1.2_Estate_Operational_Management_Policy_%26_Procedure.pdf

ESTATEOPERATIONALMANAGEMENTPOLICYANDPROCEDURE

DocumentationControl

Reference HS/EI/ApprovingBody TrustBoardDateApprovedImplementationdateVersion 1Supersedes N/AConsultationundertaken Directorate of Estate and Facilities

Management, Trust Health and SafetyCommittee, Directors' Group and TrustBoard

Date of Completion ofEqualityImpactAssessment

1March2011

Date of Completion of WeAre Here for YouAssessment

1March2011

Date of EnvironmentalImpact Assessment (ifapplicable)

18May2011

Targetaudience All Trust staff, occupiers of Trust premisesandcontractors

Supporting Documents andReferences(s)

See legislation and guidance section withinpolicydocument.

ReviewDate March2013LeadExecutive DirectorofEstatesandFacilitiesAuthor/LeadManager HeadofEstatesOperationsFurtherGuidance/Information LeadExecutive/Author/LeadManager

2of46EstateOperationalManagementPolicy&ProcedureVersion1March2012

CONTENTS1 ESTATEOPERATIONALMANAGEMENTPOLICY ............................................................4

1.1 Introduction.................................................................................................................41.2 GlossaryofTerms ......................................................................................................41.3 Rationale....................................................................................................................51.4 Aims...........................................................................................................................51.5 Definitions..................................................................................................................51.6 MethodsofDeliveryMaintenance ...............................................................................61.7 StatutoryComplianceAudit.........................................................................................61.8 PerformanceReport ...................................................................................................61.9 LegalDuties ...............................................................................................................7

2 ROLESANDRESPONSIBILITIES ......................................................................................92.1 TrustBoard.................................................................................................................92.2 ChiefExecutive...........................................................................................................92.3 DirectorofEstateandFacilitiesManagement .............................................................92.4 DirectorateManagementTeamCapital...................................................................112.5 DirectorateManagementTeamProcurement..........................................................112.6 DirectorateManagementTeamClinical&Corporate...............................................112.7 Infection,PreventionandControlTeam ....................................................................112.8 Employees................................................................................................................112.9 ProfessionalStructure...............................................................................................12

3 MAINTENANCEPRIORITIES ...........................................................................................143.1 ReactiveMaintenance ..............................................................................................143.2 PlannedPreventativeMaintenance(PPM)................................................................153.3 RechargeableRepairs ..............................................................................................163.4 ServiceContracts .....................................................................................................163.5 OutofHoursEmergencyMaintenanceService .........................................................163.6 MaintenanceRecords...............................................................................................163.7 MinorNewWorks(AllWorksLessThan5,000).......................................................173.8 CapitalWorks(AllWorksGreaterThan5,000) ........................................................173.9 RiskManagement.....................................................................................................173.10 BusinessContinuityPlans.........................................................................................18

4 STATUTORYLEGISLATION ............................................................................................194.1 HealthandSafetyAtWorkEtc.Act1974 ..................................................................194.2 TheRegulatoryReform(FireSafety)Order2005 ......................................................194.3 ControlofSubstancesHazardoustoHealth(COSHH)Regulations(2004)................194.4 ConfinedSpacesRegulations(1997) ........................................................................194.5 ProvisionandUseofWorkEquipmentRegulations(PUWER)(1998)........................194.6 LiftingOperationsandLiftingEquipmentRegulations(LOLER)(1998) ......................204.7 Construction(DesignandManagement)Regulations(2007).....................................204.8 PressureSystemsSafetyRegulations(2000)...........................................................204.9 WorkAtHeightRegulations(2005) ...........................................................................20

5 HEALTHCARESTANDARDS ...........................................................................................225.1 GeneralDesignPrinciples(6946:0.3:England) ..........................................................225.2 GeneralEngineeringPrinciples(69898:0.1:England) ................................................225.3 PerformanceRequirementsforBuildingElementsUsedinHealthcareFacilities(8941:0.6England).................................................................................................................225.4 FireCode.................................................................................................................225.5 PoliciesandPrinciplesofHealthcareEngineering.....................................................225.6 SpecialistEngineeringServices ................................................................................235.7 SpecialistEngineeringServicesHealthTechnicalMemorandums(HTM) ................235.8 SpecialistEngineeringServicesHealthBuildingNotes(HBN) .................................235.9 HTM00:BestPracticeGuidanceforHealthcareEngineering....................................235.10 HealthFacilitiesNotes(HFN's) .................................................................................24

6 NOTTINGHAMUNIVERSITYHOPSITALSESTATE&INFRASTRUCTUREPOLICIES..256.1 AsbestosManagementandControlPolicyandProcedures(NUH)............................256.2 BuildingandEngineeringServicesDisabilityAccessPolicy(NUH)............................256.3 ControlofContractorsPolicy(NUH)..........................................................................256.4 ControlofContractorsPolicy&GuidanceBooklet(Estates&Facilities) ....................256.5 ElectricityAtWorkPolicy(NUH)................................................................................266.6 HighVoltageSafetyProcedure(Estates&Facilities)................................................266.7 LowVoltageSafetyProcedure(Estates&Facilities) .................................................26


6.8 ElectricalStandbyPolicy(NUH)................................................................................266.9 EnergyManagementPolicy(NUH) ...........................................................................266.10 EnvironmentalManagementPolicy(NUH) ................................................................266.11 FireSafetyPolicy(NUH)...........................................................................................276.12 InfectionPreventionandControlintheBuiltEnvironmentPolicy(NUH) ....................276.13 LegionellaManagementandControlPolicyandProcedure(NUH) ............................276.14 LiftsMaintenanceandManagementPassengerandGoodsLiftPolicy(NUH) .........276.15 MedicalGasPipelineSystemPolicy(NUH)...............................................................276.16 MedicalGasPipelineSystemProcedure(Estates&Facilities) ..................................276.17 PressureSystemsFixedInstallationsPolicy(NUH).................................................276.18 VentilationSystemsMaintenanceandManagementPolicy(NUH) ..........................286.19 WardNameManagementPolicyandProcedure(NUH) ............................................286.20 WasteManagementPolicy(NUH).............................................................................286.21 WindowManagementPolicy(NUH) ..........................................................................296.22 EstateStoresProcedures(Estates&Facilities).........................................................296.23 PreferredEquipmentReportandSchedule(Estates&Facilities)..............................29

7 RELATEDESTATESPROCEDURES...............................................................................307.1 FourStageRiskModelProgramme(Ultimon) ...........................................................307.2 SafeControlSystem.................................................................................................307.3 EstatesOperationsDepartmentIssuingofKeys .....................................................317.4 EstatesOperationsDepartmentRecordDrawings ..................................................327.5 EstatesOperationsDepartmentAssetRegister......................................................327.6 EstatesOperationsDepartmentStaffTraining ........................................................327.7 EstatesAnnualInspectionRequirements................................................................327.8 EstatesAnnualDateCollectionRequirements ........................................................34

8 ESTATEOPERATIONALPROCEDURE...........................................................................379 RESPONSIBILITES&WORKSUNDERTAKEN................................................................37

9.1 ElectricalMaintenance..............................................................................................379.2 MechanicalMaintenance ..........................................................................................379.3 BuildingMaintenance................................................................................................389.4 Security ....................................................................................................................389.5 Energy......................................................................................................................389.6 Decontamination.......................................................................................................389.7 VacantEstate ...........................................................................................................39

10 EQUALITYANDDIVERSITYSTATEMENT ......................................................................3911 EQUALITYIMPACTASSESSMENT .................................................................................3912 ENVIRONMENTALIMPACTASSESSMENT ....................................................................4013 WEAREHEREFORYOU................................................................................................4014 IMPLEMENTATIONPLAN................................................................................................4015 MONITORINGANDREVIEWING .....................................................................................4016 APPENDIXA WORKCATEGORIESANDCONSULTATIONPROTOCOL.....................4117 APPENDIXBASPERGILLUSINTHEENVIRONMENT .................................................4318 APPENDIXCCONTACTINFORMATION.........................................................................4519 APPENDIXDEMPLOYEERECORD................................................................................46


1 ESTATEOPERATIONALMANAGEMENTPOLICY

1.1 IntroductionThe built environment, which is used to accommodate the treatment, diagnosis and care ofpatients,serviceusersandstaffandmustbeprovided inaformthat thefabric,fixtures,fittingsandservicesminimisetheriskofHealthCareAssociatedInfections(HCAI).

TheHealth andSafety atWork etcAct 1974, theManagement ofHealth andSafety atWorkRegulations1999andtheConstruction(DesignandManagement)Regulations2007all imposespecific duties to safeguard the health and safety of those who are and who are not in theemploymentoftheNottinghamUniversityHospitalsNHSTrust. Thesedutiesequallyapplytoacontractor or subcontractor on Trust premises, in respect of safeguarding our employees,patientsandvisitors fromtheiractivities.

Nottingham University Hospitals NHS Trust (NUH) is committed to fulfilling the requirementsoutlined in the Health Act 2006 Code of Practice for Prevention & Control of Health CareAssociated Infections (Department of Health 2006) revised January 2008, by ensuring that aPlannedPreventativeMaintenancesystemisinplacetominimisetheriskofHCAI.

In addition, the Trust recognises and accepts the responsibilities outlined by the CareQualityCommission(October2010)thatitshallmeettheessentialstandardsofqualityandcare.

SpecifictoEstatesOperationsinclude:

Youcanexpecttobesafe Youwillbecaredforinacleanenvironmentwhereyouareprotectedfrominfection. Youwillbecaredforinasafeandaccessibleplacethatwillhelpyouasyourecover. Youwillnotbeharmedbyunsafeorunsuitableequipment.

Youcanexpectyourcareprovidertoconstantlycheckthequalityofitsservice Yourcareproviderwillcontinuouslymonitorthequalityofitsservicestomakesureyou

aresafe. Ifyou,orsomeoneactingonyourbehalf,makeacomplaintyouwillbelistenedtoandit

willbeacteduponproperly.

