
• Volunteer

Section 2 – Controlling the food safety risk from Listeria monocytogenes

2.    Is your Trust registered as a food business operator (FBO) with your local authority and/or have a primary authority relationship? 

• registered with local authority only    
• registered with local authority and primary authority relationship    
• not registered with LA    
• don’t know

3.    Does your Trust have a food safety management system based on hazard analysis critical control point (HACCP) principles? 

• Yes
• No
• Don’t know

4.    Was your Trust using the FSA guidance* before this survey?

*Reducing the Risk of Vulnerable Groups Contracting Listeriosis (2016)

• Yes
• No
• Don’t know

5.    Please rate to what extent you agree or disagree with the following statement:

Cleaning of all food contact surfaces controls the risk of Listeria monocytogenes effectively in the Trust.

• Strongly agree
• Agree
• Disagree
• Strongly disagree
• Don't know

6.    Please rate to what extent you agree or disagree with the following statement: 

Food safety controls in the Trust are effective in stopping cross-contamination of food with Listeria monocytogenes.

• Strongly agree
• Agree
• Disagree
• Strongly disagree
• Don't know

7.    What is the maximum temperature that chilled ready-to-eat foods reach in the cold chain from supply of chilled ingredients to sale or service of the food?

• 5°C
• 8°C
• less than 8°C for up to 4 hours
• less than 8°C for more than 4 hours
• don't know
• not applicable (for example, no chilled ready-to-eat foods)

b. What is the maximum temperature that chilled ready-to-eat foods reach during service or storage on wards or other patients areas?

• 5°C
• 8°C
• less than 8°C for up to 4 hours
• less than 8°C for more than 4 hours
• don't know
• not applicable (for example, no chilled ready-to-eat foods)

8.    Please rate to what extent you agree or disagree with the following statement: 

Across the Trust, we monitor and record temperatures throughout the cold chain, including on the wards, consistently and accurately.

• Strongly agree
• Agree
• Disagree
• Strongly disagree
• Don't know
• Not applicable

9.    Please rate to what extent you agree or disagree with the following statement: 

Across the Trust, we carry out regular sampling for Listeria monocytogenes to verify compliance with microbiological criteria regulations. 

• Strongly agree
• Agree
• Disagree
• Strongly disagree
• Don't know
• Not applicable

10.     Please rate to what extent you agree or disagree with the following statement: 
The maximum shelf-life for ready-to-eat sandwiches sold or distributed on the Trust’s sites is day of production plus 2 days* unless shelf-life studies are provided.

* Please note that day of production plus 2 days is a not a legal requirement. 

• Agree
• Disagree
• Strongly disagree
• Don't know

11.    Please rate to what extent you agree or disagree with the following statement: 

The Trust’s food safety management system covers all food pathways on our site(s). For example, On-site catering, retail, food prepared off-site, visitor supplied food.

• Strongly agree
• Agree
• Disagree
• Strongly disagree
• Don't know
• Not applicable

12.    Please rate to what extent you agree or disagree with the following statement: 
Across the Trust, we monitor and record the performance of all our controls for Listeria monocytogenes effectively and take effective action when required as a result.

• Strongly agree
• Agree
• Disagree
• Strongly disagree
• Don't know
• Not applicable

13.    Across the Trust, who receives training about how to control the risk of Listeria monocytogenes? 

Please select all that apply.

• Kitchen staff
• Service and food retail staff
• Ward staff
• Volunteers
• None of the above
• Don’t know

14.    Please rate to what extent you agree or disagree with the following statement:
Across the Trust, we ensure that the risk of Listeria monocytogenes is controlled effectively in the whole supply chain, for example, we ensure that there are effective safety controls in place at our suppliers and their suppliers.

• Strongly agree
• Agree
• Disagree
• Strongly disagree
• Don't know
• Not applicable

15.    Has the Trust implemented the legal requirements outlined in the FSA’s guidance Reducing the risk of vulnerable groups contracting listeriosis?

Section name	Yes, fully implemented	Yes implemented to some extent	No not implemented	Don't know
Section 2: Control of Contamination	-	-	-	-
Section 3 Control of Growth	-		-	-
Section 4: Management Controls	-	-	-	-

16.    Has the Trust implemented the best practice outlined in the FSA’s guidance Reducing the risk of vulnerable groups contracting listeriosis?

Section name	Yes, fully implemented	Yes implemented to some extent	No not implemented	Don't know
Section 2: Control of Contamination	-	-	-	-
Section 3 Control of Growth	-		-	-
Section 4: Management Controls	-	-	-	-

17.    Please indicate what barriers make it difficult to implement the FSA guidance* in full in your Trust. Please select all that apply.

* Reducing the risk of vulnerable groups contracting listeriosis (2016)

• the guidance is unclear
• the guidance is not a legal requirement
• the guidance is incorrect
• the guidance is too demanding
• money
• insufficient knowledge of the guidance
• insufficient training in the guidance
• time pressures
• low skilled or unskilled staff
• high staff turnover
• lack of control over food service
• lack of control over food preparation
• lack of control over food storage
• lack of control over supply chain
• inadequate premises
• inadequate food preparation equipment
• inadequate food storage facilities 
• poor maintenance of equipment or premises
• other issues take priority 
• pressure from more senior management
• other barrier not listed above [FREE TEXT OPTION]
• don’t know
• not applicable – for example, no barriers

Section 3 – Your comments on the FSA guidance Reducing the risk of vulnerable groups contracting listeriosis (2016)

The next questions provide you with the opportunity to comment on each section of the FSA guidance Reducing the risk of vulnerable groups contracting listeriosis (2016). 

You do not have to comment. We particularly welcome any suggestions for how to improve the guidance and how to overcome barriers to implementing it in full.

18.     Please comment on Section 1: Introduction of the FSA guidance Reducing the risk of vulnerable groups contracting listeriosis (2016).

[FREE TEXT BOX]

19.     Please comment on Section 2: Control of Contamination of the FSA guidance Reducing the risk of vulnerable groups contracting listeriosis (2016).

[FREE TEXT BOX]

20.     Please comment on Section 3: Control of Growth of the FSA guidance Reducing the risk of vulnerable groups contracting listeriosis (2016).

[FREE TEXT BOX]

21.     Please comment on Section 4: Management Controls of the FSA guidance Reducing the risk of vulnerable groups contracting listeriosis (2016).

[FREE TEXT BOX]

Thank you for completing the survey and helping us to ensure that food is safe. 

End note:

IFF Research illuminates the world for organisations businesses and individuals helping them to make better-informed decisions.”

Our Values:
1. Being human first:
Whether employer or employee, client or collaborator, we are all humans first and foremost. Recognising this essential humanity is central to how we conduct our business, and how we lead our lives. We respect and accommodate each individual’s way of thinking, working and communicating, mindful of the fact that each has their own story and means of telling it.

2. Impartiality and independence:
IFF is a research-led organisation which believes in letting the evidence do the talking. We don’t undertake projects with a preconception of what “the answer” is, and we don’t hide from the truths that research reveals. We are independent, in the research we conduct, of political flavour or dogma. We are open-minded, imaginative and intellectually rigorous.

3. Making a difference:
At IFF, we want to make a difference to the clients we work with, and we work with clients who share our ambition for positive change. We expect all IFF staff to take personal responsibility for everything they do at work, which should always be the best they can deliver.