ESTATE OPERATIONAL MANAGEMENT POLICY AND PROCEDURE Documentation Control Reference HS/EI/ Approving Body Trust Board Date Approved Implementation date Supersedes N/A Consultation undertaken Directorate of Estate and Facilities Management, Trust Health and Safety Committee, Directors' Group and Trust Board Date of Completion of 1 March 2011 Equality Impact Assessment Date of Completion of We 1 March 2011 Are Here for You Assessment Date of Environmental 18 May 2011 Impact Assessment (if applicable) Target audience All Trust staff, occupiers of Trust premises and contractors Supporting Documents and References(s) See legislation and guidance section within policy document. Review Date March 2013 Lead Executive Director of Estates and Facilities Author/Lead Manager Head of Estates Operations Further Guidance/Information Lead Executive / Author / Lead Manager
CONTENTS 1 ESTATE OPERATIONAL MANAGEMENT POLICY...4 1.1 Introduction...4 1.2 Glossary of Terms...4 1.3 Rationale...5 1.4 Aims...5 1.5 Definitions...5 1.6 Methods of Delivery Maintenance...6 1.7 Statutory Compliance Audit...6 1.8 Performance Report...6 1.9 Legal Duties...7 2 ROLES AND RESPONSIBILITIES...9 2.1 Trust Board...9 2.2 Chief Executive...9 2.3 Director of Estate and Facilities Management...9 2.4 Directorate Management Team Capital...11 2.5 Directorate Management Team Procurement...11 2.6 Directorate Management Team Clinical & Corporate...11 2.7 Infection, Prevention and Control Team...11 2.8 Employees...11 2.9 Professional Structure...12 3 MAINTENANCE PRIORITIES...14 3.1 Reactive Maintenance...14 3.2 Planned Preventative Maintenance (PPM)...15 3.3 Rechargeable Repairs...16 3.4 Service Contracts...16 3.5 Out of Hours Emergency Maintenance Service...16 3.6 Maintenance Records...16 3.7 Minor New Works (All Works Less Than 5,000)...17 3.8 Capital Works (All Works Greater Than 5,000)...17 3.9 Risk Management...17 3.10 Business Continuity Plans...18 4 STATUTORY LEGISLATION...19 4.1 Health and Safety At Work Etc. Act 1974...19 4.2 The Regulatory Reform (Fire Safety) Order 2005...19 4.3 Control of Substances Hazardous to Health (COSHH) Regulations (2004)...19 4.4 Confined Spaces Regulations (1997)...19 4.5 Provision and Use of Work Equipment Regulations (PUWER) (1998)...19 4.6 Lifting Operations and Lifting Equipment Regulations (LOLER) (1998)...20 4.7 Construction (Design and Management) Regulations (2007)...20 4.8 Pressure Systems Safety Regulations (2000)...20 4.9 Work At Height Regulations (2005)...20 5 HEALTHCARE STANDARDS...22 5.1 General Design Principles (6946:0.3:England)...22 5.2 General Engineering Principles (69898:0.1:England)...22 5.3 Performance Requirements for Building Elements Used in Healthcare Facilities (8941:0.6England)...22 5.4 Fire Code...22 5.5 Policies and Principles of Healthcare Engineering...22 5.6 Specialist Engineering Services...23 5.7 Specialist Engineering Services Health Technical Memorandums (HTM)...23 5.8 Specialist Engineering Services Health Building Notes (HBN)...23 5.9 HTM 00: Best Practice Guidance for Healthcare Engineering...23 5.10 Health Facilities Notes (HFN's)...24 6 NOTTINGHAM UNIVERSITY HOPSITALS ESTATE & INFRASTRUCTURE POLICIES..25 6.1 Asbestos Management and Control Policy and Procedures (NUH)...25 6.2 Building and Engineering Services Disability Access Policy (NUH)...25 6.3 Control of Contractors Policy (NUH)...25 6.4 Control of Contractors Policy & Guidance Booklet (Estates & Facilities)...25 6.5 Electricity At Work Policy (NUH)...26 6.6 High Voltage Safety Procedure (Estates & Facilities)...26 6.7 Low Voltage Safety Procedure (Estates & Facilities)...26 2 of 46
6.8 Electrical Standby Policy (NUH)...26 6.9 Energy Management Policy (NUH)...26 6.10 Environmental Management Policy (NUH)...26 6.11 Fire Safety Policy (NUH)...27 6.12 Infection Prevention and Control in the Built Environment Policy (NUH)...27 6.13 Legionella Management and Control Policy and Procedure (NUH)...27 6.14 Lifts Maintenance and Management Passenger and Goods Lift Policy (NUH)...27 6.15 Medical Gas Pipeline System Policy (NUH)...27 6.16 Medical Gas Pipeline System Procedure (Estates & Facilities)...27 6.17 Pressure Systems Fixed Installations Policy (NUH)...27 6.18 Ventilation Systems Maintenance and Management Policy (NUH)...28 6.19 Ward Name Management Policy and Procedure (NUH)...28 6.20 Waste Management Policy (NUH)...28 6.21 Window Management Policy (NUH)...29 6.22 Estate Stores Procedures (Estates & Facilities)...29 6.23 Preferred Equipment Report and Schedule (Estates & Facilities)...29 7 RELATED ESTATES PROCEDURES...30 7.1 Four Stage Risk Model Programme (Ultimon)...30 7.2 Safe Control System...30 7.3 Estates Operations Department Issuing of Keys...31 7.4 Estates Operations Department Record Drawings...32 7.5 Estates Operations Department Asset Register...32 7.6 Estates Operations Department Staff Training...32 7.7 Estates Annual Inspection Requirements...32 7.8 Estates Annual Date Collection Requirements...34 8 ESTATE OPERATIONAL PROCEDURE...37 9 RESPONSIBILITES & WORKS UNDERTAKEN...37 9.1 Electrical Maintenance...37 9.2 Mechanical Maintenance...37 9.3 Building Maintenance...38 9.4 Security...38 9.5 Energy...38 9.6 Decontamination...38 9.7 Vacant Estate...39 10 EQUALITY AND DIVERSITY STATEMENT...39 11 EQUALITY IMPACT ASSESSMENT...39 12 ENVIRONMENTAL IMPACT ASSESSMENT...40 13 WE ARE HERE FOR YOU...40 14 IMPLEMENTATION PLAN...40 15 MONITORING AND REVIEWING...40 16 APPENDIX A WORK CATEGORIES AND CONSULTATION PROTOCOL...41 17 APPENDIX B ASPERGILLUS IN THE ENVIRONMENT...43 18 APPENDIX C CONTACT INFORMATION...45 19 APPENDIX D EMPLOYEE RECORD...46 3 of 46
1 ESTATE OPERATIONAL MANAGEMENT POLICY 1.1 Introduction The built environment, which is used to accommodate the treatment, diagnosis and care of patients, service users and staff and must be provided in a form that the fabric, fixtures, fittings and services minimise the risk of Health Care Associated Infections (HCAI). The Health and Safety at Work etc Act 1974, the Management of Health and Safety at Work Regulations 1999 and the Construction (Design and Management) Regulations 2007 all impose specific duties to safeguard the health and safety of those who are and who are not in the employment of the Nottingham University Hospitals NHS Trust. These duties equally apply to a contractor or sub contractor on Trust premises, in respect of safeguarding our employees, patients and visitors from their activities. Nottingham University Hospitals NHS Trust (NUH) is committed to fulfilling the requirements outlined in the Health Act 2006 Code of Practice for Prevention & Control of Health Care Associated Infections (Department of Health 2006) revised January 2008, by ensuring that a Planned Preventative Maintenance system is in place to minimise the risk of HCAI. In addition, the Trust recognises and accepts the responsibilities outlined by the Care Quality Commission (October 2010) that it shall meet the essential standards of quality and care. Specific to Estates Operations include: You can expect to be safe You will be cared for in a clean environment where you are protected from infection. You will be cared for in a safe and accessible place that will help you as you recover. You will not be harmed by unsafe or unsuitable equipment. You can expect your care provider to constantly check the quality of its service Your care provider will continuously monitor the quality of its services to make sure you are safe. If you, or someone acting on your behalf, make a complaint you will be listened to and it will be acted upon properly. 1.2 Glossary of Terms AE Authorising Engineer AP Authorised Person BCP Business Continuity Plans CHC City Hospital Campus DEL Directly Employed Labour DG Director's Group DMTO Directorate Management Team Operational DP Designated Person ERIC Estates Return Information Collection HBN Health Building Note HFN Health Facility Note HGN Health Guidance Note HTM Health Technical Memorandum IPCT Infection Prevention Control Team MGPS Medical Gas Pipeline System MNW Minor New Works NUH Nottingham University Hospitals NHS Trust PAM Premises Assurance Model PPM Planned Preventative Maintenance PTW Permit to Work QMC Queens Medical Centre SOM Senior Operational Manager VFM Value for Money 4 of 46
1.3 Rationale NUH recognises its legal obligations to take necessary measures in the provision of effective maintenance of buildings, fixed or portable equipment, engineering plant, systems and services. The key objectives of this policy are: Compliance with statutory requirements; Compliance with the Care Quality Commission; Compliance with the Health Act 2006; Provision of a safe environment; To reduce hospital acquired infection. To define the delivery of an effective maintenance service. The concept of providing and maintaining safe estate services carries a high statutory priority and applies across the widest range of applications. It must apply to patients, staff and the general public, that is, all users of the healthcare environment. In a similar way, the duty of care in operational maintenance performance can contribute towards the overall safety and efficiency of our healthcare organisation. NUH shall provide and maintain safe and healthy working conditions, equipment and systems of work for all staff and visitors and to provide such resources, instruction, training, information and supervision as they need for this purpose. NUH aims to do all that is reasonably practicable to manage its building and engineering services and to follow the steps laid out in this Policy. 1.4 Aims This policy will: Provide guidance to those responsible for the maintenance of healthcare environments; Assist in maintaining the value of the estate, extending the economic life of property and engineering systems as far as possible; Minimise disruption to ensure business continuity; Maintain the patient environment in a manner conducive to high quality clinical care; Ensure that buildings and all associated services operate at optimum levels of performance and within design criteria in the useful life cycle. Ensure that robust monitoring and reporting mechanisms are in place. This policy pursues and expects the good upkeep of buildings, engineering plant and equipment by regular inspection and maintenance in line with the Department of Health guidance documents (Health Technical Memorandum series) and other recognised guidance, legislation and standards. Maintenance of medical devices is covered under a separate Trust policy. 1.5 Definitions For the purposes of this document the following definitions apply: Maintenance: The combination of all the technical and associated administrative actions intended to retain an item in, or restore it to, a state in which it can perform its required function. Given due consideration to viability and economic financial responsibilities; Reactive Maintenance (Breakdown): Operation of restoring an item to fulfil its original function after a failure in its performance. This is Maintenance that is required by the customer on a day to day basis to repair faults that occur in equipment, building fabric or the environmental system. This type of work is undertaken by directly employed labour (DEL) supplemented by General and Specialist Contractors. Planned Preventative Maintenance (PPM): Maintenance carried out at predetermined intervals or corresponding to pre described criteria, and intended to reduce the probability of failure, breakdown or the performance degradation of an asset. 5 of 46
Service Contracts: Maintenance carried out by an external contractor at predetermined intervals and intended to reduce the probability of failure, breakdown or the performance degradation of an asset. Out of Hours Emergency Maintenance Service: This service provides a 365 day maintenance service that operates outside of normal working hours. It is accessed through the hospital switchboard. The objective of the Out of Hour s Service is to make safe plant or equipment and to repair or rectify critical items to maintain a safe service. Calls are logged by the switch board and the on call directly employed labour (DEL) tradesman is contacted to attend. If the call out requires assistance, specialist advice or specialist contractor the On Call Estates Operations Manager/Officer is contacted to assist. Rechargeable Repairs: These are repairs required following wilful damage to the Trust structure, fixtures and fittings. Minor New Works: Requests for improvements from Directorates will be funded via a Minor New Works request (MNW) and these forms are available on the Estates and Facilities Web Page. Minor New Works have a cost limit not exceeding five thousand pounds ( 5,000). Minor New Works include items such as shelving, notice boards, minor decorations, key cutting, replacement flooring, new sinks, new data points and new power sockets. Capital Works: Request for improvements from Directorates which will be greater than five thousand pounds ( 5,000) will have to be approved by the Trusts Investment Governance Committee (IGC). 1.6 Methods of Delivery Maintenance Maintenance is delivered by three methods that may employ the use of DEL, general contractors or specialist contractors. The specific work of these groups are supervised by the Estates Operations Managers, Estates Operations Officers and Team Leaders who are accountable for obtaining quotations, placing orders, supervising and certifying completion in accordance with the Trust s Standing Financial Instructions and Standing Orders for contractors. For DEL labour they must ensure an effective and efficient service that demonstrates best value. Audit trails exist for these methods of delivery as records may be requested to demonstrate work undertaken for litigation purposes. 1.7 Statutory Compliance Audit On a two yearly basis a statutory compliance audit will be undertaken by external consultants appointed by the Director of Estates and Facilities. The methodology of the audit will be to review with the Directorate Management Team Operations through interviews and inspections of records how they are complying with statutes and how they are satisfactorily discharged. A random selection of buildings are inspected by the Estates Operations Manager to verify that statutory maintenance has been carried out, that all documentation is available and has been correctly certified. A report will be issued and corrective action sheet will be provided. This will be reported to the Audit Committee on an annual basis. 1.8 Performance Report A monthly report will be provided to the Operational Management Team on the performance of the Operational Service and progress on corrective action sheets issued following audits. The report will identify activity measures including: Number of emergency Out of Hours calls Number of reactive maintenance requests received. % of reactive maintenance requests completed within response timeframes. Number of statutory planned preventative maintenance jobs issued. % of statutory planned preventative maintenance jobs completed within response timeframes. Identify critical incidents. Stock rotation and holding. Complaints and comments. Training undertaken. 6 of 46