1.2 GlossaryofTermsAE AuthorisingEngineerAP AuthorisedPersonBCP BusinessContinuityPlansCHC CityHospitalCampusDEL DirectlyEmployedLabourDG Director'sGroupDMTO DirectorateManagementTeamOperationalDP DesignatedPersonERIC EstatesReturnInformationCollectionHBN HealthBuildingNoteHFN HealthFacilityNoteHGN HealthGuidanceNoteHTM HealthTechnicalMemorandumIPCT InfectionPreventionControlTeamMGPS MedicalGasPipelineSystemMNW MinorNewWorksNUH NottinghamUniversityHospitalsNHSTrustPAM PremisesAssuranceModelPPM PlannedPreventativeMaintenancePTW PermittoWorkQMC QueensMedicalCentreSOM SeniorOperationalManagerVFM ValueforMoney


1.3 RationaleNUH recognises its legal obligations to take necessarymeasures in the provision of effectivemaintenanceofbuildings,fixedorportableequipment,engineeringplant,systemsandservices.Thekeyobjectivesofthispolicyare:

Compliancewithstatutoryrequirements CompliancewiththeCareQualityCommission CompliancewiththeHealthAct2006 Provisionofasafeenvironment Toreducehospitalacquiredinfection. Todefinethedeliveryofaneffectivemaintenanceservice.

Theconceptofprovidingandmaintainingsafeestateservicescarriesahighstatutorypriorityandappliesacrossthewidestrangeofapplications. Itmustapplytopatients,staffandthegeneralpublic, that is, all users of the healthcare environment. In a similar way, the duty of care inoperationalmaintenanceperformancecancontributetowardstheoverallsafetyandefficiencyofourhealthcareorganisation.

NUHshallprovideandmaintainsafeandhealthyworkingconditions,equipmentandsystemsofworkforallstaffandvisitorsandtoprovidesuchresources,instruction,training,informationandsupervisionastheyneedforthispurpose.NUHaimstodoallthatisreasonablypracticabletomanageitsbuildingandengineeringservicesandtofollowthestepslaidoutinthisPolicy.

1.4 AimsThispolicywill:

Provide guidance to those responsible for the maintenance of healthcareenvironments

Assistinmaintainingthevalueoftheestate,extendingtheeconomiclifeofpropertyandengineeringsystemsasfaraspossible

Minimisedisruptiontoensurebusinesscontinuity Maintainthepatientenvironmentinamannerconducivetohighqualityclinicalcare Ensure that buildings and all associated services operate at optimum levels of

performanceandwithindesigncriteriaintheusefullifecycle. Ensure that robustmonitoring and reportingmechanisms are in place. This policy

pursuesandexpectsthegoodupkeepofbuildings,engineeringplantandequipmentby regular inspection and maintenance in line with the Department of Healthguidancedocuments (HealthTechnicalMemorandumseries)andother recognisedguidance,legislationandstandards.

MaintenanceofmedicaldevicesiscoveredunderaseparateTrustpolicy.

1.5 DefinitionsForthepurposesofthisdocumentthefollowingdefinitionsapply:

Maintenance: The combination of all the technical and associated administrativeactionsintendedtoretainanitemin,orrestoreitto,astateinwhichitcanperformitsrequired function. Given due consideration to viability and economic financialresponsibilities

Reactive Maintenance (Breakdown): Operation of restoring an item to fulfil itsoriginal function after a failure in its performance. This is Maintenance that isrequired by the customer on a day to day basis to repair faults that occur inequipment, building fabric or the environmental system. This type of work isundertaken by directly employed labour (DEL) supplemented by General andSpecialistContractors.

Planned Preventative Maintenance (PPM): Maintenance carried out at predetermined intervals or corresponding to predescribed criteria, and intended toreduce the probability of failure, breakdown or the performance degradation of anasset.


Service Contracts: Maintenance carried out by an external contractor at predeterminedintervalsand intendedtoreduce theprobabilityoffailure,breakdownortheperformancedegradationofanasset.

OutofHoursEmergencyMaintenanceService:Thisserviceprovidesa365daymaintenanceservicethatoperatesoutsideofnormalworkinghours. It isaccessedthrough thehospital switchboard. Theobjectiveof theOutofHoursService is tomakesafeplantorequipmentandtorepairorrectifycriticalitemstomaintainasafeservice. Calls are logged by the switch board and the on call directly employedlabour (DEL) tradesman is contacted to attend. If the call out requires assistance,specialist advice or specialist contractor the On Call Estates OperationsManager/Officeriscontactedtoassist.

RechargeableRepairs: These are repairs required followingwilful damage to theTruststructure,fixturesandfittings.

MinorNewWorks:RequestsforimprovementsfromDirectorateswillbefundedviaaMinorNewWorksrequest(MNW)andtheseformsareavailableontheEstatesandFacilitiesWebPage. MinorNewWorkshaveacostlimitnotexceedingfivethousandpounds(5,000). MinorNewWorks include itemssuchasshelving,noticeboards,minordecorations,keycutting,replacementflooring,newsinks,newdatapointsandnewpowersockets.

CapitalWorks: Request for improvements fromDirectorateswhich will be greaterthan five thousand pounds (5,000) will have to be approved by the TrustsInvestmentGovernanceCommittee(IGC).

1.6 MethodsofDeliveryMaintenanceMaintenanceisdeliveredbythreemethodsthatmayemploytheuseofDEL,generalcontractorsorspecialistcontractors.ThespecificworkofthesegroupsaresupervisedbytheEstatesOperationsManagers,EstatesOperationsOfficers and Team Leaders who are accountable for obtaining quotations, placingorders, supervisingandcertifyingcompletion inaccordancewith theTrustsStandingFinancialInstructionsandStandingOrdersforcontractors.ForDELlabourtheymustensureaneffectiveandefficientservicethatdemonstratesbestvalue.Audittrailsexistforthesemethodsofdeliveryasrecordsmayberequestedtodemonstrateworkundertakenforlitigationpurposes.

1.7 StatutoryComplianceAuditOna two yearly basis a statutory compliance auditwill be undertaken by external consultantsappointedbytheDirectorofEstatesandFacilities.Themethodologyoftheauditwillbetoreviewwith the Directorate Management Team Operations through interviews and inspections ofrecordshowtheyarecomplyingwithstatutesandhowtheyaresatisfactorilydischarged.ArandomselectionofbuildingsareinspectedbytheEstatesOperationsManagertoverifythatstatutorymaintenance has been carried out, that all documentation is available and has beencorrectlycertified.Areportwillbeissuedandcorrectiveactionsheetwillbeprovided.ThiswillbereportedtotheAuditCommitteeonanannualbasis.

1.8 PerformanceReportAmonthly reportwillbeprovidedto theOperationalManagementTeamon theperformanceoftheOperationalServiceandprogressoncorrectiveactionsheetsissuedfollowingaudits.Thereportwillidentifyactivitymeasuresincluding:

NumberofemergencyOutofHourscalls Numberofreactivemaintenancerequestsreceived. %ofreactivemaintenancerequestscompletedwithinresponsetimeframes. Numberofstatutoryplannedpreventativemaintenancejobsissued. % of statutory planned preventativemaintenance jobs completed within response

timeframes. Identifycriticalincidents. Stockrotationandholding. Complaintsandcomments. Trainingundertaken.


Paymentsofinvoiceswithin30days Appraisalsundertaken Sicknessrate Legislativechangesandimplications.

1.9 LegalDutiesActs:

EnvironmentProtectionAct1990 CleanNeighbourhoodsandEnvironmentAct2005 HealthandSafetyatWorkAct1974 HealthAct2006 OccupiersLiabilityAct1984 CorporateManslaughterandCorporateHomicideAct2007

RegulationsthatunderpintheActs: ConfinedSpacesRegulations1997 Construction(DesignandManagement)Regulations2007 Construction(HeadProtection)Regulations ControlofAsbestosRegulations2006 ControlofLeadatWorkRegulations2002 ControlofMajorAccidentHazardsRegulations1999(amended2005) ControlofNoiseatWorkRegulations2005 ControlofSubstancesHazardoustoHealth2004 ControlofVibrationatWorkRegulations2005 BuildingRegulations2009 ElectricityatWorkRegulations1989 GasSafety(InstallationandUse)Regulations1998 GasSafety(Management)Regulations1996 HealthandSafety(ConsultationwithEmployees)Regulations1996 HealthandSafety(DisplayScreenEquipment)Regulations Health&Safety(FirstAid)Regulations1981 HealthandSafety(Signs&Signals)Regulations1996 IonisingRadiationsRegulations1999 LiftingOperationsandLiftingEquipmentRegulations1998 ManagementofHealthandSafetyatWorkandFirePrecautions2003 ManagementofHealthandSafetyatWorkRegulations1999(amended2006) ManualHandlingOperations1992 PersonalProtectiveEquipmentRegulations2002 PressureSystemsSafetyRegulations2000 ProvisionandUseofWorkEquipmentRegulations1998 RegulatoryReform(FireSafety)Order2005 ReportingofInjuriesDiseasesandDangerousOccurrencesRegulations1995 SafetyRepresentativesandSafetyCommitteesRegulations1977 WorkatHeightRegulations2005(amended2007) WorkinCompressedAirRegulations1996 WorkingTimeDirective Workplace(Health,Safety&Welfare)Regulations1992 EnvironmentalProtection(DutyofCare)Regulations2005 Hazardouswaste(England&Wales)Regulations2005 WasteElectrical&ElectronicEquipmentRegulations2006 WasteManagementRegulations1996

BritishStandards BS7671:2008RequirementsforElectricalInstallations BS8300: 2009 Design of Buildings and Their Approach to Meet the Needs of

DisabledPeople.


DepartmentofHealthGuidance HealthFacilitiesNotes HeathBuildingNotes HealthGuidanceNotes HealthTechnicalMemorandums EstateCode


2 ROLESANDRESPONSIBILITIES

TrustBoard

ChiefExecutive

DirectorofEstatesandFacilities

DeputyDirectorofEstatesandFacilities

HeadofEstatesOperations

AssistantHeadofEstates Operations(CityCampus)

EstatesOperationsManagers&Officers

Building Stores(NUH) Electrical MechanicalSecurity(Infrastructure)

(NUH)

AssistantHeadofEstates Operations(QMC&Ropewalk)

EstatesOperationsManagers&Officers

Building Energy(NUH) Electrical MechanicalDecontamination

(NUH)

2.1 TrustBoardTheTrustBoardhasoverallaccountabilityforalltheactivitiesoftheorganisation,whichincludesthemanagementandmaintenanceoftheTrustsestate.

