Implementation of the FSA Listeriosis Guidance: Chapter 7: Report of FSA Survey of NHS Trusts

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.