Payments of invoices within 30 days Appraisals undertaken Sickness rate Legislative changes and implications. 1.9 Legal Duties Acts: Environment Protection Act 1990 Clean Neighbourhoods and Environment Act 2005 Health and Safety at Work Act 1974 Health Act 2006 Occupiers Liability Act 1984 Corporate Manslaughter and Corporate Homicide Act 2007 Regulations that underpin the Acts: Confined Spaces Regulations 1997 Construction (Design and Management) Regulations 2007 Construction (Head Protection) Regulations Control of Asbestos Regulations 2006 Control of Lead at Work Regulations 2002 Control of Major Accident Hazards Regulations 1999 (amended 2005) Control of Noise at Work Regulations 2005 Control of Substances Hazardous to Health 2004 Control of Vibration at Work Regulations 2005 Building Regulations 2009 Electricity at Work Regulations 1989 Gas Safety (Installation and Use) Regulations 1998 Gas Safety (Management) Regulations 1996 Health and Safety (Consultation with Employees) Regulations 1996 Health and Safety (Display Screen Equipment) Regulations Health & Safety (First Aid) Regulations 1981 Health and Safety (Signs & Signals) Regulations 1996 Ionising Radiations Regulations 1999 Lifting Operations and Lifting Equipment Regulations 1998 Management of Health and Safety at Work and Fire Precautions 2003 Management of Health and Safety at Work Regulations 1999 (amended 2006) Manual Handling Operations 1992 Personal Protective Equipment Regulations 2002 Pressure Systems Safety Regulations 2000 Provision and Use of Work Equipment Regulations 1998 Regulatory Reform (Fire Safety) Order 2005 Reporting of Injuries Diseases and Dangerous Occurrences Regulations 1995 Safety Representatives and Safety Committees Regulations 1977 Work at Height Regulations 2005 (amended 2007) Work in Compressed Air Regulations 1996 Working Time Directive Workplace (Health, Safety & Welfare) Regulations 1992 Environmental Protection (Duty of Care) Regulations 2005 Hazardous waste (England & Wales) Regulations 2005 Waste Electrical & Electronic Equipment Regulations 2006 Waste Management Regulations 1996 British Standards BS 7671: 2008 Requirements for Electrical Installations BS8300: 2009 Design of Buildings and Their Approach to Meet the Needs of Disabled People. 7 of 46
Department of Health Guidance Health Facilities Notes Heath Building Notes Health Guidance Notes Health Technical Memorandums EstateCode 8 of 46
2 ROLES AND RESPONSIBILITIES Trust Board Chief Executive Director of Estates and Facilities Deputy Director of Estates and Facilities Head of Estates Operations Assistant Head of Estates Operations (City Campus) Assistant Head of Estates Operations (QMC & Ropewalk) Estates Operations Managers & Officers Estates Operations Managers & Officers Building Stores (NUH) Electrical Security Mechanical (Infrastructure) (NUH) Building Energy Electrical (NUH) Mechanical Decontam ination (NUH) 2.1 Trust Board The Trust Board has overall accountability for all the activities of the organisation, which includes the management and maintenance of the Trusts estate. This includes the following: land and property matters planning strategic investment in the estate land and property appraisal asset management building maintenance engineering maintenance energy management. The Trust Board delegates the responsibility for the management and maintenance of the estate to the Chief Executive. 2.2 Chief Executive The Chief Executive has the ultimate managerial responsibility for the management and maintenance of the estate and delegates the operational day to day responsibility and authority to the Director of Estate and Facilities Management who will manage, maintain and control the estate as set out in this policy and other related policies. 2.3 Director of Estate and Facilities Management The Director of Estates and Facilities will operate the management and control systems outlined in this policy and procedure document. 9 of 46 Estate Operational Management Policy & Procedure Version 1 March 2012
2.3.1 Directorate Management Team Operations The Directorate Management Team have overall responsibility for the delivery of the Operational Services and Budget. This team comprises of the Head of Estates Operations and the Assistant Head(s) of Estates for City Campus and Queens Medical Centre/Ropewalk Campuses 2.3.2 Estates Operational Managers and Operational Officers The Estates Operational Managers/Officers have a responsibility to ensure that their staff are instructed, trained, informed and supervised and are suitably competent to carry out their roles in a safe, effective and efficient manner. The Estates Operational Managers/Officers are the designated officers for estates maintenance services. This position fulfils the role of Responsible/Authorised Person (AP) for specialist engineering and building services (these appointments are site specific). Operational management of estates services includes building, engineering, equipment, specialist maintenance and grounds and gardens with appropriate maintenance programmes and an annual review of maintenance activities Operational management of estate services includes: building; engineering; equipment; specialist maintenance and; grounds and gardens. All services have an appropriate maintenance programme and an annual review of maintenance activities. The Estates Operational Managers/Officers are responsible for the implementation of the operational requirements of this policy which include: Staff management (i.e. sickness, appraisals etc.) Promoting a safety culture amongst all staff; Assessment and quantification of risk; Reduction of risks to as low as reasonably practicable; Identify and report higher level risks in the day to day business planning process; Review all risks periodically or when there is a change in activity; Instigating safe systems of work and working practices to minimise risks Maintaining appropriate records; Compliance with all statutory legislation and Health Estates guidance as applicable to the healthcare environment; Consulting with all stakeholders affected by building, engineering and maintenance activities. Undertaking dilapidation and condition surveys. 2.3.3 Team Leader, Day Technician & Shift Technician The Team Leaders provide day to day supervision and support to their specific discipline to ensure that the section is able to provide give the highest level of safe, courteous and efficient service to the building s users. The Day/Shift Technicians are employed to work across both engineering disciplines (mechanical and electrical). Their higher level of responsibility includes steam boilers and CHP plant, lifts, compressors, medical gas systems, fire systems, emergency generators, electrical, heating, cooling and water systems, drains and the site wide air tube conveyor and security access systems. Shift Technicians (Out of hours) will also be the key person in responding to fire alarms, persons trapped in lifts and mechanical and electrical engineering emergencies. They will carry out planned maintenance duties in operating theatres and other areas of limited access, but will also respond to engineering maintenance faults and breakdowns throughout the site. 10 of 46
2.3.4 Craftsmen The craftsmen provides skilled installation and/or maintenance of specialist services and will be directed, appointed, or authorised to work (if a contractor) by their Team Leader dependant on the work involved. Maintenance Assistants and Maintenance Assistants (Higher Level) provide semi skilled support to this role with direction from Team Leaders. 2.4 Directorate Management Team Capital The Head of Capital Projects/Procure21+ Capital Projects Director is responsible for the overall programme management of all Estate Capital schemes. The Directorate Management Team Capital will ensure all new works are efficient in terms of value for money (VFM), energy usage, reducing future maintenance requirements and to comply with relevant HTM/HBN s and other legislation. The Head of Capital Projects/Procure21+ Capital Projects Director will also monitor progress of agreed schemes and prepare and issue reports to inform and advise Trust Senior Management on a monthly basis. 2.5 Directorate Management Team Procurement The Procurement Department is responsible for ensuring that Trust estates services are procured via a legally tendered procurement route and that the Trust s Standing Financial Instructions are complied with. This includes national, regional and negotiated framework and contract agreements. A collaborative approach is adopted between Estates and the Procurement Department. 2.6 Directorate Management Team Clinical & Corporate Directorate Management Teams are responsible for ensuring that their staff are aware of their duty to report building and engineering defects, breakdowns and repairs through the appropriate channels (Web Helpdesk [Non Emergency] and Switchboard [Emergency] and also to operate the building and its equipment in a safe and appropriate way with appropriate training and competency. 2.7 Infection, Prevention and Control Team It is the responsibility of the Infection Prevention and Control Team (IPCT) to provide specific input and support for all matters relating to the hospital environment, maintenance of hospital buildings and engineering systems and to work with Estates Operations. This will include the provision of: Education for maintenance staff and management on infection prevention and control and the reduction in HCAI s; Guidance and support when advice on controlling the environment is required; Advice on risk assessments for controlling the environment; Identify priorities for action; Assisting in reducing risk caused by aspergillus during works (See Appendix B). 2.8 Employees All Trust employees (including agency staff and contract staff) have a duty of care to each other as set out within the Health and Safety at Work Act and to co operate with their employer and not to tamper with safety devices and to reports defects and failures in accordance with Trust procedures. They should also comply with reporting systems with regard to building and plant faults. Further information on the role of contractors can be found in the NUH Control of Contractors Policy and the 'EFM Control of Contractors Policy'. 11 of 46
2.9 Professional Structure While the Chief Executive and the Trust Board carry ultimate responsibility for the safe and secure healthcare environment the structure below represents the professional adopted approach to the delivery of high risk impact specialist services within NUH. These include the management of high voltage electricity, low voltage electricity, decontamination, medical gas pipelines, asbestos, water safety and quality, ventilation systems, lifts, pressure systems etc. Designated Person Appointed senior executive (board level) with assigned responsibility for service Authorising Engineer Appointed independent professional engineer (specific to service) Authorised Person Appointed qualified technical engineer (specific to service) Trust Senior Operational Manager Informed client/intelligent customer Competent Person Assessed and qualified craftsperson (specific to service) 2.9.1 Designated Person This person provides the essential senior management link between the organisation and professional support, which also provides independence of the audit reporting process. The DP will also provide an informed position at board level. The DP will work closely with the Senior Operational Manager to ensure that provision is made to adequately support specialist services. 2.9.2 Trust Senior Operational Manager (SOM) The SOM may have operational and professional responsibility for a wide range of specialist services. It is important that the SOM has access to robust, service specific professional support which can promote and maintain the role of the informed client within the healthcare organisation. This will embrace both maintenance and the development of service specific improvements; support the provision of the intelligent customer role and give assurance of service quality. 2.9.3 Authorising Engineer (AE) The AE acts as an independent professional adviser to the healthcare organisation. The AE should be appointed by the organisation with a brief to provide services in accordance with Health Technical Memorandum guidance. This may vary in accordance with the specialist service being supported. 12 of 46
The AE will act as assessor and make recommendations for the appointment of Authorised Persons, monitor the performance of the service, and provide an annual audit to the DP. To effectively carry out this role, particularly with regard to audit, it is preferable that the AE remains independent of the operational structure of the trust. 2.9.4 Authorised Person (AP) The Authorised Person(s) have the key operational responsibility for high risk impact specialist engineering services such as medical gases and high voltage works. The appointed person will be qualified, sufficiently experienced and skilled to fully operate the specialist service. The AP will be nominated by the AE and appointed by the SOM (or Chief Executive) and be able to demonstrate: his/her application through familiarisation with the system; attendance at an appropriate professional course; a level of experience; and evidence of knowledge and skills.; The Estates Operational Managers/Officers fulfil these roles and the appointments are site specific. An important element of this role is the maintenance of records, quality of service and maintenance of system safety (integrity). The AP is responsible for establishing and maintaining the roles and validation of Competent Persons, who may be employees of the organisation or appointed contractors. The Trust has more than one AP for a particular service. Administrative duties such as record keeping are assigned to specific APs and recorded in the related operational policies. 2.9.5 Competent Person (CP) The Competent Person(s) are skilled in the installation and/or maintenance of the specialist service. The CP will be appointed, or authorised to work (if a contractor), by the AP and be able to demonstrate: a sound trade background, qualifications and specific skill set in the specialist service; he/she will work under the direction of the AP and in accordance with operating procedures, policies and standards of the service as determined by NUH. The Team Leaders, Day Technicians, Shift Technicians and Craftsmen fulfil these roles and the appointments are site specific. 13 of 46