Thisincludesthefollowing: landandpropertymatters planningstrategicinvestmentintheestate landandpropertyappraisal assetmanagement buildingmaintenance engineeringmaintenance energymanagement.

TheTrustBoarddelegatestheresponsibilityforthemanagementandmaintenanceoftheestatetotheChiefExecutive.

2.2 ChiefExecutiveThe Chief Executive has the ultimate managerial responsibility for the management andmaintenanceoftheestateanddelegatestheoperationaldaytodayresponsibilityandauthoritytothe Director of Estate and FacilitiesManagement who will manage,maintain and control theestateassetoutinthispolicyandotherrelatedpolicies.

2.3 DirectorofEstateandFacilitiesManagementTheDirectorofEstatesandFacilitieswilloperatethemanagementandcontrolsystemsoutlinedinthispolicyandproceduredocument.


2.3.1 DirectorateManagementTeam OperationsTheDirectorateManagementTeamhaveoverallresponsibilityforthedeliveryoftheOperationalServicesandBudget. ThisteamcomprisesoftheHeadofEstatesOperationsandtheAssistantHead(s)ofEstates forCityCampusandQueensMedicalCentre/RopewalkCampuses

2.3.2 EstatesOperationalManagersandOperationalOfficersThe Estates Operational Managers/Officers have a responsibility to ensure that their staff areinstructed,trained,informedandsupervisedandaresuitablycompetenttocarryouttheirrolesinasafe,effectiveandefficientmanner.

TheEstatesOperationalManagers/Officersare thedesignatedofficersforestatesmaintenanceservices. This position fulfils the role of Responsible/Authorised Person (AP) for specialistengineering and building services (these appointments are site specific). Operationalmanagement of estates services includes building, engineering, equipment, specialistmaintenance and grounds and gardens with appropriate maintenance programmes and anannualreviewofmaintenanceactivities

Operationalmanagementofestateservicesincludes: building engineering equipment specialistmaintenanceand groundsandgardens.

Allserviceshaveanappropriatemaintenanceprogrammeandanannualreviewofmaintenanceactivities.

The Estates Operational Managers/Officers are responsible for the implementation of theoperationalrequirementsofthispolicywhichinclude:

Staffmanagement(i.e.sickness,appraisalsetc.) Promotingasafetycultureamongstallstaff Assessmentandquantificationofrisk Reductionofriskstoaslowasreasonablypracticable Identifyandreporthigherlevelrisksinthedaytodaybusinessplanningprocess Reviewallrisksperiodicallyorwhenthereisachangeinactivity Instigatingsafesystemsofworkandworkingpracticestominimiserisks Maintainingappropriaterecords CompliancewithallstatutorylegislationandHealthEstatesguidanceasapplicabletothe

healthcareenvironment Consulting with all stakeholders affected by building, engineering and maintenance

activities. Undertakingdilapidationandconditionsurveys.

2.3.3 TeamLeader,DayTechnician&ShiftTechnicianThe Team Leaders provide daytoday supervision and support to their specific discipline toensure that thesection isable toprovidegive thehighest levelofsafe,courteousandefficientservicetothebuildingsusers.

TheDay/ShiftTechniciansareemployedtoworkacrossbothengineeringdisciplines(mechanicaland electrical). Their higher level of responsibility includessteamboilers andCHPplant, lifts,compressors, medical gas systems, fire systems, emergency generators, electrical, heating,cooling and water systems, drains and the sitewide air tube conveyor and security accesssystems.

ShiftTechnicians(Outofhours)willalsobethekeypersoninrespondingtofirealarms,personstrapped in lifts and mechanical and electrical engineering emergencies. They will carry outplannedmaintenancedutiesinoperatingtheatresandotherareasoflimitedaccess,butwillalsorespondtoengineeringmaintenancefaultsandbreakdownsthroughoutthesite.


2.3.4 CraftsmenThecraftsmenprovidesskilledinstallationand/ormaintenanceofspecialistservicesandwillbedirected,appointed,orauthorised towork(ifacontractor)by theirTeamLeaderdependantonthework involved. MaintenanceAssistantsandMaintenanceAssistants(HigherLevel)providesemiskilledsupporttothisrolewithdirectionfromTeamLeaders.

2.4 DirectorateManagementTeam CapitalTheHeadofCapitalProjects/Procure21+CapitalProjectsDirector is responsiblefortheoverallprogrammemanagementofallEstateCapitalschemes. TheDirectorateManagementTeamCapitalwillensureallnewworksareefficientintermsofvalueformoney(VFM),energyusage,reducing futuremaintenance requirements and to comply with relevant HTM/HBNs and otherlegislation. TheHeadofCapitalProjects/Procure21+CapitalProjectsDirectorwillalsomonitorprogressofagreed schemesandprepareand issue reports to inform andadviseTrustSeniorManagementonamonthlybasis.

2.5 DirectorateManagementTeam ProcurementTheProcurementDepartmentisresponsibleforensuringthatTrustestatesservicesareprocuredviaalegallytenderedprocurementrouteandthattheTrustsStandingFinancialInstructionsarecomplied with. This includes national, regional and negotiated framework and contractagreements. A collaborative approach is adopted between Estates and the ProcurementDepartment.

2.6 DirectorateManagementTeam Clinical&CorporateDirectorateManagementTeamsare responsible forensuring that their staffareaware of theirdutytoreportbuildingandengineeringdefects,breakdownsandrepairsthroughtheappropriatechannels (WebHelpdesk [NonEmergency] andSwitchboard [Emergency] and also to operatethe building and its equipment in a safe and appropriate way with appropriate training andcompetency.

2.7 Infection,PreventionandControlTeamIt is the responsibility of the InfectionPrevention andControl Team (IPCT) to provide specificinput and support for allmatters relating to the hospital environment,maintenance of hospitalbuildingsandengineeringsystemsandtoworkwithEstatesOperations.

Thiswillincludetheprovisionof: Education formaintenance staff andmanagement on infection prevention and control

andthereductioninHCAIs Guidanceandsupportwhenadviceoncontrollingtheenvironmentisrequired Adviceonriskassessmentsforcontrollingtheenvironment Identifyprioritiesforaction Assistinginreducingriskcausedbyaspergillusduringworks(SeeAppendixB).

2.8 EmployeesAllTrustemployees(includingagencystaffandcontractstaff)haveadutyofcaretoeachotherassetoutwithintheHealthandSafetyatWorkActandtocooperatewiththeiremployerandnotto tamper with safety devices and to reports defects and failures in accordance with Trustprocedures. Theyshouldalsocomplywith reportingsystemswith regard tobuildingandplantfaults.Further informationon the roleof contractorscanbe found in the NUHControlofContractorsPolicyandthe'EFMControlofContractorsPolicy'.


2.9 ProfessionalStructureWhile the Chief Executive and the Trust Board carry ultimate responsibility for the safe andsecurehealthcareenvironmentthestructurebelowrepresentstheprofessionaladoptedapproachtothedeliveryofhighriskimpactspecialistserviceswithinNUH.Theseincludethemanagementof high voltage electricity, low voltage electricity, decontamination, medical gas pipelines,asbestos,watersafetyandquality,ventilationsystems,lifts,pressuresystemsetc.

AuthorisedPerson

Appointedqualifiedtechnicalengineer

(specifictoservice)

DesignatedPerson

Appointedseniorexecutive

(boardlevel)withassigned

responsibilityforservice

TrustSeniorOperationalManager

Informedclient/intelligentcustomer

CompetentPerson

Assessedandqualified

craftsperson(specifictoservice)

AuthorisingEngineerAppointed

independentprofessionalengineer(specifictoservice)

2.9.1 DesignatedPersonThis person provides the essential senior management link between the organisation andprofessionalsupport,whichalsoprovidesindependenceoftheauditreportingprocess. TheDPwill alsoprovidean informedpositionatboard level. TheDPwillworkcloselywith theSeniorOperationalManagertoensurethatprovisionismadetoadequatelysupportspecialistservices.

2.9.2 TrustSeniorOperationalManager(SOM)The SOMmay have operational and professional responsibility for a wide range of specialistservices.ItisimportantthattheSOMhasaccesstorobust,servicespecificprofessionalsupportwhich can promote and maintain the role of the informed client within the healthcareorganisation. This will embrace both maintenance and the development of servicespecificimprovements support the provision of the intelligent customer role and give assurance ofservicequality.

2.9.3 AuthorisingEngineer(AE)The AE acts as an independent professional adviser to the healthcare organisation. The AEshouldbeappointedbytheorganisationwithabrieftoprovideservicesinaccordancewithHealthTechnicalMemorandumguidance. Thismayvaryinaccordancewiththespecialistservicebeingsupported.


The AE will act as assessor and make recommendations for the appointment of AuthorisedPersons,monitor the performance of the service, and provide an annual audit to theDP. Toeffectivelycarryoutthisrole,particularlywithregardtoaudit,itispreferablethattheAEremainsindependentoftheoperationalstructureofthetrust.

2.9.4 AuthorisedPerson(AP)TheAuthorisedPerson(s)have thekeyoperational responsibility forhigh risk impact specialistengineeringservicessuchasmedicalgasesandhighvoltageworks. Theappointedpersonwillbequalified,sufficientlyexperiencedandskilled tofullyoperate thespecialistservice. TheAPwill be nominated by the AE and appointed by theSOM (or Chief Executive) and be able todemonstrate:

his/herapplicationthroughfamiliarisationwiththesystem attendanceatanappropriateprofessionalcourse alevelofexperience andevidenceofknowledgeandskills.

The Estates Operational Managers/Officers fulfil these roles and the appointments are sitespecific.

An important element of this role is the maintenance of records, quality of service andmaintenanceofsystemsafety(integrity).TheAPisresponsibleforestablishingandmaintainingthe rolesandvalidationofCompetentPersons,whomaybeemployeesof theorganisationorappointedcontractors.TheTrusthasmorethanoneAPforaparticularservice.Administrativeduties such as recordkeeping are assigned to specific APs and recorded in the relatedoperationalpolicies.

2.9.5 CompetentPerson(CP)The Competent Person(s) are skilled in the installation and/or maintenance of the specialistservice.TheCPwillbeappointed,orauthorisedtowork(ifacontractor),bytheAPandbeabletodemonstrate:

asoundtradebackground,qualificationsandspecificskillsetinthespecialistservice he/she will work under the direction of the AP and in accordance with operating

procedures,policiesandstandardsoftheserviceasdeterminedbyNUH.

