Authorising Engineer (Medical Gas Pipeline Systems) Annual Summary Report Cwm Taf University Health Board
Authorising Engineer (Medical Gas Pipeline Systems) Annual Summary Report Cwm Taf University Health Board NWSSP-SES JOB NO : 312WA002 REPORT DATE : April 2015 AUTHORISING ENGINEER : J. Tidball COUNTER SIGNED : K. Ridge
REPORT CONTENTS 1.0 Purpose of the report. 1 2.0 Background. 1 3.0 Audits of systems & installations carried out. 2 4.0 Additional reports / advice provided. 3 5.0 Quality Controller Services. 3 6.0 Investigations of adverse incidents & dissemination of related advice. 4 7.0 Issues of concern 4 8.0 Summary 4 9.0 Recommendations Cwm Taf - Authorsing Engineer (MGPS) Annual Summary Report - Issue 1 Revision 0
1.00 PURPOSE OF THE REPORT 1.01 The following report is a summary of the duties undertaken by the Authorising Engineer for Medical Gas Pipeline Systems (AE (MGPS)) appointed by the Cwm Taf University Health Board, for the period January to December 2014. This report is in accordance with the guidance set out in Welsh Health Technical Memorandum 00 - which stipulates the requirement for the Authorising Engineer to produce an annual audit (Refer to HTM 00 Best practice guidance for healthcare engineering Para 4.19). 2.00 BACKGROUND 2.01 Healthcare organisations have a duty of care to patients, their workforce and the general public. This is to ensure that a safe and appropriate environment for healthcare is provided, which is a requirement identified in a wide range of legislation. The following report will help the Healthcare organisation concerned to discharge this duty. 2.02 The role of the AE (MGPS) is detailed within HTM 00 Best practice guidance for healthcare engineering and HTM 02-01 Medical gas pipeline systems, and the following is a summary of the principal duties undertaken by the AE (MGPS) in relation to the Health Board s statutory duties with regard to their medical gas installations. 2.03 The AE (MGPS) appointed by Cwm Taf Health Board is Mr John Tidball of NWSSP- SES and his role as AE (MGPS) includes the following;- Acting as an independent professional adviser to the healthcare organisation on medical gas issues. Act as an assessor and make recommendations for the appointment of Approved Person (Medical Gas Pipeline Systems) ((AP (MGPS)), Monitor the performance of the service and provide an annual audit of the medical gas system to the Health Board Designated Person. 2.04 The Health Board s APs (MGPS) have the key operational responsibility for the medical gas pipelines systems installed within the Health Board s hospitals. Table 1 lists the APs (MGPS) that the Health Board currently has employed to authorise and supervise work on the medical gas systems within its hospitals. AP (MGPS) Hospital Date Appointed Appointment Expires Alun Evans Royal Glamorgan 22 nd August 2012 August 2015 Stuart Bayliss Royal Glamorgan 5 th August 2013 August 2016 Neal Whitehead Royal Glamorgan Not assessed N/A Alwyn Evans Prince Charles 8 th August 2013 August 2016 Colin Brennan Prince Charles 8 th August 2013 August 2016 Mike Green Community Hospitals 23 rd April 2014 April 2017 Cwm Taf - Authorising Engineer (MGPS) Annual Summary Report - Issue 1 Revision 0 1
AP (MGPS) Hospital Date Appointed Appointment Expires Leighton Jenkins Community Hospitals 23 rd April 2014 April 2017 Gary Humphrey Royal Glamorgan 17 th February 2015 February 2018 Table 1 - Details of Authorised Persons (MGPS) 2.05 It can be seen from Table 1 that of the eight APs (MGPS), six have been assessed by the AE (MGPS) and formally appointed by the Health Board. One of the other AP (MGPS) is scheduled to be assessed in February 2015. 3.00 AUDITS OF OPERATIONAL MANAGEMENT AND INSTALLATIONS. 