3 MAINTENANCE PRIORITIES The Trust deploys specialist software to assist with the delivery, monitoring, and control of procedures associated with maintaining and improving the provision of healthcare such as reactive maintenance and planned preventative maintenance. It is via this software that the requestors log for assistance is recorded and managed. Reactive maintenance requests can be logged quickly, and the requestors have access to interrogate the database without the need to navigate around the software. The requestor can check the current status of any maintenance request, and review full request history enabling queries to be answered immediately. A library of standard client requests are available to assist in the reporting of maintenance issues and enables frequent issues to be prioritised and grouped together. Planned Preventative Maintenance is carried out using the same software and this enables the Directorate Management Team to monitor progress against statutory legislation and compliance. The specialist software enables the Directorate Management Team to maintain a plan/service history by recording work done, breakdowns etc, which assists in prioritising plant and equipment replacement programmes. Appendix A highlights the differing type of work that the Estate Operations undertake and the consultation protocol that shall be followed. The work is categorised as follows: Category 1 Low Hazard: Reactive Maintenance (Room); Category 2 Low Hazard: Reactive Maintenance (Common Area); Category 3 Low Hazard Service Shut Down: Reactive or Planned Preventative Maintenance Requiring a Local Service Shut Down; Category 4 Medium Hazard Service Shut Down: Reactive or Planned Preventative Maintenance Requiring Service Shut Down; Category 5 Medium Hazard: Pre Planned Larger Work; Category 6 High Hazard: Pre Planned Large Scale Work Capital Development & Demolition. 3.1 Reactive Maintenance Reactive Maintenance can be summarised under the following points: Reactive maintenance can generally be defined as a single order which complies with standing financial instructions. All reactive maintenance will be carried out with minimum disruption to the Directorates and Departments of the Trust via good communication links. All requests are channelled via the Estates Webpage/Help Desk where they are logged, given a unique number that is also provided to the customer, a priority for the work is agreed against specific criteria and the work logged on the computer system. On completion of the work, costs are calculated and the date of completion is entered. The Estates Website gives 24 hour access for the logging of reactive maintenance works. Maintenance will be carried out by either: Direct Labour Team (Under the control of Team Leaders) General Contractors (Under the control of the Estates Operational Managers/Officers) Specialist Contractors (Under the control of the Estates Operational Managers/Officers) In order to provide a service, the Trust prioritises its reactive maintenance as follows (Estatecode Definitions), this also includes examples of certain situations (this list is not exhaustive): Immediate response; Priority 1 Situations that could cause danger or distress to patients or prevent an essential service from being provided. Examples include floods (either from pipework or leaking roofs), glazing (where security or safety is 14 of 46
compromised), electrical (loss of power to an area/building or bare electrical cables), passenger lifts (persons trapped in a lift), gas leaks and fire alarms; Within 8 hours; Priority 2 Situations that will degrade to an emergency if not addressed within this time band. Examples include no heating, no water, lighting (where it provides the only illumination in an area) and lights on staircases; Within 24 hours; Priority 3 Situations that cause major disruption to services but do not cause danger or prevent the provision of patient care. Examples include no hot water, Shower not working (where it is the only one), localised electrical failure, security lighting, blocked toilets or drains, lifts out of action, corridor lighting and no heating. Within 3 days; Priority 4 Situations that affect services without causing distress to patients. Within 7 days; Priority 5 Situations that will cause a minor disruption to services. Within 14 days or agreed deadlines; Priority 6 Situations that will not directly disrupt services but cause inconvenience. Within 28 days or agreed deadlines; Priority 7 Development work, upgrades or non urgent repairs The Directorate Management Team Operational staff are responsible, for the quality of the maintenance service provided and shall carry out a 1 in 10 job post inspection, to determine satisfactory completion and acceptable workmanship and to authorise appropriate payment for the work (General and specialist contractors). All budgets for reactive maintenance are controlled by the Directorate Management Team Operational Managers who are responsible for their management. All requests for maintenance are to be reported through the Estates Directorates website Estates Helpdesk Link 3.2 Planned Preventative Maintenance (PPM) Planned preventive maintenance is regular, scheduled work carried out to keep equipment in good working order and to optimize its efficiency, cost effectiveness and availability. This activity involves regular, routine cleaning, lubricating, testing, calibrating and adjusting, checking for wear and tear and eventually replacing components to avoid breakdown. Most of the work that the Directorate Management Team Operational carry out is unseen by Directorates and Departments and this is the planned maintenance. Planned maintenance is carried out in accordance with schedules arranged by the Estates Operations Managers, Estates Operations Officers, Team Leaders and also manufacturer's recommendations and warranty criteria. This service is not usually requested by heads of departments, and the maintenance of the estate is carried out according to the annual programme which is reviewed annually or where there is a major service change. However each head of department will be informed of any planned maintenance in or that may affect their specific areas of responsibility. If a head of department is concerned about any item in their area which is on the planned maintenance schedule they should discuss the matter directly with the Estates Operations Managers. PPM works are normally carried out during working hours to the agreed schedule. There are two types of PPM's: Statutory Maintenance is undertaken to comply with statutes and underpinning regulations relating to the building/engineering elements within a building and operations undertaken from the premises such as 5 yearly fixed wiring tests, portable appliance testing, asbestos management, management of water systems, lift inspections, pressure systems. Mandatory / Business Critical Maintenance is carried out under the recommendation made by organisations that are not enshrined in statute but will be referred to as best 15 of 46
practice in a coroners court, a criminal or civil action for damages against the Trust or individual officers of the Trust. These include Approved Codes of Practice, British Standards, ISO Standards, Hospital Technical Memorandum(s) and manufacturers recommended instructions. 3.3 Rechargeable Repairs These are repairs required following wilful damage to the NUH structure, fixtures and fittings by staff, patients and visitors. This could include the loss of nurse call handsets, vandalism and loss of keys. If required relevant authorities such as the police would be informed to investigate further through the Security Management Team. 3.4 Service Contracts Service contracts require more consideration from the client side, as inherent in the function of a service contract is the partial transfer of risk and responsibility from the Estates Operations Department to the contractor. Equipment of a complex or specialist nature is usually covered by a service contract. Response time for repairs may vary depending on the terms of the contract. Information regarding these terms can be supplied by the Estates Operations Managers. An example of a service contract for NUH is all grounds and gardens works (including snow clearance and gritting) which is carried out by contract grounds staff. Conditions are monitored during the winter months to ensure that roads and footpaths are maintained. Another example is the specialist maintenance of all the NUH lifts. 3.5 Out of Hours Emergency Maintenance Service There are a range of situations and activities within the Hospital that require some form of emergency on call arrangement to ensure health and safety and business continuity for 24 hours a day, 7 days a week. Examples will be reasonably limited, as most situations can be deferred and dealt with during normal working hours. The service provided by the Estates Operations Department for out of hours emergency maintenance is to isolate and make safe. Individuals are not expected to remain on Hospital premises whilst on call. However, they will be expected and required, by virtue of this agreement, to respond to calls during their on call period and to deal with them appropriately and within a reasonable timeframe, including attendance at the workplace if necessary. The individual will not be permitted to refer the call on to others, unless it has been directed to them inappropriately. Individuals are expected to fulfil responsibilities arising as a result of being on call to acceptable standards. 3.5.1 Support Levels There are two types of support as follows: Level One Support This type of support is management cover when there is a serious untoward incident such as a major disaster. Level Two Support This type of support allows staff to be contacted in order to provide support outside the staff member s normal hours of work. The member of staff is available during non working hours and the member of staff will decide whether the emergency can be dealt with, without attending site, or to request additional support through contractors. 3.6 Maintenance Records Records kept by the Maintenance Section include details of the existing condition of a building together with details of, services and past maintenance history 16 of 46
At the handover of a new development the Capital Team will make available an operational and maintenance manual including as built drawings to provide a description and details of construction relevant to the design and fittings provided within a scheme, and its ongoing maintenance requirements. In addition, the consultant will provide at handover to the Trust a Health and Safety file for the respective building, in compliance with the Construction Design and Management Regulations 2007. The information for the setting out of maintenance operational manuals can be found in Section A37 of form OTF6 from the Capital Team. An analysis of statistics and appropriate record systems will enable the Trust to identify its future maintenance issues. In particular it will highlight any premature failure of components, ensuring that replacement/renewal is made with higher quality fixtures and fittings capable of withstanding every day use in a healthcare environment. An approved list of fixtures and fittings is available from the Estates Operations Team. 3.7 Minor New Works (All Works Less Than 5,000) Where alterations or improvements are required these require to be specifically funded, normally from an appropriate revenue budget. For this type of work a Minor New Works Form (Available from the Intranet) will be completed by the requesting Directorate or Department and should be submitted to the Minor New Works Team (electronically). For example the work might comprise of reconfiguring and redecorating a small office, providing adjustable shelving, suspended ceilings or a change of floor coverings. For work of this nature a site visit is organised, the Estates person will confirm the requirements, provide a specification complete with an estimate of cost for the required works. All minor new works are priced and managed by the Capital Team and not Estates Operations. Minor New Works Website Link 3.8 Capital Works (All Works Greater Than 5,000) Capital expenditure is defined as expenditure on a tangible productive resource with an expected life in excess of one year. The items will usually require repair and maintenance. The capitalisation threshold has been determined as expenditure of 5,000 (including VAT where this is not recoverable). All works and queries regarding capital works should be discussed with the Finance Department or Investment Governance Committee contacts in the first instance. 3.9 Risk Management The associated risks with the operation of the estate will be managed by a process of prioritisation of work within available resources, using professional expertise. The Trust has developed a Risk Management Policy, and as part of the ongoing development of this, the Directorate Management Team Operations, in partnership with Operational Risk Management Team, have developed risk management controls for the estates including risk registers (DATIX), risk assessments, control measures and contingency plans. The Trust accepts that due to the nature of its activities there will be risks present in those activities and monitor these. 17 of 46