TheTeamLeaders,DayTechnicians,ShiftTechniciansandCraftsmenfulfil theserolesandtheappointmentsaresitespecific.


3 MAINTENANCEPRIORITIESThe Trust deploys specialist software to assist with the delivery, monitoring, and control ofprocedures associatedwithmaintaining and improving the provision of healthcare such as reactive maintenance and planned preventative maintenance. It is via this software that therequestorslogforassistanceisrecordedandmanaged.

Reactive maintenance requests can be logged quickly, and the requestors have access tointerrogate thedatabasewithout theneedtonavigatearoundthesoftware. Therequestorcancheck the current status of anymaintenance request, and review full request history enablingqueriestobeansweredimmediately.

Alibraryofstandardclientrequestsareavailabletoassistinthereportingofmaintenanceissuesandenablesfrequentissuestobeprioritisedandgroupedtogether.

PlannedPreventativeMaintenance iscarriedoutusing thesamesoftwareand thisenables theDirectorateManagementTeamtomonitorprogressagainststatutorylegislationandcompliance.The specialist software enables the DirectorateManagement Team tomaintain a plan/servicehistorybyrecordingworkdone,breakdownsetc,whichassistsinprioritisingplantandequipmentreplacementprogrammes.

AppendixA highlights the differing type ofwork that theEstateOperations undertake and theconsultationprotocolthatshallbefollowed.Theworkiscategorisedasfollows:

Category1LowHazard:ReactiveMaintenance(Room) Category2LowHazard:ReactiveMaintenance(CommonArea) Category3LowHazardServiceShutDown:ReactiveorPlannedPreventative

MaintenanceRequiringaLocalServiceShutDown Category4MediumHazardServiceShutDown:ReactiveorPlannedPreventative

MaintenanceRequiringServiceShutDown Category5MediumHazard:PrePlannedLargerWork Category6HighHazard:PrePlannedLargeScaleWorkCapitalDevelopment&

Demolition.

3.1 ReactiveMaintenanceReactiveMaintenancecanbesummarisedunderthefollowingpoints:

Reactivemaintenance can generally be defined as a single order which complieswithstandingfinancialinstructions.

All reactive maintenance will be carried out with minimum disruption to theDirectoratesandDepartmentsoftheTrustviagoodcommunicationlinks.

All requests are channelled via the EstatesWebpage/Help Desk where they arelogged,givenauniquenumberthatisalsoprovidedtothecustomer,apriorityfortheworkisagreedagainstspecificcriteriaandtheworkloggedonthecomputersystem.On completion of the work, costs are calculated and the date of completion isentered.

TheEstatesWebsitegives24houraccess for the loggingof reactivemaintenanceworks.

Maintenancewillbecarriedoutbyeither: DirectLabourTeam(UnderthecontrolofTeamLeaders) General Contractors (Under the control of the Estates Operational

Managers/Officers) Specialist Contractors (Under the control of the Estates Operational

Managers/Officers)

Inordertoprovideaservice,theTrustprioritisesitsreactivemaintenanceasfollows(EstatecodeDefinitions),thisalsoincludesexamplesofcertainsituations(thislistisnotexhaustive):

ImmediateresponsePriority1Situationsthatcouldcausedangerordistresstopatients or prevent an essential service from being provided. Examples includefloods (either frompipework or leaking roofs), glazing (where security or safety is


compromised),electrical(lossofpowertoanarea/buildingorbareelectricalcables),passengerlifts(personstrappedinalift),gasleaksandfirealarms

Within 8 hours Priority 2 Situations that will degrade to an emergency if notaddressedwithin this time band. Examples includeno heating, nowater, lighting(whereitprovidestheonlyilluminationinanarea)andlightsonstaircases

Within24hoursPriority3Situationsthatcausemajordisruptiontoservicesbutdonotcausedangerorpreventtheprovisionofpatientcare.Examplesincludenohotwater,Showernotworking(whereitistheonlyone),localisedelectricalfailure,securitylighting,blockedtoiletsordrains,liftsoutofaction,corridorlightingandnoheating.

Within3daysPriority4Situationsthataffectserviceswithoutcausingdistresstopatients.

Within7daysPriority5Situationsthatwillcauseaminordisruptiontoservices. Within 14daysor agreeddeadlinesPriority 6 Situations thatwill not directly

disruptservicesbutcauseinconvenience. Within28daysoragreeddeadlinesPriority7Developmentwork,upgradesor

nonurgentrepairs

The Directorate Management Team Operational staff are responsible, for the quality of themaintenance service provided and shall carry out a 1 in 10 job post inspection, to determinesatisfactory completion and acceptableworkmanship and to authorise appropriate payment forthework(Generalandspecialistcontractors).

All budgets for reactive maintenance are controlled by the Directorate Management Team OperationalManagerswhoareresponsiblefortheirmanagement.

AllrequestsformaintenancearetobereportedthroughtheEstatesDirectorateswebsiteEstatesHelpdeskLink

3.2 PlannedPreventativeMaintenance(PPM)Planned preventivemaintenance is regular, scheduled work carried out to keep equipment ingoodworkingorderandtooptimizeitsefficiency,costeffectivenessandavailability. Thisactivityinvolvesregular,routinecleaning,lubricating,testing,calibratingandadjusting,checkingforwearandtearandeventuallyreplacingcomponentstoavoidbreakdown.

Mostof thework that theDirectorateManagementTeam Operational carryout isunseenbyDirectorates and Departments and this is the plannedmaintenance. Plannedmaintenance iscarriedoutinaccordancewithschedulesarrangedbytheEstatesOperationsManagers,EstatesOperations Officers, Team Leaders and also manufacturer's recommendations and warrantycriteria.

Thisserviceisnotusuallyrequestedbyheadsofdepartments,andthemaintenanceoftheestateiscarriedoutaccordingtotheannualprogrammewhichisreviewedannuallyorwherethereisamajor service change. However each head of department will be informed of any plannedmaintenanceinorthatmayaffecttheirspecificareasofresponsibility.

If a head of department is concerned about any item in their area which is on the plannedmaintenance schedule they should discuss the matter directly with the Estates OperationsManagers.

PPMworksarenormallycarriedoutduringworkinghourstotheagreedschedule.

TherearetwotypesofPPM's: Statutory Maintenance is undertaken to comply with statutes and underpinning

regulations relating to the building/engineering elements within a building andoperationsundertakenfromthepremisessuchas5yearlyfixedwiringtests,portableappliance testing, asbestos management, management of water systems, liftinspections,pressuresystems.

Mandatory /BusinessCriticalMaintenance iscarriedoutunder therecommendationmadebyorganisationsthatarenotenshrinedinstatutebutwillbereferredtoasbest


practiceinacoronerscourt,acriminalorcivilactionfordamagesagainsttheTrustorindividual officers of the Trust. These include Approved Codes of Practice, BritishStandards, ISO Standards, Hospital Technical Memorandum(s) and manufacturersrecommendedinstructions.

3.3 RechargeableRepairsThesearerepairsrequiredfollowingwilfuldamagetotheNUHstructure,fixturesandfittingsbystaff,patientsandvisitors.Thiscouldincludethelossofnursecallhandsets,vandalismandlossof keys. If required relevant authorities such as the police would be informed to investigatefurtherthroughtheSecurityManagementTeam.

3.4 ServiceContractsServicecontractsrequiremoreconsiderationfromtheclientside,asinherentinthefunctionofaservice contract is the partial transfer of risk and responsibility from the Estates OperationsDepartmenttothecontractor.

Equipmentofacomplexorspecialistnatureisusuallycoveredbyaservicecontract.Responsetimefor repairsmayvarydependingon the termsof thecontract. Informationregarding thesetermscanbesuppliedbytheEstatesOperationsManagers.

An example of a service contract for NUH is all grounds and gardens works (including snowclearanceandgritting)whichiscarriedoutbycontractgroundsstaff.Conditionsaremonitoredduringthewintermonthstoensurethatroadsandfootpathsaremaintained. AnotherexampleisthespecialistmaintenanceofalltheNUHlifts.

3.5 OutofHoursEmergencyMaintenanceServiceThere are a range of situations and activities within the Hospital that require some form ofemergencyoncallarrangementtoensurehealthandsafetyandbusinesscontinuityfor24hoursaday,7daysaweek.Exampleswillbereasonablylimited,asmostsituationscanbedeferredanddealtwithduringnormalworkinghours.

The service provided by the Estates Operations Department for out of hours emergencymaintenance is to isolate andmake safe. Individuals are not expected to remain onHospitalpremiseswhilstoncall.However,theywillbeexpectedandrequired,byvirtueofthisagreement,torespondtocallsduringtheironcallperiodandtodealwiththemappropriatelyandwithinareasonabletimeframe,includingattendanceattheworkplaceifnecessary.Theindividualwillnotbepermitted to refer thecall on toothers,unless it hasbeendirected to them inappropriately.Individualsareexpectedtofulfilresponsibilitiesarisingasaresultofbeingoncalltoacceptablestandards.

3.5.1 SupportLevelsTherearetwotypesofsupportasfollows:

LevelOneSupportThistypeofsupportismanagementcoverwhenthereisaseriousuntowardincidentsuchasamajordisaster.

LevelTwoSupportThistypeofsupportallowsstafftobecontactedinordertoprovidesupportoutsidethestaffmembersnormalhoursofwork. Thememberofstaffisavailableduringnonworkinghoursand the member of staff will decide whether the emergency can be dealt with, withoutattendingsite,ortorequestadditionalsupportthroughcontractors.

3.6 MaintenanceRecordsRecordskeptby theMaintenanceSection includedetailsof theexistingconditionofabuildingtogetherwithdetailsof,servicesandpastmaintenancehistory


AtthehandoverofanewdevelopmenttheCapitalTeamwillmakeavailableanoperationalandmaintenance manual including as built drawings to provide a description and details ofconstruction relevant to the design and fittings provided within a scheme, and its ongoingmaintenancerequirements.

Inaddition, theconsultantwillprovideathandoverto theTrustaHealthandSafetyfilefor therespective building, in compliancewith theConstructionDesign andManagementRegulations2007.

TheinformationforthesettingoutofmaintenanceoperationalmanualscanbefoundinSectionA37offormOTF6fromtheCapitalTeam.

