Implementation of the FSA Listeriosis Guidance: Chapter 4: Implementing good practice and the barriers to implementation

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