3.10 Business Continuity Plans Business Continuity Plans (BCP) will be maintained through training and exercise and regular audit and review, to ensure the continuity of all estate requirements and reactive maintenance. Business Impact Analysis (BIA) processes will be undertaken by the Estate Managers in conjunction with the Emergency Preparedness Team to ensure that all Estate requirements support and integrate with other departmental arrangements and the overarching Trust BCP. The Estate Business Continuity Management (EBCM) arrangements will be made available to all members of the Estates Team and other Trust departments. 18 of 46
4 STATUTORY LEGISLATION 4.1 Health and Safety At Work Etc. Act 1974 The Health and Safety at Work etc Act 1974, also referred to as HASAWA or HSW, is the primary piece of legislation covering occupational health and safety in the United Kingdom. The Health and Safety Executive and Local Authority is responsible for enforcing the Act and a number of other Acts and Statutory Instruments relevant to the working environment. Statutory instruments are the secondary types of legislation made under specific Acts of Parliament. These cover a wide range of subjects, from control of asbestos at work, ionising radiation and working at height. 4.2 The Regulatory Reform (Fire Safety) Order 2005 The new Order simplifies, rationalises and consolidates existing fire safety legislation. It provides for a risk based approach to fire safety allowing more efficient and effective enforcement by the fire and rescue service. At the core of the legislation lies the fire risk assessment. This is an organised appraisal of the Trusts work activities and the workplace to enable to identify potential fire hazards, and to decide who (including employees and visitors) might be in danger in the event of fire, and their location. The Fire Safety Team will then evaluate the risks arising from the hazards and decide whether the existing fire precautions are adequate, or whether more needs to be done. 4.3 Control of Substances Hazardous to Health (COSHH) Regulations (2004) Using chemicals or other hazardous substances at work can put people s health at risk, causing diseases including asthma, dermatitis or cancer. The COSHH regulations require employers to control substances that can harm workers' health. For Further Information See INDG 136 4.4 Confined Spaces Regulations (1997) A confined space is a place which is substantially enclosed (though not always entirely), and where serious injury can occur from hazardous substances or conditions within the space or nearby (e.g. lack of oxygen). These Regulations contain the following key duties: avoid entry to confined spaces, e.g. by doing the work from the outside; if entry to a confined space is unavoidable, follow a safe system of work; put in place adequate emergency arrangements before the work start The Management of Health and Safety at Work Regulations 1999 require employers and selfemployed people to carry out a suitable and sufficient assessment of the risks for all work activities for the purpose of deciding what measures are necessary for safety. For work in confined spaces this means identifying the hazards present, assessing the risks and determining what precautions to take. For Further Information See INDG 258 4.5 Provision and Use of Work Equipment Regulations (PUWER) (1998) The Regulations require risks to people s health and safety, from equipment that they use at work, to be prevented or controlled. In addition to the requirements of PUWER, lifting equipment is also subject to the requirements of the Lifting Operations and Lifting Equipment Regulations 1998. The Regulations require that equipment provided for use at work is: Suitable for the intended use; 19 of 46
Safe for use, maintained in a safe condition and, in certain circumstances and inspected to ensure this remains the case; used only by people who have received adequate information, instruction and training; and accompanied by suitable safety measures, e.g. protective devices, markings, warnings. Work equipment must have met all the requirements of the Regulations from 5 December 1998. Examples of use of equipment which are covered by the Regulations include starting or stopping the equipment, repairing, modifying, maintaining, servicing, cleaning and transporting. For Further Information See INDG 291 4.6 Lifting Operations and Lifting Equipment Regulations (LOLER) (1998) The LOLER Regulations aim to reduce risks to people s health and safety from lifting equipment provided for use at work. In addition to the requirements of LOLER, lifting equipment is also subject to the requirements of the Provision and Use of Work Equipment Regulations 1998 (PUWER) The Regulations require that lifting equipment provided for use at work is: strong and stable enough for the particular use and marked to indicate safe working loads; positioned and installed to minimise any risks; used safely, i.e. the work is planned, organised and performed by competent people; and subject to ongoing thorough examination and, where appropriate, inspection by competent people For Further Information See INDG 290 4.7 Construction (Design and Management) Regulations (2007) These Regulations concern occupational health, safety and welfare in construction. They place duties in relation to management arrangements and practical measures on a range of construction project participants, including clients, designers, maintenance workers and contractors For Further Information See INDG 411 4.8 Pressure Systems Safety Regulations (2000) Users and owners of pressure systems are required to demonstrate that they know the safe operating limits, principally pressure and temperature, of their pressure systems, and that the systems are safe under those conditions. They need to ensure that a suitable written scheme of examination is in place before the system is operated. They also need to ensure that the pressure system is actually examined in accordance with the written scheme of examination. For Further Information See INDG 178 4.9 Work At Height Regulations (2005) The Work at Height Regulations 2005 apply to all work at height where there is a risk of a fall liable to cause personal injury. They place duties on employers, the self employed, and any person who controls the work of others (e.g. facilities managers or building owners who may contract others to work at height) to the extent they control the work. A place is at height if a person could be injured falling from it, even if it is at or below ground level. Work includes moving around at a place of work (except by a staircase in a permanent workplace) but not travel to or from a place of work. 20 of 46
For Further Information See INDG 401 21 of 46
5 HEALTHCARE STANDARDS Overarching design and engineering principles are applicable to all health and community care buildings and these were updated in January 2011. In some cases these have now replaced the original HTM's and the designers should be fully aware of these alterations. A brief overview is supplied here but further information is available from the space for health website. 5.1 General Design Principles (6946:0.3:England) This manual sets out general design principles for health and community care buildings. Specific guidance for individual clinical settings is available within the clinical topic itself. Designers should ensure that they read this manual as a whole, since further design guidance may be outlined and cross referenced throughout. 5.2 General Engineering Principles (69898:0.1:England) This topic provides general guidance on the engineering, technical and environmental aspects of healthcare building design. Specific guidance for individual clinical settings is available within the clinical topic itself. Designers should ensure that they read the manual in this topic as a whole, since further engineering guidance may be outlined and cross referenced throughout. 5.3 Performance Requirements for Building Elements Used in Healthcare Facilities (8941:0.6England) This manual outlines the policy and performance requirements for building elements used in healthcare facilities. These requirements are a set of essential standards of quality and safety that building elements must comply with. The building elements included are: Floor, finishes and skirtings; Walls/Partitions Ceilings; and Sanitary and Pre Plumbed Assemblies 5.4 Fire Code The FIRECODE titles of the HTM's series contain requirements on trusts that are mandatory. 5.5 Policies and Principles of Healthcare Engineering Healthcare commissioners should expect that the facilities to which they refer patients should provide a safe, caring environment which aids a patient s recovery and does not expose them to undue risk. Therefore the resilience of critical engineering services and business continuity linked to policies for emergency preparedness and the ability to respond to major incidents is high on NUH's agenda. The additional documents which designers should refer to for support and information are: Policy, Context and Requirements Manual (93034:0.2:England) ; Professional Support Policy Manual (3281:0.2:England); Emergency Preparedness Policy Manual (3227:0.1:England); Maintenance Policy Manual (3277:0.2:England); Operational Policy Manual (3279:0.2:England); Professional Support Policy Manual (3281:0.2:England); Statutory and Legislative Requirements Manual (3284:0.2:England); Training, Information and Communications Policy Manual (3286:0.2:England) 22 of 46
5.6 Specialist Engineering Services The following documentation will assist designers during the initial design stage of all schemes and shall be adhered to where applicable: Acoustics: Technical Design Manual (4032:0.3:England); Bedhead Services: Technical Design Manual (130:0.3:Engand) 5.7 Specialist Engineering Services Health Technical Memorandums (HTM) The HTMs series of publications sets healthcare specific standards for building components such as, windows and sanitary ware and the design and operation of engineering services, such as medical gas installations and fire safety requirements. The HTMs are supported by other technical guidance, such as the Model Engineering Specifications. HTM 00 Policies and Principles HTM 01 Decontamination HTM 02 Medical Gases HTM 03 Heating & Ventilation HTM 04 Water systems HTM 05 Fire safety HTM 06 Electrical services HTM 07 Environment and sustainability HTM 08 Specialist services 5.8 Specialist Engineering Services Health Building Notes (HBN) The HBN's are a series of publications that set the DoH's best practice standards in the planning and design of healthcare facilities. They inform project teams about accommodating specific department or service requirements. 00 Core elements 01 Cardiac care 02 Cancer care 03 Mental health 04 Inpatient care 05 Older people 06 Diagnostics 07 Renal care 08 Long stay care 09 Children, young people and maternity 10 Surgery 11 Community care 12 Outpatient care 13 Decontamination 14 Medicine management 15 Emergency care 16 Pathology. 5.9 HTM 00: Best Practice Guidance for Healthcare Engineering The aim of Health Technical Memorandum 00 is to ensure that everyone concerned with the managing, design, procurement and use of the healthcare facility understands the requirements of the specialist, critical building and engineering technology involved. Only by having a knowledge of these requirements can the organisation s board and senior managers understand their duty of care to provide safe, efficient, effective and reliable systems which are critical in supporting direct patient care. By locally interpreting and following this guidance, NUH can demonstrate compliance with their responsibilities and thereby support a culture of professionalism which instils public confidence in the capability of the NHS at local level. 23 of 46
5.10 Health Facilities Notes (HFN's) The Health Facilities Notes (HFNs) address topical subjects, often in response to NHS driven initiatives, and aim to provide an insight into the issues. They may draw widely from, and challenge, trends in the UK, Europe and North America. HFNs do not include formal policy input from the Department of Health. In many cases, HFNs consider a wide range of alternative options and the implications of those options in terms of cost consequence and acceptability to users. 24 of 46
6 NOTTINGHAM UNIVERSITY HOPSITALS ESTATE & INFRASTRUCTURE POLICIES The policies and procedures have been prepared to directly assist Estate Management staff in the practical application of legislation. They are simply intended to act as a point of reference to assist staff in their day to day roles. Detailed below is a list of all NUH Policies and Procedures that are included within the Estates Operations Section: 6.1 Asbestos Management and Control Policy and Procedures (NUH) The policy covers the management of asbestos, and applies to all buildings owned, occupied or maintained by NUH. It covers activities where inadvertent exposure to asbestos may occur (e.g. maintenance work, refurbishment and demolition). All Trust premises have had a Management Survey for asbestos materials. Records are held on an external hosted website. Prior to demolition or alteration works a Refurbishment and Demolition Survey will be performed as appropriate. For Further Information See Control of Asbestos Regulations 2006 6.2 Building and Engineering Services Disability Access Policy (NUH) This policy underpins the principles of the Trust's Equal Opportunities Policy in which the Trust and its employees are required not to discriminate against people with disabilities in the field of employment and in the provisions of goods, facilities and services. Employees are expected to behave in a non discriminatory manner towards both the public and colleagues with disabilities. All employees have the right to work in an environment free from discrimination. For Further Information See BS8300 :2009 Design of Buildings and Their Approach to Meet the Needs of Disabled People 6.3 Control of Contractors Policy (NUH) The aim of this policy is to establish consistent trust wide standards for the employment, management and control of contractors to work on behalf of the Trust and to ensure compliance with all relevant legislation. The term Contractor' means anyone brought in by the Trust to work at or on the Trusts premises who is not an employee of the Trust. The term contractor is equally applicable to a subcontractor but also includes the following:. Maintenance/Construction workers Volunteers Students Agency/bank Staff Consultants NHS Professionals Locum services Company representatives 6.4 Control of Contractors Policy & Guidance Booklet (Estates & Facilities) This document defines responsibilities for the management of Estates and Facilities contractors working on Trusts premises and sets out the arrangements for minimising risk. The Estates Department recognises that the use of contractors is a necessity and that they are employed throughout the Trust. Work undertaken for the Trust by an Estate and Facilities contractor must be covered by a civil or commercial contract. It is good practice for health and safety requirements to be incorporated into the contract, and it should be highlighted that health and safety responsibilities are defined in criminal law and cannot be delegated by a contract. 25 of 46