AnanalysisofstatisticsandappropriaterecordsystemswillenabletheTrusttoidentifyitsfuturemaintenanceissues.Inparticularitwillhighlightanyprematurefailureofcomponents,ensuringthatreplacement/renewalismadewithhigherqualityfixturesandfittingscapableofwithstandingeverydayuseinahealthcareenvironment.

AnapprovedlistoffixturesandfittingsisavailablefromtheEstatesOperationsTeam.

3.7 MinorNewWorks(AllWorksLessThan5,000)Wherealterationsorimprovementsarerequiredtheserequiretobespecificallyfunded,normallyfromanappropriaterevenuebudget.ForthistypeofworkaMinorNewWorksForm(AvailablefromtheIntranet)willbecompletedbytherequestingDirectorateorDepartmentandshouldbesubmittedtotheMinorNewWorksTeam(electronically).

Forexampletheworkmightcompriseofreconfiguringandredecoratingasmalloffice,providingadjustableshelving,suspendedceilingsorachangeoffloorcoverings.Forworkofthisnatureasitevisit isorganised, theEstatespersonwill confirm the requirements,provideaspecificationcompletewithanestimateofcostfortherequiredworks.

AllminornewworksarepricedandmanagedbytheCapitalTeamandnotEstatesOperations.

MinorNewWorksWebsiteLink

3.8 CapitalWorks(AllWorksGreaterThan5,000)Capitalexpenditureisdefinedasexpenditureonatangibleproductiveresourcewithanexpectedlife in excess of one year. The items will usually require repair and maintenance. Thecapitalisationthresholdhasbeendeterminedasexpenditureof5,000(includingVATwherethisisnotrecoverable).

AllworksandqueriesregardingcapitalworksshouldbediscussedwiththeFinanceDepartmentorInvestmentGovernanceCommitteecontacts inthefirstinstance.

3.9 RiskManagementThe associated risks with the operation of the estate will be managed by a process ofprioritisationofworkwithinavailableresources,usingprofessionalexpertise.

TheTrusthasdevelopedaRiskManagementPolicy,andaspartoftheongoingdevelopmentofthis, the Directorate Management Team Operations, in partnership with Operational RiskManagement Team, have developed risk management controls for the estates including riskregisters(DATIX),riskassessments,controlmeasuresandcontingencyplans.

The Trust accepts that due to the nature of its activities there will be risks present in thoseactivitiesandmonitorthese.


3.10 BusinessContinuityPlansBusinessContinuityPlans (BCP)will bemaintained through training and exercise and regularauditandreview, toensure thecontinuityofallestaterequirementsandreactivemaintenance.Business Impact Analysis (BIA) processes will be undertaken by the Estate Managers inconjunction with the Emergency Preparedness Team to ensure that all Estate requirementssupportandintegratewithotherdepartmentalarrangementsandtheoverarchingTrustBCP. TheEstate Business Continuity Management (EBCM) arrangements will be made available to allmembersoftheEstatesTeamandotherTrustdepartments.


4 STATUTORYLEGISLATION

4.1 HealthandSafetyAtWorkEtc.Act1974TheHealthandSafetyatWorketcAct1974,alsoreferredtoasHASAWAorHSW,istheprimarypieceoflegislationcoveringoccupationalhealthandsafetyintheUnitedKingdom.TheHealthandSafetyExecutiveandLocalAuthority is responsible forenforcing theActandanumberofotherActsandStatutoryInstrumentsrelevanttotheworkingenvironment.

Statutory instruments are the secondary types of legislation made under specific Acts ofParliament. These cover a wide range of subjects, from control of asbestos at work, ionisingradiationandworkingatheight.

4.2 TheRegulatoryReform(FireSafety)Order2005ThenewOrdersimplifies,rationalisesandconsolidatesexistingfiresafetylegislation.Itprovidesforariskbasedapproachtofiresafetyallowingmoreefficientandeffectiveenforcementbythefireandrescueservice.

Atthecoreofthelegislationliesthefireriskassessment.Thisisanorganisedappraisalof theTrustsworkactivitiesandtheworkplacetoenabletoidentifypotentialfirehazards,andtodecidewho(includingemployeesandvisitors)mightbeindangerintheeventoffire,andtheirlocation.TheFireSafetyTeamwillthenevaluate therisksarisingfromthehazardsanddecidewhethertheexistingfireprecautionsareadequate,orwhethermoreneedstobedone.

4.3 ControlofSubstancesHazardoustoHealth(COSHH)Regulations(2004)Usingchemicalsorotherhazardoussubstancesatworkcanputpeopleshealthatrisk,causingdiseasesincludingasthma,dermatitisorcancer.

TheCOSHHregulationsrequireemployerstocontrolsubstancesthatcanharmworkers'health.ForFurtherInformationSeeINDG136

4.4 ConfinedSpacesRegulations(1997)A confined space is a place which is substantially enclosed (though not always entirely), andwhere serious injury can occur from hazardous substances or conditions within the space ornearby(e.g.lackofoxygen).

TheseRegulationscontainthefollowingkeyduties: avoidentrytoconfinedspaces,e.g.bydoingtheworkfromtheoutside ifentrytoaconfinedspaceisunavoidable,followasafesystemofwork putinplaceadequateemergencyarrangementsbeforetheworkstart

TheManagementofHealthandSafetyatWorkRegulations1999 requireemployersand selfemployed people to carry out a suitable and sufficient assessment of the risks for all workactivities for the purpose of deciding what measures are necessary for safety. For work inconfinedspacesthismeansidentifyingthehazardspresent,assessingtherisksanddeterminingwhatprecautionstotake.

ForFurtherInformationSeeINDG258

4.5 ProvisionandUseofWorkEquipmentRegulations(PUWER)(1998)The Regulations require risks to peoples health and safety, from equipment that they use atwork,tobepreventedorcontrolled.InadditiontotherequirementsofPUWER,liftingequipmentisalsosubject to the requirementsof theLiftingOperationsandLiftingEquipmentRegulations1998.

TheRegulationsrequirethatequipmentprovidedforuseatworkis: Suitablefortheintendeduse


Safe for use, maintained in a safe condition and, in certain circumstances andinspectedtoensurethisremainsthecase

used only by people who have received adequate information, instruction andtrainingand

accompanied by suitable safety measures, e.g. protective devices, markings,warnings.

WorkequipmentmusthavemetalltherequirementsoftheRegulationsfrom5December1998.ExamplesofuseofequipmentwhicharecoveredbytheRegulationsincludestartingorstoppingtheequipment,repairing,modifying,maintaining,servicing,cleaningandtransporting.


4.6 LiftingOperationsandLiftingEquipmentRegulations(LOLER)(1998)TheLOLERRegulationsaimtoreduceriskstopeopleshealthandsafetyfromliftingequipmentprovided for use at work. In addition to the requirements of LOLER, lifting equipment is alsosubject to the requirements of the Provision and Use of Work Equipment Regulations 1998(PUWER)

TheRegulationsrequirethatliftingequipmentprovided foruseatworkis: strongandstableenoughfortheparticularuseandmarkedtoindicatesafeworking

loads positionedandinstalledtominimiseanyrisks usedsafely,i.e.theworkisplanned,organisedandperformedbycompetentpeople

and subject to ongoing thorough examination and, where appropriate, inspection by

competentpeople


4.7 Construction(DesignandManagement)Regulations(2007)TheseRegulationsconcernoccupationalhealth,safetyandwelfareinconstruction.Theyplaceduties in relation to management arrangements and practical measures on a range ofconstruction project participants, including clients, designers, maintenance workers andcontractors


4.8 PressureSystemsSafetyRegulations(2000)Users and owners of pressure systems are required to demonstrate that they know the safeoperating limits, principally pressure and temperature, of their pressure systems, and that thesystemsaresafeunderthoseconditions.Theyneedtoensurethatasuitablewrittenschemeofexaminationisinplacebeforethesystemis operated. They also need to ensure that the pressure system is actually examined inaccordancewiththewrittenschemeofexamination.


4.9 WorkAtHeightRegulations(2005)

TheWorkatHeightRegulations2005apply toallworkatheightwhere there isariskofa fallliable to cause personal injury. They place duties on employers, the selfemployed, and anyperson who controls the work of others (e.g. facilitiesmanagers or building owners whomaycontractotherstoworkatheight)totheextenttheycontrolthework.

Aplace is atheight ifapersoncouldbe injuredfalling fromit,even if it isatorbelowgroundlevel. Workincludesmovingaroundataplaceofwork(exceptbyastaircase inapermanentworkplace)butnottraveltoorfromaplaceofwork.


5 HEALTHCARESTANDARDSOverarchingdesignandengineeringprinciplesareapplicable toallhealthandcommunitycarebuildingsandthesewereupdatedinJanuary2011.InsomecasesthesehavenowreplacedtheoriginalHTM'sandthedesignersshouldbefullyawareofthesealterations.Abriefoverviewissuppliedherebutfurtherinformationisavailablefromthespaceforhealthwebsite.

5.1 GeneralDesignPrinciples(6946:0.3:England)Thismanualsetsoutgeneraldesignprinciplesforhealthandcommunitycarebuildings.Specificguidanceforindividualclinicalsettingsisavailablewithintheclinicaltopicitself.Designersshouldensure that they read thismanualasawhole, since furtherdesignguidancemaybeoutlinedandcrossreferencedthroughout.

5.2 GeneralEngineeringPrinciples(69898:0.1:England)Thistopicprovidesgeneralguidanceontheengineering,technicalandenvironmentalaspectsofhealthcarebuildingdesign.Specificguidanceforindividualclinicalsettingsisavailablewithintheclinicaltopicitself.Designers should ensure that they read the manual in this topic as a whole, since furtherengineeringguidancemaybeoutlinedandcrossreferencedthroughout.

5.3 PerformanceRequirementsforBuildingElementsUsedinHealthcareFacilities(8941:0.6England)Thismanualoutlines thepolicyandperformancerequirementsforbuildingelementsused inhealthcare facilities. These requirements are a set of essential standards of quality and safetythatbuildingelementsmustcomplywith.