3.01 Table 2 details the hospitals that audits of the operational management arrangements have been carried out. It must be noted that the two hospitals audited account for approximately 66% of the available beds within the Health Board. Ongoing audits will be carried out over the forthcoming year in accordance with the dates detailed in Table 2. Hospital Date of audit Date of next audit Name of auditee Prince Charles 6 th March 2014 Scheduled for May 2015 Colin Brennan Royal Glamorgan 7 th August 2014 August 2015 Alun Evans Community Hospitals To be arranged N/A To be nominated Table 2 Audit of operational management arrangements for MGPS 3.02 There are a number of recommendations regarding the operational management of the MGPS which are detailed in the individual hospital reports. In summary, the following recommendations were common to both acute hospitals and examples are listed below; The Health Board s AP (MGPS) should ensure that the CPs (MGPS) receive refresher training every three years and are assessed and formally appointed as detailed in HTM 02-01. The Health Board should check the maintenance schedules for accuracy to ensure that they reflect ALL the medical gas equipment installed in Prince Charles and Royal Glamorgan Hospitals. The Health Board should produce an action plan to address the non-compliance issues highlighted in the compliance reports produced by NWSSP-SES. Arrange for the quarterly testing of the medical compressed air plant to be carried out and copies of results to be kept in the Estates Department. 3.03 There are a number of recommendations regarding the HTM 02-01 compliance of the MGPS which are detailed in the individual hospital reports. 3.04 The Health Board should produce an action plan to address the non-compliance issues highlighted in the compliance reports produced by NWSSP-SES. Cwm Taf - Authorising Engineer (MGPS) Annual Summary Report - Issue 1 Revision 0 2
4.00 ADDITIONAL REPORTS / ADVICE PROVIDED 4.01 Independent professional advice has been provided on a number of different issues throughout the period covered by this report and details are included in Appendix I of this report. 5.00 QUALITY CONTROLLER SERVICES. 5.01 The Health Board does not currently have the services of an in-house Quality Controller (MGPS) available. QC (MGPS) services are generally provided by the Health Board s medical gas contractor. 5.02 The Health Board should have a formal arrangement with a QC (MGPS) from another Health Board to provide QC (MGPS) services as and when required alternatively, the Health Board could train one of its pharmacists to carry out this role. 6.00 INVESTIGATIONS OF ADVERSE INCIDENTS AND DISSEMINATION OF RELATED ADVICE 6.01 No adverse incidents were recorded directly by the Health Board during the reporting period. Similarly, no hazard notices or alerts relating the medical gas installations have been issued / distributed by the AE (MGPS). 7.00 ISSUES OF CONCERN 7.01 Non-compliance issues highlighted in the audit and compliance reports produced by NWSSP-SES need to be addressed by the Health Board. 8.00 SUMMARY 8.01 Most of the main items of medical gas equipment are in a good condition and the existing infrastructures appear to be adequately sized for the existing hospitals. 9.00 RECOMMENDATIONS 9.01 It is noted that the Health Board has made improvements with the operational management arrangements of the MGPS at Prince Charles and Royal Glamorgan Hospitals since audits undertaken in 2014, but there are a number of recommendations that should be implemented by the Health Board. In particular the following should be implemented: The Health Board should check the maintenance schedules for accuracy to ensure they reflect all the medical gas equipment installed at Prince Charles and Royal Glamorgan Hospitals. The Health Board should produce an action plan to address the non-compliance issues highlighted in the compliance report produced by NWSSP-SES (Formerly WHE). Cwm Taf - Authorising Engineer (MGPS) Annual Summary Report - Issue 1 Revision 0 3
The Health Board should ensure that written schemes of examination are in place for those relevant MGPS under the terms of the Pressure Systems Safety Regulations 2000 and include all items of equipment, ie pressure safety valves. Arrange for the quarterly testing of the medical compressed air plant to be carried out and copies of results to be kept in the Estates Department. Cwm Taf - Authorising Engineer (MGPS) Annual Summary Report - Issue 1 Revision 0 4