6.5 Electricity At Work Policy (NUH) The aim of this policy is to ensure that the risks to staff and others from exposure to electrical hazards at work are adequately controlled and that all electrical systems are maintained to a high standard by performing in service inspection and testing. For Further Information See HTM 06 01 Electrical Services Supply and Distribution (Part's A & B); HTM 06 02 Electrical Safety Guidance For Low Voltage Systems; HTM 06 03 Electrical Safety Guidance For High Voltage Systems. 6.6 High Voltage Safety Procedure (Estates & Facilities) The aim of this policy is to ensure all Estates and Facilities staff are aware of the issues and procedures when working on the high voltage network at NUH. The Trust has two high voltage networks. There is a single ring network on the City campus and a dual ring network on the Queens Medical Centre Campus. For Further Information See HTM 06 01 Electrical Services Supply and Distribution (Part's A & B); HTM 06 03 Electrical Safety Guidance For High Voltage Systems. 6.7 Low Voltage Safety Procedure (Estates & Facilities) The aim of this policy is to ensure all Estates and Facilities staff are aware of the issues and procedures when working on the low voltage network at NUH To be developed in 2011 For Further Information See HTM 06 01 Electrical Services Supply and Distribution (Part's A & B); HTM 06 02 Electrical Safety Guidance For Low Voltage Systems. 6.8 Electrical Standby Policy (NUH) To ensure that emergency generators and fixed uninterruptible power systems (Battery Operated) are provided and maintained to enable continuity of supply in the event of mains power failure to essential services. To be developed in 2011 For Further Information See HTM 06 01 Electrical Services Supply and Distribution (Part's A & B) 6.9 Energy Management Policy (NUH) The aim of the Trust s energy policy is to minimise the use of energy consistent with operational needs to reduce energy related costs and to help conserve energy resources generally. For Further Information See HTM 07 02 Encode Making Energy Work in Healthcare 6.10 Environmental Management Policy (NUH) The NUH recognises and accepts its responsibility to minimise, wherever possible, its impact on the environment and to comply with all statutory environmental requirements. The Trust wishes to promote, amongst its staff, patients and visitors, an understanding of the environmental issues it faces and instil in them confidence that it takes its responsibilities seriously as an environmental agent. Through properly developed and executed practices, the Trust seeks to sustain and improve its own environment and contribute to the protection of the local, national and global environments. For Further Information See HTM 07 07 Sustainable Health and Social Care Buildings 26 of 46
6.11 Fire Safety Policy (NUH) This Fire Safety Policy document sets out the Trust Boards intent not only to comply with their legal obligations, but to clearly set out the roles, responsibilities and management arrangements to ensure minimum impact of fire on life, the delivery of service, the environment and property. For Further Information See HTM 05 03 Operational Provisions (Part's A to L) 6.12 Infection Prevention and Control in the Built Environment Policy (NUH) The NUH will ensure that all parts of the premises in which it provides healthcare are suitable for purpose, kept clean and maintained in good physical repair and condition. To ensure a consistent, robust and designed in approach to infection prevention, in relation to building and engineering projects, the Trust will adopt the Department of Health document, Health Facility Note 30 : Infection Control in the Built Environment 2003, as its primary guidance source to ensure a consistent, robust designed in approach to infection prevention and control in relation to building and engineering projects. For Further Information See HFN 30 Infection Control In The Built Environment 6.13 Legionella Management and Control Policy and Procedure (NUH) The aim of the Policy and Procedure is to introduce a structured Procedure and Reporting Schedule, for the Management and Control of Legionellosis, including Legionnaires Disease, in compliance with current Guidelines. All Trust premises have had a legionella risk assessment carried out which is updated at intervals specified in the legionella management plan. For Further Information See HTM 04 01 The Control of Legionella, Hygiene, Safe' Hot Water, Cold Water Systems (Part's A & B) 6.14 Lifts Maintenance and Management Passenger and Goods Lift Policy (NUH) To set out the detailed requirements for the maintenance and safe operation of all passenger and goods lifts in NUH. The lifts are to be maintained and serviced so that they do not present either a physical risk to persons using the lifts or a statutory compliance risk to the Trust. To be developed in 2011 For Further Information See HTM 08 02 Lifts 6.15 Medical Gas Pipeline System Policy (NUH) The objective of this Operational Policy is to ensure the provision of safe and reliable medical gas pipeline systems, cylinders, associated equipment and their safe and efficient operation and use. It provides the framework for the effective management of Medical Gas Pipeline Systems (MGPS) within NUH. For Further Information See HTM 02 01 Medical Gas Pipeline Systems (Part's A & B) 6.16 Medical Gas Pipeline System Procedure (Estates & Facilities) The aim of this procedure is to ensure all Estates and Facilities staff are aware of the issues and procedures when working on medical gas pipeline system procedure at NUH To be developed in 2011 For Further Information See HTM 02 01 Medical Gas Pipeline Systems (Part's A & B) 6.17 Pressure Systems Fixed Installations Policy (NUH) Pressure vessels are vessels that contain liquid, gas, air or steam under sufficient pressure that a sudden and unexpected release of contents may cause potential harm. Pressure Vessels 27 of 46
operated and/or maintained by the Trust include bench top autoclaves, air compressors and pressurised heating systems. The scope of this policy includes only fixed installation or permanently positioned pressure vessels and NOT transportable pressurised cylinders To be developed in 2011 For Further Information See Pressure Systems Safety Regulations 2000 6.18 Sterilizer Maintenance Policy (Estates & Facilities) HTM's requires sterilizers in the Trust conform to legal requirements, the minimum specifications set out in British and European standards, and any additional requirements of the UK health departments (NHS Estates 1994/97). This means that the Trust must have a documented scheme of periodic tests at yearly, quarterly, weekly and (in some cases) daily intervals and to ensure that sterilizers are subject to a documented scheme of preventative maintenance. It is the responsibility of Estates Operations staff to conduct the tests and preventative maintenance, but department managers have a responsibility for ensuring the Estates Operations staff have access to the sterilisers so that this can be completed. The Trust must also ensure that there are procedures for quality control and safe working are documented and that there are procedures in place for dealing with malfunctions, accidents and dangerous occurrences, should these occur To be developed in 2011 For Further Information See HTM 01 01 Decontamination of Re useable Medical Devices and HTM2010 Sterilization 6.19 Ventilation Systems Maintenance and Management Policy (NUH) NUH is committed to ensuring that all ventilation/air conditioning equipment is installed, inspected, serviced and maintained in accordance with all of the statutory legislation to ensure that such equipment does not pose a health or operational risk to either, staff, patients or members of the public To be developed in 2011 For Further Information See HTM 03 01 Specialised Ventilation For Healthcare Premises (Part's A & B) 6.20 Ward Name Management Policy and Procedure (NUH) The policy covers the management of the Trusts Building/Department/Ward Names, and applies to all buildings owned, occupied or maintained by NUH. For Further Information See NHS Wayfinding Document 6.21 Waste Management Policy (NUH) NUH will ensure that the requirements, both legislative and best practice, for the management, handling and disposal of waste, are observed in all areas for which it is responsible. The Trust is committed to recycling (and in some cases re using) as much of its waste as practically possible, recognising that some wastes when sold (e.g. lead acid batteries, metals and electrical wastes) can provide a source of income for the hospital. The Trust recognises the importance of correct waste disposal and the part that all staff must play to achieve this. Staff will be given training, both at induction and regularly thereafter, in the segregation and handling of waste. The Trust will install and maintain an adequate level of waste disposal infrastructure, designed to encourage a safe working environment that safeguards patients, staff and visitors. Wards and departments will all have a suitable waste storage facility which is easily accessed by ward staff 28 of 46
and waste porters. Each area will have sufficient waste receptacles to ensure that any waste can be segregated and deposited easily and correctly by staff while working. For Further Information See HTM 07 01 Safe Management of Healthcare Waste; HTM 07 05 The Treatment, Recovery Recycling and Safe Disposal of Waste Electrical and Electronic Equipment 6.22 Window Management Policy (NUH) The window installations in NUH properties are of varied types of construction, materials and performance. NUH intends to set standards and procedures relating to windows for maintenance and operating purposes. It will assist building users, maintenance contractors and others in respect of creating a safe environment and safe operation of the windows. The objective of this Policy is to give clear guidance on maintenance and safe use especially of opening windows. It is intended to give a clear statement of best practice in their use within NUH properties. To be developed in 2011 For Further Information See HTM 55 Windows 6.23 Estate Stores Procedures (Estates & Facilities) This procedural document is designed to allow the stores staff to operate the Estates Stores correctly. It covers the various areas of operation such as receiving, ordering and the issuing of stock and the operation of the computer system. This also includes stock counts, the production of the various reports, stores access and security arrangements. 6.24 Preferred Equipment Report and Schedule (Estates & Facilities) The purpose of this document is to identify the preferred equipment and suppliers, servicing NUH Estates and Facilities Management Directorate. The key requirement has been to collate a schedule that will identify what equipment/materials and suppliers are preferred for use on the Estates, this document shall then be issued to design teams and contractors for reference on projects and/or maintenance visits. In addition to making reference to standards and guidelines, the document also confirms some general requirements regarding the environment in which the equipment may be installed, generating some best practice principles. 29 of 46
7 RELATED ESTATES PROCEDURES 7.1 Four Stage Risk Model Programme (Ultimon) The Four Stage Risk Model was developed in 2001, it has been successfully been used in a number of Trusts, as it overcomes the major problems associated with the 5x5 criticality grid. With employing a series of Utility Functions it provides a fully auditable robust and repeatable trail for the assessment and scoring of risk. This resulting score is then, transferred into the standard NHS 5x5 grid for direct inclusion into a trusts risk register. As part of their mandatory governance responsibilities, Boards of NHS organisations need to conduct a review of the effectiveness of their managerial systems of internal control. As compliance to the NHS Litigation Authority standards together with other processes and systems, gives assurance to all stakeholders that a Trust s managerial systems are meeting the national codes of practice as a minimum. The system of internal control should be based on an ongoing risk management process, and monitoring system via a multi professional team. Estatecode clearly states that failure to do so could lead to corporate and/or personal liability. From the aforementioned, there is a need for managers to begin to identify in a transparent and auditable manner the risks that are being generated within their spheres of activity. And to advise their trust senior managers and others of the identity and scale of their findings; together with detailed risk treatment plans giving options, manpower, costs and timeframes for the control and/or reduction of the risks. National codes of practice provide a framework for trusts to assess their managerial systems against, and to identify those areas of weakness that could produce unacceptable levels of risk to the organisation, staff and patients. However; they can only provide a very high level of assessment, for a greater degree of appraisal a more in depth and meaningful analysis must be undertaken. The management software is called Ultimon. 7.2 Safe Control System Safe systems of work are crucial in many aspects of the work that Estates & Facilities carry out. A number of activities have been identified where the potential risks are high and the careful coordination of activities and precautions is essential to safe working. In these situations and others of similar risk potential, the permit to work (PTW) procedure will be deployed to ensure there is a safe system of work in place. An 'Isolation' PTW is required, for situations where work on the following systems would expose persons to specific hazards, where isolation is not local, or is of a complex nature (two or more sources of supply) or where isolation would have an impact on other users. The areas covered are: Hot Works Service Isolations Asbestos Access to Confined Spaces Working at Heights Electrical High Voltage Electrical Low Voltage Medical Gas Pipelines Systems Ground Excavations Further information is available within the Directorate of Estates and Facilities Management Safe Control System (Permit to Work) Document 8 February 2010. 30 of 46