Thebuildingelementsincludedare: Floor,finishesandskirtings Walls/Partitions Ceilingsand SanitaryandPrePlumbedAssemblies

5.4 FireCodeTheFIRECODEtitlesoftheHTM'sseriescontainrequirementsontruststhataremandatory.

5.5 PoliciesandPrinciplesofHealthcareEngineeringHealthcare commissioners should expect that the facilities to which they refer patients shouldprovideasafe,caringenvironmentwhichaidsapatientsrecoveryanddoesnotexposethemtoundue risk. Therefore the resilience of critical engineering services and business continuity linkedtopoliciesforemergencypreparednessandtheabilitytorespondtomajorincidentsishighonNUH'sagenda.Theadditionaldocumentswhichdesignersshouldrefertoforsupportandinformationare: Policy,ContextandRequirementsManual(93034:0.2:England) ProfessionalSupportPolicyManual(3281:0.2:England) EmergencyPreparednessPolicyManual(3227:0.1:England) MaintenancePolicyManual(3277:0.2:England) OperationalPolicyManual(3279:0.2:England) ProfessionalSupportPolicyManual(3281:0.2:England) StatutoryandLegislativeRequirementsManual(3284:0.2:England) Training,InformationandCommunicationsPolicyManual(3286:0.2:England)


5.6 SpecialistEngineeringServicesThefollowingdocumentationwillassistdesignersduring the initialdesignstageofallschemesandshallbeadheredtowhereapplicable:

Acoustics:TechnicalDesignManual(4032:0.3:England) BedheadServices:TechnicalDesignManual(130:0.3:Engand)

5.7 SpecialistEngineeringServicesHealthTechnicalMemorandums(HTM)The HTMs series of publications sets healthcare specific standards for building components suchas,windowsandsanitarywareandthedesignandoperationofengineeringservices,suchas medical gas installations and fire safety requirements. The HTMs are supported by othertechnicalguidance,suchastheModelEngineeringSpecifications.

HTM00PoliciesandPrinciples HTM01Decontamination HTM02MedicalGases HTM03Heating&Ventilation HTM04 Watersystems HTM05Firesafety HTM06Electricalservices HTM07Environmentandsustainability HTM08Specialistservices

5.8 SpecialistEngineeringServicesHealthBuildingNotes(HBN)TheHBN'sareaseriesofpublicationsthatsettheDoH'sbestpracticestandardsintheplanningand design of healthcare facilities. They inform project teams about accommodating specificdepartmentorservicerequirements.

00Coreelements 01Cardiaccare 02Cancercare 03Mentalhealth 04Inpatientcare 05Olderpeople 06Diagnostics 07Renalcare 08Longstaycare 09Children,youngpeopleandmaternity 10Surgery 11Communitycare 12Outpatientcare 13Decontamination 14Medicinemanagement 15Emergencycare 16Pathology.

5.9 HTM00:BestPracticeGuidanceforHealthcareEngineeringThe aim of Health Technical Memorandum 00 is to ensure that everyone concerned with themanaging,design,procurementanduseofthehealthcarefacilityunderstandstherequirementsofthespecialist,criticalbuildingandengineeringtechnologyinvolved.

Only by having a knowledge of these requirements can the organisations board and seniormanagersunderstand theirdutyofcare toprovidesafe,efficient,effectiveandreliablesystemswhicharecriticalinsupportingdirectpatientcare.

By locallyinterpretingand following thisguidance,NUHcandemonstratecompliancewith theirresponsibilitiesandtherebysupportacultureofprofessionalismwhichinstilspublicconfidenceinthecapabilityoftheNHSatlocallevel.


5.10HealthFacilitiesNotes(HFN's)TheHealth FacilitiesNotes (HFNs) address topical subjects, often in response toNHSdriveninitiatives, and aim to provide an insight into the issues. They may draw widely from, andchallenge,trendsintheUK,EuropeandNorthAmerica.HFNsdonotincludeformalpolicyinputfrom the Department of Health. In many cases, HFNs consider a wide range of alternativeoptionsand the implicationsofthoseoptions in termsofcostconsequenceandacceptability tousers.


6 NOTTINGHAM UNIVERSITY HOPSITALS ESTATE &INFRASTRUCTUREPOLICIESThepoliciesandprocedureshavebeenprepared todirectlyassistEstateManagementstaff inthepracticalapplicationoflegislation.Theyaresimplyintendedtoactasapointofreferencetoassiststaffintheirdaytodayroles.

Detailedbelow isa listofallNUHPoliciesandProceduresthatare includedwithintheEstatesOperationsSection:

6.1 AsbestosManagementandControlPolicyandProcedures(NUH)Thepolicycoversthemanagementofasbestos,andappliestoallbuildingsowned,occupiedormaintainedbyNUH.Itcoversactivitieswhereinadvertentexposuretoasbestosmayoccur(e.g.maintenancework,refurbishmentanddemolition).

AllTrustpremiseshavehadaManagementSurveyforasbestosmaterials.Recordsareheldonan external hosted website. Prior to demolition or alteration works a Refurbishment andDemolitionSurveywillbeperformedasappropriate.

ForFurtherInformationSeeControlofAsbestosRegulations2006

6.2 BuildingandEngineeringServicesDisabilityAccessPolicy(NUH)Thispolicyunderpins theprinciplesoftheTrust'sEqualOpportunitiesPolicy inwhich theTrustanditsemployeesarerequirednottodiscriminateagainstpeoplewithdisabilitiesinthefieldofemploymentandintheprovisionsofgoods,facilitiesandservices.Employeesareexpectedtobehaveinanondiscriminatorymannertowardsboththepublicandcolleagues with disabilities. All employees have the right to work in an environment free fromdiscrimination.

ForFurtherInformationSeeBS8300:2009DesignofBuildingsandTheirApproachtoMeettheNeedsofDisabledPeople

6.3 ControlofContractorsPolicy(NUH)The aim of this policy is to establish consistent trust wide standards for the employment,managementandcontrolofcontractorstoworkonbehalfoftheTrustandtoensurecompliancewithallrelevantlegislation.ThetermContractor'meansanyonebroughtinbytheTrusttoworkatorontheTrustspremiseswho is not an employee of the Trust. The term contractor is equally applicable to a subcontractorbutalsoincludesthefollowing:.

Maintenance/Constructionworkers Volunteers Students Agency/bankStaff Consultants NHSProfessionals Locumservices Companyrepresentatives

6.4 ControlofContractorsPolicy&GuidanceBooklet(Estates&Facilities)ThisdocumentdefinesresponsibilitiesforthemanagementofEstatesandFacilitiescontractorsworking on Trusts premises and sets out the arrangements forminimising risk. The EstatesDepartment recognises that the use of contractors is a necessity and that they are employedthroughouttheTrust.WorkundertakenfortheTrustbyanEstateandFacilitiescontractormustbecoveredbyacivilorcommercialcontract. It isgoodpracticeforhealthandsafetyrequirements tobe incorporatedintothecontract,anditshouldbehighlightedthathealthandsafetyresponsibilitiesaredefinedincriminallawandcannotbedelegatedbyacontract.


6.5 ElectricityAtWorkPolicy(NUH)Theaimof thispolicy is toensure that therisks tostaffandothers fromexposure toelectricalhazardsatworkareadequatelycontrolledandthatallelectricalsystemsaremaintainedtoahighstandardbyperforminginserviceinspectionandtesting.

ForFurther InformationSeeHTM0601ElectricalServicesSupplyandDistribution (Part'sA&B) HTM 0602 Electrical Safety Guidance For Low Voltage Systems HTM 0603 ElectricalSafetyGuidanceForHighVoltageSystems.

6.6 HighVoltageSafetyProcedure(Estates&Facilities)The aim of this policy is to ensure all Estates andFacilities staff are aware of the issues andprocedureswhenworkingonthehighvoltagenetworkatNUH. TheTrusthastwohighvoltagenetworks. There is a single ring network on the City campus and a dual ring network on theQueensMedicalCentreCampus.

ForFurther InformationSeeHTM0601ElectricalServicesSupplyandDistribution (Part'sA&B)HTM0603ElectricalSafetyGuidanceForHighVoltageSystems.

6.7 LowVoltageSafetyProcedure(Estates&Facilities)The aim of this policy is to ensure all Estates andFacilities staff are aware of the issues andprocedureswhenworkingonthelow voltagenetworkatNUHTobedevelopedin2011

ForFurther InformationSeeHTM0601ElectricalServicesSupplyandDistribution (Part'sA&B)HTM0602ElectricalSafetyGuidanceForLowVoltageSystems.

6.8 ElectricalStandbyPolicy(NUH)Toensurethatemergencygeneratorsandfixeduninterruptiblepowersystems(BatteryOperated)areprovidedandmaintainedtoenablecontinuityofsupplyintheeventofmainspowerfailuretoessentialservices.Tobedevelopedin2011

ForFurtherInformationSeeHTM0601ElectricalServicesSupplyandDistribution(Part'sA&B)

6.9 EnergyManagementPolicy(NUH)TheaimoftheTrustsenergypolicyistominimisetheuseofenergyconsistentwithoperationalneedstoreduceenergyrelatedcostsandtohelpconserveenergyresourcesgenerally.

ForFurtherInformationSeeHTM0702EncodeMakingEnergyWorkinHealthcare

6.10EnvironmentalManagementPolicy(NUH)TheNUHrecognisesandacceptsitsresponsibilitytominimise,whereverpossible,itsimpactontheenvironmentandtocomplywithallstatutoryenvironmentalrequirements. TheTrustwishestopromote,amongstitsstaff,patientsandvisitors,anunderstandingoftheenvironmentalissuesitfacesandinstilinthemconfidencethatittakesitsresponsibilitiesseriouslyasanenvironmentalagent.Throughproperlydevelopedandexecutedpractices,theTrustseekstosustainandimproveitsownenvironmentandcontributetotheprotectionofthelocal,nationalandglobalenvironments.

ForFurtherInformationSeeHTM0707SustainableHealthandSocialCareBuildings


6.11FireSafetyPolicy(NUH)ThisFireSafetyPolicydocumentsetsout theTrustBoards intentnotonly tocomplywith theirlegalobligations,buttoclearlysetouttheroles,responsibilitiesandmanagementarrangementstoensureminimumimpactoffireonlife,thedeliveryofservice,theenvironmentandproperty.