7.2.1 Access to Service Areas Access to all service areas such as boiler houses, calorifier houses, plant rooms, electric meter houses, subways, ducts are controlled by the Estates Department engineering and building staff. All contractors and Trust staff entering such places shall comply with the protocol prescribed for the area, and any local rules prevailing at the time. Installation of all cables, pipe work, service distribution networks and the like, shall only be undertaken following liaison with the Estates Department and following approval of an appropriate risk assessment and method statement in accordance with the Control of Contractors Guidance. 7.2.2 Access to Confined Spaces The definition of a confined space is one that is substantially enclosed and in which there is a reasonably foreseeable risk to the health and safety of persons from hazardous substances or conditions within the space or nearby. No work shall be carried out or access made into confined spaces by or on behalf of NUH unless: It is not reasonably practicable to avoid it; Suitable and sufficient risk assessment has been carried out; It is in accordance with an approved safe system of work and It meets the requirements of a valid permit to work Where working within a confined space is unavoidable NUH will take all reasonable steps to secure the health and safety of those involved in confined spaces working. NUH acknowledges the safety hazards inherent in confined spaces working and will ensure that any risks are reduced to a minimum by carrying out risk assessments and providing safe systems of work. 7.2.3 Working at Heights Roof work and work at heights has consistently given rise to a substantial number of fatal and serious incidents each year. The causes of roof work incidents and preventative measures are widely known and publicised. NUH will take all reasonable steps to secure the health and safety of those involved in roof work. NUH acknowledges the safety hazards inherent in roof work and will ensure that any risks are reduced to a minimum by carrying out risk assessments and providing safe systems and places of work. 7.2.4 Ground Excavations Excavation is defined as any surface removal, compaction, indentation, penetration or disturbance of any ground surface or any sub ground surface to a depth greater than 200mm (approximately 8 inches) and includes any disturbances of ground whether by hand tools, power tools and equipment or by mobile tools, mobile machinery or mobile equipment. NUH will take all reasonable precautions to avoid accidents and to secure the health and safety of all its employees and also third parties (contractors, visitors, public etc) from the risks associated with excavations. 7.2.5 Access above Suspended Ceilings, Roof and Ceiling Voids When access is required to install services above suspended ceilings or in roof and ceiling voids this must be notified to the Estates Department. Work shall only be undertaken following liaison with the Estates Department and following approval of a risk assessment and method statement in accordance with the Control of Contractors Policy (Estates and Facilities). The cost of any reinstatement and remedial work required on completion of the work will be recharged to the scheme. 7.3 Estates Operations Department Issuing of Keys Loan of keys is available through the Security Department located on B Floor at QMC and Trust Headquarters at City. 31 of 46
7.4 Estates Operations Department Record Drawings Records and drawings shall be kept up to date and records completed for all maintenance actions. At the handover of a new development the Estates Operational Managers/Officers shall ensure that all statutory as fitted information is received with log books implemented for new systems. The layout and procedures of Operational and Maintenance Manuals is set out in Section A37 of the Trusts Contract Preliminaries with all external contracts. 7.5 Estates Operations Department Asset Register An asset register is updated for all sites, buildings, levels, departments, major engineering plant, systems and equipment via a software system to enable lifecycle costs to be recorded. Current information held is: Automatic Doors Building Management Systems Chillers Fire Alarm Panels Lifts Locking Suite Macerators Nurse Call Security Systems (Intruder Alarms) CCTV Cameras Swipe Card Access 7.6 Estates Operations Department Staff Training The DMTO are to ensure that their staff are trained to the standard for the relevant task undertaken and the operatives are to be competent persons in their discipline. Regular reviews of training requirements shall be undertaken and refresher training shall be implemented as necessary. The NUH recognises that Estates Operations is a specialist area of the service with a need for continuing professional development (CPD). Training records shall be kept up to date for all staff. 7.7 Estates Annual Inspection Requirements 7.7.1 Annual Fire Risk Assessments To satisfy compliance with the Regulatory Reform (Fire Safety) Order 2005 this particular statutory requirement is the annual risk assessment that captures evidence that all the other, more frequent fire risk control measures, also part of the statutory requirement, are in place. Annual fire training for all staff, weekly fire bell testing, regular fire alarm and emergency light testing, fire drills, fire log book at each site, portable fire fighting equipment checks etc. The Fire Risk Assessments will identify actions required to bring the estate to a level of acceptable risk status 7.7.2 Gas Appliance Testing Annual test and certification of all gas appliances shall be carried out by persons who are on the Gas Safe Register. 7.7.3 Electrical Testing Each site requires a mains electrical (circuit) test every five years by a certified (NIC/EIC/ECA approved) engineer. Actions arising from each test will identify the electrical risks and remedial works required to ensure compliancy. Alterations to any circuits within a premise carried out 32 of 46
between each 5 year test requires a new certificate to be issued for those circuits which should be recorded on file with the original test certificate. 7.7.4 Portable Electrical Appliance Testing (PAT) The level of inspection and testing required is dependent upon the risk of the appliance becoming faulty, which is in turn dependent upon the type of appliance, the nature of its use and the environment in which it is used. 7.7.5 Asbestos Surveys Every non domestic building is required to have an asbestos register, containing the asbestos risk assessment. The register is required to be updated every year with a survey identifying the current status of the asbestos condition. Each survey will identify the presence and condition of any asbestos within the building and any actions required to reduce the risk of contamination. The risk register should be held on site and should be brought to the attention of any operative who is to carry out invasive work on the premises to enable a risk assessment to be carried out of the risk of disturbing the asbestos during the works and the precautions required to close out those risks. Prior to any major invasive works, a Refurbishment and Demolition survey must be carried out on the premises prior to handover to a contractor. A Refurbishment and Demolition survey can only be carried out on a vacated building or sealed part thereof; 7.7.6 Water Safety (Legionella and Temperature) A full water services (Legionella) risk assessment is due every two years. However, there are a number of more frequent tests required to be carried out to ensure that premises are being maintained to reduce the risk from either contaminated water or water temperature. Some of these testing regimes are required to be carried out weekly and form part of the Trust s Planned Preventative Maintenance (PPM) schedules which are then tested for compliancy under due diligence testing; 7.7.7 Lifts and Hoists An annual test and insurance inspection for all lifts and portable lifting equipment is required. Any lift or piece of lifting equipment which fails its annual test should be taken out of action until the defect is remedied. Lifts will be inspected annually by an independent Competent Person. 7.7.8 Pressure Vessels Schedules of regular maintenance and inspection shall be determined for each Pressure Vessel having regard to the vessels type, operating pressure, frequency of use and statutory obligations. Where appropriate, Pressure Vessels will be inspected annually by an independent Competent Person. 7.7.9 Air Conditioning Energy Efficiency Audit To meet the requirements of the European Energy Performance of Buildings Directive (EPBD) all air conditioning systems with an effective rated output greater than 12KW must now have their energy efficiency assessed annually. The reports give information about each individual air conditioning units performance and identifies opportunities to reduce CO2 emissions by improvements to the maintenance regime, how the system is operated and recommendations on the specification of a more efficient replacement system. 7.7.10 Audits The Trust also has statutory independent audits undertaken on a yearly basis (or less) of the following areas: Low Voltage Network Legionella / Water Management (Quarterly) High Voltage Network 33 of 46
Medical Gas Pipework Systems Decontamination Compliance Asbestos Management These are available for review through the Directorate Management Team 7.8 Estates Annual Date Collection Requirements 7.8.1 Estates Return Information Collection ERIC enables the analysis of Estates and Facilities information from NHS Trusts and PCTs in England. This is a mandatory response to the DH required annually at the end of April (Emergency Planning required at the end of February It is a compulsory requirement that NHS Trusts submit an Estates Return. This is so the DH can provide an indication of the status of Estates and Facilities services in the NHS for the Department of Health. The development of the Priority and Planning Framework and new National Standards has led to the data now being used to inform a set of indicators to assess the performance of a Trusts Estates and Facilities Services. Over time these will permit Trusts to demonstrate year on year improvement. The guidance document, 'A risk based methodology for establishing and managing backlog', provides trusts with guidance on how to review the estate and indicate immediate and future investment requirements. The guidance was produced in response to Standards for Better Health and National Standards, Local Action which set out a new approach to improving standards in the NHS, including the reduction of backlog maintenance for NHS facilities. The guidance document improves on previous methodologies by taking into account the different levels of risk to patients, visitors and staff arising from deficiencies in statutory safety and physical condition of the built environment. The methodology contained in the document thus provides a representation of the priorities in which investment is needed. All returns can be viewed against other similar acute Trusts. 7.8.2 Six Facet Information In accordance with Department of Health requirements a Six Facet Survey has been undertaken in 2008 and is a multi faceted survey which enables an appraisal of an NHS Trust's Estate and provides a snapshot of the physical condition of individual buildings, which can inform the Estates Strategy. The results of the survey are used to determine and manage backlog maintenance, along with measuring risk in relation to sub standard assets so that investment can be prioritised. Once the risk associated with sub standard elements has been assessed, capital and revenue investment can be targeted. In order to ensure consistency the survey uses the definitions used by Estatecode. These are: Physical Condition Survey (Fabric & M&E) Statutory Compliance Audit (incl. Fire) Space Utilisation Audit Functional Suitability Review Quality Audit Environmental Management Audit The stock condition survey data is updated on a regular basis to identify and quantify the projected workload and provide detailed information on both the internal and external elements of the building. It is envisaged that a continuous rolling programme of stock condition surveys is the most appropriate method for collation of information. Every property will have an annual survey, both internally and externally and a complete survey every five years. 34 of 46
Such data allows for the rapid retrieval of information, permitting expenditure forecasts, budget preparation, and resource smoothing. In addition it enables expenditure to be targeted at areas of greatest need. Further developments of the Six Facet Survey are currently underway in partnership with external consultants. Copies of the Six Facet Survey Document is available on request, broken down by Departments and Directorates. The six facet survey is reviewed regularly and updated by the Directorate Management Team Operations. 7.8.3 Premises Assurance Model (PAM) The NHS Premises Assurance Model (PAM) has been developed to support the delivery of the (QIPP) quality and productivity challenge, public value and carbon reduction programmes. The intention being to introduce a methodology for cross NHS provider and commissioner discussions. The model is intended to promote the sharing of best practice and lessons learnt across providers with a common aim of improving the performance of premises utilised in the delivery of clinical services and delivering on premises aspects of the quality and productivity challenge The NHS PAM seeks to align local provider needs and priorities with Departmental policy to support delivery on: High Quality Care for All, published in June 2008, setting out the vision for putting quality at the heart of everything the NHS does; The Quality, Innovation, Productivity and Prevention (QIPP) challenge; The NHS Constitution; The NHS Operating Framework 2010/11; Quality Accounts. The focus of the model is on five key domains; Finance/ Value for Money; Safety; Effectiveness; Patient Experience; and Board Governance. 7.8.4 Drinking Water Returns The Trust has to submit water samples to the Local Authority under the private water supply regulations to ensure that the water is acceptable to drink. This is because the Local authority is responsible for regulating private water supplies used by the Trust and the Trust uses borehole extraction. 7.8.5 Environmental Permit The Environmental Permitting Regulations 2010 means that the Trust has to have an environmental permit to be able to use the Combined Heat and Power Plant at the QMC. The permit has to be renewed annually/ 7.8.6 Water Abstraction Licence The Trust abstracts more than 20 cubic metres of water a day from its boreholes so we have an abstraction licence from the Environment Agency which is renewed annually. 35 of 46
7.8.7 Display Energy Certificates Display Energy Certificates (DECs) show the actual energy usage of a building, the Operational Rating, and help the public see the energy efficiency of a building. This is based on the energy consumption of the building as recorded by gas, electricity and other meters. The DEC should be clearly displayed at all times and clearly visible to the public. A DEC is always accompanied by an Advisory Report that lists cost effective measures to improve the energy rating of the building. Display Energy Certificates are only required for buildings with a total useful floor area over 1,000m 2 and are valid for one year. The accompanying Advisory Report is valid for seven years. The requirement for Display Energy Certificates came into effect on 1 October 2008, they are done annually and run out every October. (From this date the Trust has three months to renew) 7.8.8 European Union Emission Trading Scheme (EUETS) The European Union Emissions Trading Scheme (EU ETS) was introduced across Europe to encourage businesses to reduce greenhouse gas emissions. The Department for Energy and Climate Change (DECC) has appointed the Environment Agency to regulate the scheme in England and Wales, as well as to maintain the trading Registries on behalf of the UK. The cost of ongoing regulation of a permit is recovered through the annual subsistence charge and covers the on going use of the registry and allows the Trust to buy emission units due to it having centralised boiler houses on each site. Charges are based on annual emissions and are payable on 1 April each year for the financial year ahead. The Trust buys allowances on the basis of predicted emissions and where the Trust can make efficiency savings then excess allowances may be traded for a financial return. At the other end of the spectrum, if the Trust is unable to remain within their budgeted allowances they will have to buy additional allowances from the scheme. 7.8.9 Pollution Inventory Reporting The Pollution Inventory (PI) is an annual record of pollution in England and Wales from selected activities the Environment Agency regulate. It is the annual mass releases of specified substances to air, water and land, and off site transfers of waste by the Trust which has to be submitted. The PI now includes seven years of data from major industrial sites and the main objectives of the pollution inventory are to: tell the public about pollution from industrial and other sources in their local area and nationally help environmental regulators to protect the environment help the Government to meet national and international commitments and reporting obligations 36 of 46
8 ESTATE OPERATIONAL PROCEDURE The procedure document within this policy aims to show the responsibilities and requirements under the remit of the Operational Estates Department. 9 RESPONSIBILITES & WORKS UNDERTAKEN The Estates Operations Department exists to deal with ongoing operations, faults and problems with the building fabric and engineering services across all the Trust's campuses. This includes flickering lights, faulty heating or cooling, blocked drains, broken paving slabs and leaking roofs. All sections also carry out planned preventative maintenance. There is no direct charge for maintenance repairs (unless they are tenant's service charges). Each section will respond to a report or request for maintenance in accordance with the Departments standard priority code system as detailed in Maintenance Priorities. If there is a reason why this cannot be achieved the person making the original request will be informed of that reason. Where there is an outstanding safety issue associated with such a job we will ensure that temporary measures are implemented to ensure the safety of all staff and patients. To ensure standards are being maintained all staff employed by each section are kept up to date with technical and Health and Safety related issues through a combination of in house and bought in training and approved procedures have been formulated for all activities. As well as a technical assessment all specialist contractors undergo an initial Health and Safety vetting procedure (IOSH Managing Safely) to ensure that their standards at least reach those expected by the Trust and that their level of public liability insurance is sufficient for the tasks they are to perform, this procedure is repeated every 3 years. Also on going and regular spot checks and safety audits are carried out on both employees and contractors, to quickly identify and correct any poor practices and to ensure that the work provided by the section remains of a good standard. 9.1 Electrical Maintenance (Infrastructure) To ensure that the electrical infrastructure of the Trust owned properties is maintained and operated in a safe and efficient manner and in compliance with all relevant and current legislation using a combination of directly employed staff and specialist contractors. The Department undertakes both planned and reactive maintenance work, which includes: Periodic inspection and test program of electrical infrastructure in accordance with BS7671; Periodic testing and maintenance of emergency lighting systems; Periodic testing and maintenance of fire alarm systems; Periodic testing and maintenance of lightning conductor systems; Maintenance of internal and external lighting; Maintenance of power circuits up to the point of use, (local isolator or socket outlet); Support and advise all other sections of Estates; Day to day operations on the 11,000 volt network; Provision of a 24 hour 365 days a year emergency call out service. This service is provided to make safe until the next working day only. In addition to these activities the section manages central contracts for the service and maintenance of other equipment and plant. The work is carried out by fully qualified in house craftsmen, supported by a team of carefully selected and approved contractors. 9.2 Mechanical Maintenance The Mechanical Maintenance section of Estates and Facilities (E&F) is responsible for the overall design and safe, efficient operational control of the Mechanical Services installations. 37 of 46
The Department undertakes both planned and reactive maintenance work, which includes: All plumbing and drainage Domestic hot and cold water systems Full or part comfort cooling air conditioning systems General heating and ventilation systems Passenger lifts and lifting equipment Support and advise all other sections of Estates. Provision of a 24 hour 365 days a year emergency call out service. This service is provided to make safe until the next working day only. The work is carried out by fully qualified in house craftsmen, supported by a team of carefully selected and approved contractors. Specialist equipment is maintained under Service Contracts between E&F and the specialist providers, with in house technical staff providing initial response and contract management. 9.3 Building Maintenance The team are responsible for the upkeep and maintenance of all trust buildings and surroundings. The Department undertakes both planned and reactive maintenance work, which includes: Brickwork & plastering Carpentry & joinery Doors & windows Ceiling repairs and finishes External drainage Floor repairs & finishes Locking systems Painting & decorating Roads & pavings Roof works Signage The work is carried out by fully qualified in house craftsmen, supported by a team of carefully selected and approved contractors. 9.4 Security The Estates team will ensure that all electronic security systems (intruder alarms, CCTV in use) are serviceable and covered by appropriate maintenance and monitoring contracts at all times and ensure that suitable records of such maintenance are kept. 9.5 Energy The Estates team are responsible for energy services in the following key specialist fields: Energy Management and related regulatory compliance. Management duties of the Energy Production units. Building Energy Management Systems (BEMS) Contract management for third party service and fuel suppliers Promotion of effective and efficient use of utility resources across the Trust 9.6 Decontamination Operational Estates organise the planning, programming, implementation, supervision and control of engineering maintenance and operations in relations to all decontamination services. This includes the responsibility of the maintenance and testing of sterilisers and disinfectors. All in accordance with HTM 2010, 2030, 2031 and when, superseded with HTM 01 01 (Parts A D). 38 of 46
9.7 Vacant Estate The financial implications of having vacant property are as with occupied estate: capital charges, rates and maintenance; however the added risk with vacant property is that of security breach and damage resulting from vandalism, potentially illegal occupation and fire. 10 EQUALITY AND DIVERSITY STATEMENT All patients, employees and members of the public shall be treated fairly and with respect, regardless of age, disability, gender, marital status, membership or non membership of a trade union, race, religion, domestic circumstances, sexual orientation, ethnic or national origin, social & employment status, HIV status, or gender re assignment. 11 EQUALITY IMPACT ASSESSMENT Name of Policy or Service Responsible Manager John Simpson Name of Person Completing the EIA Mark Jackson Date EIA Completed 1 March 2011 Description and Aims of Policy / Service (including relevance to equalities) This Policy and Procedural Document provides the infrastructure for the implementation of the Trust s Maintenance Programme. It is expected that this Document be complied with by Trust employees, on all Trust sites, and by all appointed contractors, in whatsoever capacity, with or without contractual agreements. Brief Summary of Research and Relevant Data There is no research or relevant data at the present time Methods and Outcome of Consultation Consultations have been carried out with the following: Estates and Facilities Directorate Risk Management Committee Trust Health and Safety Committee Directors' Group Trust Board Results of Initial Screening Equality Group Age Gender Race Sexual Orientation Religion or belief Disability Dignity and Human Rights Working Patterns Social Deprivation Assessment of Impact None None None None None None None None None Results of Initial Screening From the information contained in the policy, it is my decision that a full assessment is not required at the present time. 39 of 46
Equality Action Plan (if required) N/A Monitoring and Review Arrangements (including date of next full review) It is recommended that this policy and EIA be reviewed yearly in line with the requirements in this policy. 12 ENVIRONMENTAL IMPACT ASSESSMENT A stage one Environmental Impact Assessment has been carried out on this policy and procedure document and based on the information set out in the Trust Procedure, it has been confirmed that an environmental impact assessment is not necessary. 13 WE ARE HERE FOR YOU This Trust is committed to providing the highest quality of care to our patients, so we can pledge to them that we are here for you. This Trust supports a patient centred culture of continuous improvement delivered by our staff. The Trust established the Values and Behaviours programme to enable Nottingham University Hospitals to continue to improve patient safety, outcomes and experiences. The set of twelve agreed values and behaviours explicitly describe to employees the required way of working and behaving, both to patients and each other, which would enable patients to have clear expectations as to their experience of our services. 14 IMPLEMENTATION PLAN Reference HS/ Title Estate Operational Management Policy and Procedure Date TBC Lead Officer Mark Jackson Target Audience All Clinical Areas, Estates and Facilities and all other occupiers on Trust Premises Training and Education Requirements On going training as set out by the Lead Officer Implementation Plan Insertion of notice in Trust Briefing, accompanying the promulgation of. Training has already begun and will continue on a yearly basis. Separate meetings with Trust occupiers Forums will be held at Matrons Meetings, ICOG etc. throughout the year. Timetable for Completion of On going Implementation 15 MONITORING AND REVIEWING This procedure will be reviewed in a year's time or when there are changes to legislation which impacts on the procedures effectiveness. 40 of 46