ForFurtherInformationSeeHTM0503OperationalProvisions(Part'sAtoL)

6.12 InfectionPreventionandControlintheBuiltEnvironmentPolicy(NUH)TheNUHwillensurethatallpartsofthepremisesinwhichitprovideshealthcarearesuitableforpurpose,keptcleanandmaintainedingoodphysicalrepairandcondition.

Toensureaconsistent, robust and designedinapproach to infectionprevention, in relation tobuilding and engineering projects, the Trust will adopt the Department of Health document,HealthFacilityNote30:InfectionControlintheBuiltEnvironment2003,asitsprimaryguidancesourcetoensureaconsistent,robustdesignedinapproachtoinfectionpreventionandcontrolinrelationtobuildingandengineeringprojects.

ForFurtherInformationSeeHFN30InfectionControlInTheBuiltEnvironment

6.13 LegionellaManagementandControlPolicyandProcedure(NUH)The aim of the Policy and Procedure is to introduce a structured Procedure and ReportingSchedule,for theManagementandControlofLegionellosis, includingLegionnairesDisease, incompliancewithcurrentGuidelines.AllTrustpremiseshavehadalegionellariskassessmentcarriedoutwhichisupdatedatintervalsspecifiedinthelegionellamanagementplan.

For Further InformationSeeHTM0401TheControl of Legionella,Hygiene,Safe'HotWater,ColdWaterSystems(Part'sA&B)

6.14 LiftsMaintenanceandManagementPassengerandGoodsLiftPolicy(NUH)TosetoutthedetailedrequirementsforthemaintenanceandsafeoperationofallpassengerandgoodsliftsinNUH.TheliftsaretobemaintainedandservicedsothattheydonotpresenteitheraphysicalrisktopersonsusingtheliftsorastatutorycompliancerisktotheTrust.Tobedevelopedin2011

ForFurtherInformationSeeHTM0802Lifts

6.15 MedicalGasPipelineSystemPolicy(NUH)TheobjectiveofthisOperationalPolicyistoensuretheprovisionofsafeandreliablemedicalgaspipelinesystems,cylinders,associatedequipmentandtheirsafeandefficientoperationanduse.It provides the framework for the effective management of Medical Gas Pipeline Systems(MGPS)withinNUH.

ForFurtherInformationSeeHTM0201MedicalGasPipelineSystems(Part'sA&B)

6.16MedicalGasPipelineSystem Procedure(Estates&Facilities)TheaimofthisprocedureistoensureallEstatesandFacilitiesstaffareawareoftheissuesandprocedureswhenworkingonmedicalgaspipelinesystemprocedureatNUHTobedevelopedin2011

ForFurtherInformationSeeHTM0201MedicalGasPipelineSystems(Part'sA&B)

6.17 PressureSystemsFixedInstallationsPolicy(NUH)Pressurevesselsarevesselsthatcontainliquid,gas,airorsteamundersufficientpressurethatasudden and unexpected release of contents may cause potential harm. Pressure Vessels


operated and/or maintained by the Trust include bench top autoclaves, air compressors andpressurisedheatingsystems.

The scope of this policy includes only fixed installation or permanently positioned pressurevesselsandNOTtransportablepressurisedcylindersTobedevelopedin2011

ForFurtherInformationSeePressureSystemsSafetyRegulations2000

6.18SterilizerMaintenancePolicy(Estates&Facilities)HTM'srequiressterilizersintheTrustconformtolegalrequirements,theminimumspecificationsset out in British and European standards, and any additional requirements of the UK healthdepartments (NHS Estates 1994/97). This means that the Trust must have a documentedschemeofperiodictestsatyearly,quarterly,weeklyand(insomecases)daily intervalsand toensurethatsterilizersaresubjecttoadocumentedschemeofpreventativemaintenance.

It is the responsibility of Estates Operations staff to conduct the tests and preventativemaintenance,butdepartmentmanagershavearesponsibilityforensuringtheEstatesOperationsstaffhaveaccesstothesteriliserssothatthiscanbecompleted.

TheTrustmustalsoensure that there areprocedures forquality controlandsafeworkingaredocumentedandthatthereareproceduresinplacefordealingwithmalfunctions,accidentsanddangerousoccurrences,shouldtheseoccurTobedevelopedin2011

For Further InformationSeeHTM0101Decontamination ofReuseableMedicalDevices andHTM2010Sterilization

6.19 VentilationSystemsMaintenanceandManagementPolicy(NUH)NUH is committed to ensuring that all ventilation/air conditioning equipment is installed,inspected, servicedandmaintained inaccordancewithall of thestatutory legislation toensurethat such equipment does not pose a health or operational risk to either, staff, patients ormembersofthepublicTobedevelopedin2011

ForFurtherInformationSeeHTM0301SpecialisedVentilationForHealthcarePremises(Part'sA&B)

6.20 WardNameManagementPolicyandProcedure(NUH)ThepolicycoversthemanagementoftheTrustsBuilding/Department/WardNames,andappliestoallbuildingsowned,occupiedormaintainedbyNUH.

ForFurtherInformationSeeNHSWayfindingDocument

6.21 WasteManagementPolicy(NUH)NUHwillensure that therequirements,both legislativeandbestpractice,for themanagement,handlinganddisposalofwaste,areobservedinallareasforwhichitisresponsible. TheTrustiscommittedtorecycling(andinsomecasesreusing)asmuchofitswasteaspracticallypossible,recognisingthatsomewasteswhensold(e.g.leadacidbatteries,metalsandelectricalwastes)canprovideasourceofincomeforthehospital.

TheTrustrecognisestheimportanceofcorrectwastedisposalandthepartthatallstaffmustplayto achieve this. Staff will be given training, both at induction and regularly thereafter, in thesegregationandhandlingofwaste.

TheTrustwillinstallandmaintainanadequatelevelofwastedisposalinfrastructure,designedtoencourage a safeworking environment that safeguards patients, staff andvisitors.Wards anddepartmentswillallhaveasuitablewastestoragefacilitywhichiseasilyaccessedbywardstaff


andwasteporters.Eachareawillhavesufficientwastereceptaclestoensurethatanywastecanbesegregatedanddepositedeasilyandcorrectlybystaffwhileworking.

ForFurtherInformationSeeHTM0701SafeManagementofHealthcareWasteHTM0705TheTreatment,RecoveryRecyclingandSafeDisposalofWasteElectricalandElectronicEquipment

6.22 WindowManagementPolicy(NUH)The window installations in NUH properties are of varied types of construction,materials andperformance. NUHintendstosetstandardsandproceduresrelatingtowindowsformaintenanceand operating purposes. It will assist building users, maintenance contractors and others inrespectofcreatingasafeenvironmentandsafeoperationofthewindows.

TheobjectiveofthisPolicyistogiveclearguidanceonmaintenanceandsafeuseespeciallyofopeningwindows.ItisintendedtogiveaclearstatementofbestpracticeintheirusewithinNUHproperties.Tobedevelopedin2011

ForFurtherInformationSeeHTM55Windows

6.23 EstateStoresProcedures(Estates&Facilities)This procedural document is designed to allow the stores staff to operate the Estates Storescorrectly.Itcoversthevariousareasofoperationsuchasreceiving,orderingandtheissuingofstockandtheoperationofthecomputersystem.Thisalsoincludesstockcounts,theproductionofthevariousreports,storesaccessandsecurityarrangements.

6.24 PreferredEquipmentReportandSchedule(Estates&Facilities)Thepurposeofthisdocumentistoidentifythepreferredequipmentandsuppliers,servicingNUHEstatesandFacilitiesManagementDirectorate.

Thekeyrequirementhasbeentocollateaschedule thatwill identifywhatequipment/materialsandsuppliersarepreferredforuseontheEstates,thisdocumentshallthenbeissuedtodesignteamsandcontractorsforreferenceonprojectsand/ormaintenancevisits.

Inaddition tomakingreference tostandardsandguidelines, thedocumentalsoconfirmssomegeneral requirements regarding the environment in which the equipment may be installed,generatingsomebestpracticeprinciples.


7 RELATEDESTATESPROCEDURES

7.1 FourStageRiskModelProgramme(Ultimon)TheFourStageRiskModelwas developed in 2001, it has been successfully been used in anumber of Trusts, as it overcomes themajor problems associatedwith the 5x5 criticality grid.Withemployingaseriesof UtilityFunctions itprovidesa fullyauditablerobustandrepeatabletrail for the assessment and scoring of risk. This resulting score is then, transferred into thestandardNHS5x5gridfordirectinclusionintoatrustsriskregister.

As part of their mandatory governance responsibilities, Boards of NHS organisations need toconduct a review of the effectiveness of their managerial systems of internal control. AscompliancetotheNHSLitigationAuthoritystandardstogetherwithotherprocessesandsystems,givesassurance toallstakeholders thataTrustsmanagerialsystemsaremeeting thenationalcodesofpracticeasaminimum.Thesystemofinternalcontrolshouldbebasedonanongoingrisk management process, and monitoring system via a multiprofessional team. Estatecodeclearlystatesthatfailuretodosocouldleadtocorporateand/orpersonalliability.

Fromtheaforementioned,thereisaneedformanagerstobegintoidentifyinatransparentandauditablemannertherisksthatarebeinggeneratedwithintheirspheresofactivity.Andtoadvisetheir trust seniormanagers and others of the identity and scale of their findings togetherwithdetailed risk treatment plans giving options, manpower, costs and timeframes for the controland/orreductionoftherisks.

National codes of practice provide a framework for trusts to assess theirmanagerial systemsagainst,andtoidentifythoseareasofweaknessthatcouldproduceunacceptablelevelsofrisktothe organisation, staff and patients. However they can only provide a very high level ofassessment,foragreaterdegreeofappraisalamoreindepthandmeaningfulanalysismustbeundertaken.

ThemanagementsoftwareiscalledUltimon.

7.2 SafeControlSystemSafesystemsofworkarecrucialinmanyaspectsoftheworkthatEstates&Facilitiescarryout.

Anumberofactivitieshavebeenidentifiedwherethepotentialrisksarehighandthecarefulcoordinationofactivitiesandprecautionsisessentialtosafeworking.Inthesesituationsandothersofsimilarriskpotential,thepermittowork(PTW)procedurewillbedeployedtoensurethereisasafesystemofworkinplace.

An'Isolation'PTWisrequired,forsituationswhereworkonthefollowingsystemswouldexposepersonstospecifichazards,whereisolationisnotlocal,orisofacomplexnature(twoormoresourcesofsupply)orwhereisolationwouldhaveanimpactonotherusers.