16 APPENDIX A WORK CATEGORIES AND CONSULTATION PROTOCOL Category 1 Low Hazard (Room) Reactive Maintenance This is the type of work requested by the Ward Sister/Head of Department/Occupier/Stakeholder, usually for an item which has failed in service such as a door lock not operating properly, or a light bulb which has failed. The problem is usually confined locally to an area or room, and direct arrangements for access/repair can be made between the originator of the request for repair and Estates Operations to undertake the work. Prior to the work being carried out, the Ward Sister/Department Manager/Occupier/Stakeholder will be consulted by the operative undertaking the task and asked for any special procedure to be adopted. The area will be spot cleaned by the craftsmen on completion of the task. Category 2 Low Hazard (Common Areas) Reactive Maintenance This is work requested by the Ward Sister/Head of Department/Occupier/Stakeholder, but is not confined to a room, and may require work to be undertaken in common areas of a Ward or Department such as a corridor but will be of a short duration such as replacing a defective light fitting or adjustment of a fire door. If the work can be carried out safely with little disruption, arrangements will be made between the originator of the call and the Trade Person for access to carry out the repair. The Estates Department will undertake the repair at a convenient time to the Users of the service where possible. The area shall be spot cleaned by the craftsmen on completion of the task. Category 3 Low Hazard Service Shut Down Reactive or Planned Preventative Maintenance Requiring a Local Service Shut Down Where work initially requested by the Ward Sister/Head of Department/Occupier/Stakeholder, on closer examination is more extensive in nature to correct, and requires a local service shut down such as turning off the water supply to a wash basin to change taps or to facilitate a planned preventative maintenance activity, the following procedure shall be observed: The full extent of the work shall be assessed and the minimum shut down time required determined. The Ward Sister/Department Manager/Occupier/Stakeholder shall be informed of the extent and nature of the problem and what needs to be done to correct the defect. An agreed strategy for undertaking the work shall be determined incorporating any safety and control of infection measures deemed necessary and approval to proceed shall be given by the above. DMTO, Estates Operational Officer, Supervisors and Capital Project Managers ensure that the agreed method is carried out, and any time constraints to shut down of service are adhered to. The area shall be spot cleaned by the craftsmen or contractor on completion of the task. Category 4 Medium Hazard Service Shut Down Reactive or Planned Preventative Maintenance Requiring Service Shut Down Work affecting a whole Ward or Department the following procedure shall be observed: The full extent of the repair or planned preventative maintenance activity shall be assessed and the minimum shut down time required determined. The Ward Sister and Service Manager, Occupier or Stakeholder shall be informed of the extent and nature of the problem and what needs to be done to correct the defect. One of the following procedures shall then be adopted: a) An agreed strategy for undertaking the work shall be determined incorporating any safety and infection prevention and control measures agreed as necessary, and approval to proceed shall be given by the Ward/Service Manager with those listed below being informed of the work as necessary by the Estates Department. 41 of 46
b) The Estates Operations Staff / Project Manager shall arrange a coordinating meeting of those listed below (if appropriate) not less than 14 days before the required shut down: Ward/Department Managers Service Managers Risk Management Infection Prevention and Control Team Fire Safety Team Estate Services Hotel Services Security Switchboard Occupational Health Information Technology Health and Safety An agreed strategy for undertaking the work shall be determined incorporating all safety and infection prevention and control measures deemed necessary or temporary service needed to be provided. DMTO, Estates Operational Officer, Supervisors and Capital Project Managers ensure that the agreed method is carried out, and any time constraints to shut down of service are adhered to. Category 5 Medium Hazard Pre Planned Larger Work Small pre planned alterations/refurbishment or larger maintenance tasks which require structural work or will present significant inconvenience to the users of the Ward/Department whilst the work is in progress. The full extent of the work shall be determined, and a method statement prepared. The responsible officer shall call a pre start meeting not less than 14 days before the planned commencement date with (if appropriate): Ward/Department Manager Service Managers Risk Management Infection Prevention and Control Team Fire Safety Team Estates Services Hotel Services Security Switchboard Occupational Health Information Technology Health and Safety An agreed strategy for undertaking the work shall be determined in accordance with the Infection prevention and control risk assessment during construction/ refurbishment of a healthcare facility protocol (Appendix 2 Infection Control in the Built Environment Design and Planning). The agreed strategy will incorporate any safety and infection prevention and control measures deemed necessary, e.g. temporary screening, dust mats, negative air pressure to the area and the timescale involved. DMTO, Estates Operational Officer, Supervisors and Capital Project Managers shall ensure that the agreed method is carried out, and any time constraints to shut down of service are adhered to. Category 6 High Hazard Pre Planned Large Scale Work Capital Development & Demolition Large scale projects have the potential to present major health & safety and control of infection risks, disruption or nuisance. It is essential that this type of work is subject to detailed consultation and planning. It will be subject to a full range of the health & safety and infection prevention and control requirements together with statutory obligations and guidance published by a wide range of sources, e.g. Health Technical Memoranda and Health Building Notes. 42 of 46
17 APPENDIX B ASPERGILLUS IN THE ENVIRONMENT The airborne route of transmission is important for a number of pathogenic micro organisms such as aspergillus, and every attempt should be made to maintain an environment as free from dust, aerosols and spores as possible during building and engineering works carried out in the healthcare environment. Sources of airborne microbes include: Fungal spores; Water droplets; Skin scales directly shed from skin, or indirectly distributed from clothes or patient equipment; Mechanical action through cleaning, demolition and construction work Respiratory tract coughing, sneezing (also indirect via tissues and fabrics) At Risk Patients Patients who are most at risk are those who are immunocompromised or suppressed for extended periods of time, especially those who have prolonged periods of neutropenia. These include: Haematology Bone Marrow Transplants Organ Transplants Oncology ICU/HDU Burns Other patient groups who are at an elevated level of risk are: Patients on high dose steroids HIV positive patients Patients after major surgery Due to the extent and prevalence of aspergillus in the environment, a two stage protection protocol should be considered. The first stage is good housekeeping and hygiene measures to minimise the release of spores. The second is to provide specific protection to known areas of high risk by the use of positive HEPA filtration ventilation systems. Risk Assessment Due to the nature of microbiological infections and the patients at risk from infection a risk assessment process shall be employed to establish the extent and nature of precautions required through consultation with the Infection Prevention Control Team. Permanent Protection Some classification of patients will require permanent protection due to the nature of their illness or treatment. These patients will be identified by clinical staff following liaison with the Infection Prevention and Control Team who are responsible for agreeing the degree of protection required with professional advice from the responsible Estates Technical Staff / Project Manager on the practical solutions available. Temporary Protection All technical officers/project managers are responsible for liaising with the Infection Prevention and Control Team and jointly assessing the risks from infection on any works which are planned to be undertaken. The Estates Technical Staff / Project Manager will assess the works and detail any risk areas and the precautions to be adopted prior to any works commencing. The technical officer/project manager is available for specific advice and is accountable to senior management for auditing compliance to the agreed precautions for all and any works on Trust premises. The degree of precautions will be dependent on the area involved, nature of works and the risk of dust release and spread. Minor Demolition/Refurbishment If undertaking limited demolition or renovation works within the confines of an existing building, e.g. ward upgrade, the area must be effectively sealed off from other occupied areas of the hospital and thoroughfares. Dedicated access and egress routes need to be established. 43 of 46
Access/exit routes need to be established to minimise the spread of dust and contact with patients, visitors and staff. The use of dedicated staircases or lifts for trade staff should be considered with use of sticky mats or changing/transition areas for personnel entering or leaving a works construction area. Provision for separate toilet facilities for the use of construction staff must be made. If such precautions are deemed necessary, then they must be subject to regular audit and maintenance to ensure effectiveness (define role of domestic monitoring team/supervisors). Minor Repairs Numerous maintenance activities can give rise to the creation of dust (drilling, sanding, plastering, etc). If such works are limited to a small area or are required to be done in a high risk patient area, then the use of LEV systems are recommended. These can take the form of either a hepa filtered vacuum cleaner or mobile extract fan system. The extent and nature of the works will determine the type of system required. Non hepa filtered vacuum cleaners do not eliminate aspergillus particles and therefore cannot be used in high risk areas. In practice all areas may have patients from the risk categories above, so all clinical areas should be classed as high risk. Cleaning Protocols In addition to minimising the spread of dust through Estates precautions, consideration should be given to increasing the existing cleaning regimes during the course of any prolonged or major redevelopment work to prevent dust accumulation on surfaces, ceilings and air duct grilles. This should be built into the initial planning stage of works. Damp dusting and not dry cleaning is recommended. Any air filtration system should be regularly checked and maintained, including adjoining theatres and at risk areas. Pedestrian Traffic Pedestrian traffic from the construction area should be directed away from patient areas, with tradesmen having a separate entrance to the construction site and where possible, patients should avoid entering the hospital via entrances adjacent to major construction/demolition works where debris or dust is being removed from the work areas. Other Considerations Cleaning Equipment A known area of aspergillus growth and contamination is the use of non hepa filtered vacuum cleaners and the cross infection risks of non dedicated devices for critical areas. Refuse Skips All skips used for the temporary storage and disposal of waste material should be fully covered and lockable to prevent dust release and unauthorised disturbance. Where this is not practicable, skips must be covered by means of a secure intact tarpaulin at all times, when not being filled. If filling a skip via mechanical plant or when using heavily dust laden materials, consideration should be given to prevailing wind direction and dust suppression techniques such as damping down or enclosure. Monitoring Protocols Prior to the commencement of major development, maintenance or demolition works, monitoring counts before, during and after works can help in establishing the normal background and action levels should be considered. Such monitoring is the responsibility of the Infection Prevention and Control Team and liaison between the Estates Technical Staff / Project Manager and Infection Prevention and Control Team will determine when and if such monitoring is necessary. 44 of 46
18 APPENDIX C CONTACT INFORMATION Estates and Facilities Website Estates Helpdesk Estates Website Minor New Works Requests Head of Estates Operations Assistant Head of Estates Operations (City) Estates & Facilities Website Link Estates Helpdesk Link Estates Website Link Minor New Works Website Link Mark Jackson Andrew Camina Assistant Head of Estates Operations (QMC) Estates Operations Manager Engineering (City) Estates Operations Manager Engineering (QMC) Estates Operations Manager Building (City) Estates Operations Manager Building (QMC) Access Control Manager (Infrastructure) (NUH) Energy Manager (NUH) Decontamination Manager (NUH) Gareth Jones Graham Pugh Raymond Stanton Mark Boothroyd Paul Heaton Geoff Leafe 45 of 46
19 APPENDIX D EMPLOYEE RECORD CERTIFICATION OF EMPLOYEE AWARENESS Document Title Estate Operational Management Policy and Procedure Version (number) 1 Version (date) I hereby certify that I have: Identified (by reference to the document control sheet of the above policy/ procedure) the staff groups within my area of responsibility to whom this policy / procedure applies. Made arrangements to ensure that such members of staff have the opportunity to be aware of the existence of this document and have the means to access, read and understand it. Signature Print name Date Directorate/ Department The manager completing this certification shall retain it for audit and/or other purposes for a period of six years (even if subsequent versions of the document are implemented). The suggested level of certification is: Clinical Directorates General Managers Non Clinical Directorates Deputy Director or Equivalent Infection Prevention and Control Team All members Estates and Facilities Directorate Operational Department Staff and Capital Project Managers. The manager may, at their discretion, also require that subordinate levels of their directorate / department utilize this form in a similar way, but this would always be an additional (not replacement) action. 46 of 46