Theareascoveredare: HotWorks ServiceIsolations Asbestos AccesstoConfinedSpaces WorkingatHeights ElectricalHighVoltage ElectricalLowVoltage MedicalGasPipelinesSystems GroundExcavations

FurtherinformationisavailablewithintheDirectorateofEstatesandFacilitiesManagementSafeControlSystem(PermittoWork)DocumentVersion18February2010.


7.2.1 AccesstoServiceAreasAccesstoallserviceareassuchasboilerhouses,calorifierhouses,plantrooms,electricmeterhouses,subways,ductsarecontrolledbytheEstatesDepartmentengineeringandbuildingstaff.

AllcontractorsandTruststaffenteringsuchplacesshallcomplywiththeprotocolprescribedforthearea,andanylocalrulesprevailingatthetime.

Installation of all cables, pipe work, service distribution networks and the like, shall only beundertakenfollowingliaisonwiththeEstatesDepartmentandfollowingapprovalofanappropriateriskassessmentandmethodstatementinaccordancewiththeControlofContractorsGuidance.

7.2.2 AccesstoConfinedSpacesThedefinitionofaconfinedspace isone that is substantiallyenclosedand inwhich there isareasonably foreseeable risk to thehealthandsafetyofpersons fromhazardoussubstancesorconditionswithinthespaceornearby.

NoworkshallbecarriedoutoraccessmadeintoconfinedspacesbyoronbehalfofNUHunless: Itisnotreasonablypracticabletoavoidit Suitableandsufficientriskassessmenthasbeencarriedout Itisinaccordancewithanapprovedsafesystemofworkand Itmeetstherequirementsofavalidpermittowork

Where working within a confined space is unavoidable NUH will take all reasonable steps tosecurethehealthandsafetyofthoseinvolvedinconfinedspacesworking.NUHacknowledgesthesafetyhazardsinherentinconfinedspacesworkingandwillensurethatanyrisksarereducedtoaminimumbycarryingoutriskassessmentsandprovidingsafesystemsofwork.

7.2.3 WorkingatHeightsRoofworkandworkatheightshasconsistentlygiven rise toasubstantialnumberof fatalandseriousincidentseachyear. Thecausesofroofwork incidentsandpreventativemeasuresarewidelyknownandpublicised.NUHwilltakeallreasonablestepstosecurethehealthandsafetyofthoseinvolvedinroofwork.NUHacknowledgesthesafetyhazardsinherentinroofworkandwill ensure that any risks are reduced to a minimum by carrying out risk assessments andprovidingsafesystemsandplacesofwork.

7.2.4 GroundExcavationsExcavation is defined as any surface removal, compaction, indentation, penetration ordisturbance of any ground surface or any subground surface to a depth greater than 200mm(approximately8inches)andincludesanydisturbancesofgroundwhetherbyhandtools,powertoolsandequipmentorbymobiletools,mobilemachineryormobileequipment.

NUHwilltakeallreasonableprecautionstoavoidaccidentsandtosecurethehealthandsafetyof all its employees and also third parties (contractors, visitors, public etc) from the risksassociatedwithexcavations.

7.2.5 AccessaboveSuspendedCeilings,RoofandCeilingVoidsWhenaccessisrequiredtoinstallservicesabovesuspendedceilingsorinroofandceilingvoidsthismustbenotifiedtotheEstatesDepartment. WorkshallonlybeundertakenfollowingliaisonwiththeEstatesDepartmentandfollowingapprovalofariskassessmentandmethodstatementinaccordancewiththeControlofContractorsPolicy(EstatesandFacilities).The cost of any reinstatement and remedial work required on completion of the work will berechargedtothescheme.

7.3 EstatesOperationsDepartmentIssuingofKeysLoanofkeysisavailablethroughtheSecurityDepartmentlocatedonBFlooratQMCandTrustHeadquartersatCity.


7.4 EstatesOperationsDepartmentRecordDrawingsRecords and drawings shall be kept up to date and records completed for all maintenanceactions.AtthehandoverofanewdevelopmenttheEstatesOperationalManagers/Officersshallensure that all statutory asfitted information is received with log books implemented for newsystems.

ThelayoutandproceduresofOperationalandMaintenanceManualsissetoutinSectionA37oftheTrustsContractPreliminarieswithallexternalcontracts.

7.5 EstatesOperationsDepartmentAssetRegisterAnassetregisterisupdatedforallsites,buildings,levels,departments,majorengineeringplant,systemsandequipmentviaasoftwaresystemtoenablelifecyclecoststoberecorded.

Currentinformationheldis: AutomaticDoors BuildingManagementSystems Chillers FireAlarmPanels Lifts LockingSuite Macerators NurseCall SecuritySystems(IntruderAlarms) CCTVCameras SwipeCardAccess

7.6 EstatesOperationsDepartmentStaffTrainingThe DMTO are to ensure that their staff are trained to the standard for the relevant taskundertakenandtheoperativesaretobecompetentpersonsintheirdiscipline.Regularreviewsof training requirements shall be undertaken and refresher training shall be implemented asnecessary.

TheNUHrecognisesthatEstatesOperationsisaspecialistareaoftheservicewithaneedforcontinuingprofessionaldevelopment(CPD). Trainingrecordsshallbekeptuptodateforallstaff.

7.7 EstatesAnnualInspectionRequirements

7.7.1 AnnualFireRiskAssessmentsTo satisfy compliance with the Regulatory Reform (Fire Safety) Order 2005 this particularstatutory requirement is the annual risk assessment that captures evidence that all the other,morefrequentfireriskcontrolmeasures,alsopartofthestatutoryrequirement,areinplace.

Annual fire training for all staff,weekly fire bell testing, regular fire alarm and emergency lighttesting,firedrills,firelogbookateachsite,portablefirefightingequipmentchecksetc. TheFireRiskAssessmentswill identifyactions required tobring theestate toa levelofacceptable riskstatus

7.7.2 GasApplianceTestingAnnualtestandcertificationofallgasappliancesshallbecarriedoutbypersonswhoareontheGasSafeRegister.

7.7.3 ElectricalTestingEachsite requiresamainselectrical (circuit) testevery fiveyearsbyacertified (NIC/EIC/ECAapproved)engineer.Actionsarisingfromeachtestwillidentifytheelectricalrisksandremedialworks required to ensure compliancy. Alterations to any circuits within a premise carried out


betweeneach5yeartestrequiresanewcertificatetobeissuedforthosecircuitswhichshouldberecordedonfilewiththeoriginaltestcertificate.

7.7.4 PortableElectricalApplianceTesting(PAT)Thelevelofinspectionandtestingrequiredisdependentupontheriskoftheappliancebecomingfaulty, which is in turn dependent upon the type of appliance, the nature of its use and theenvironmentinwhichitisused.

7.7.5 AsbestosSurveysEverynondomesticbuildingisrequiredtohaveanasbestosregister,containingtheasbestosriskassessment. The register is required to be updated every year with a survey identifying thecurrentstatusoftheasbestoscondition.Eachsurveywillidentifythepresenceandconditionofanyasbestoswithinthebuildingandanyactionsrequiredtoreducetheriskofcontamination.

Theriskregistershouldbeheldonsiteandshouldbebroughttotheattentionofanyoperativewhoistocarryoutinvasiveworkonthepremisestoenableariskassessmenttobecarriedoutofthe risk of disturbing the asbestos during theworks and the precautions required to close outthoserisks.Priortoanymajorinvasiveworks,aRefurbishmentandDemolitionsurveymustbecarriedouton thepremisesprior tohandover toacontractor.ARefurbishmentandDemolitionsurveycanonlybecarriedoutonavacatedbuildingorsealedpartthereof

7.7.6 WaterSafety(LegionellaandTemperature)Afullwaterservices(Legionella)riskassessmentisdueeverytwoyears. However,thereareanumber of more frequent tests required to be carried out to ensure that premises are beingmaintained to reduce the risk from either contaminated water or water temperature. Some ofthesetestingregimesarerequiredtobecarriedoutweeklyandformpartoftheTrustsPlannedPreventative Maintenance (PPM) schedules which are then tested for compliancy under duediligencetesting

7.7.7 LiftsandHoistsAnannualtestandinsuranceinspectionforallliftsandportableliftingequipmentisrequired.Anyliftorpieceofliftingequipmentwhichfailsitsannualtestshouldbetakenoutofactionuntilthedefectisremedied.LiftswillbeinspectedannuallybyanindependentCompetentPerson.

7.7.8 PressureVesselsSchedulesofregularmaintenanceandinspectionshallbedeterminedforeachPressureVesselhavingregardtothevesselstype,operatingpressure,frequencyofuseandstatutoryobligations.Whereappropriate,PressureVesselswillbe inspectedannuallybyan independentCompetentPerson.

7.7.9 AirConditioningEnergyEfficiencyAuditTomeettherequirementsoftheEuropeanEnergyPerformanceofBuildingsDirective(EPBD)allairconditioningsystemswithaneffectiveratedoutputgreater than12KWmustnowhave theirenergyefficiencyassessedannually.

The reports give information about each individual air conditioning units performance andidentifiesopportunities to reduceCO2emissionsby improvements to themaintenance regime,how the system is operated and recommendations on the specification of a more efficientreplacementsystem.

7.7.10 AuditsTheTrust also has statutory independent audits undertaken on a yearly basis (or less) of thefollowingareas:

LowVoltageNetwork Legionella/WaterManagement(Quarterly) HighVoltageNetwork


MedicalGasPipeworkSystems DecontaminationCompliance AsbestosManagement

TheseareavailableforreviewthroughtheDirectorateManagementTeam

7.8 EstatesAnnualDateCollectionRequirements

7.8.1 EstatesReturnInformationCollectionERICenables theanalysisofEstatesandFacilities information fromNHSTrustsandPCTs inEngland. This is a mandatory response to the DH required annually at the end of April(EmergencyPlanningrequiredattheendofFebruary

ItisacompulsoryrequirementthatNHSTrustssubmitanEstatesReturn.ThisissotheDHcanprovide an indication of the status of Estates and Facilities services in the NHS for theDepartmentofHealth.

ThedevelopmentofthePriorityandPlanningFrameworkandnewNationalStandardshasledtothe data now being used to inform a set of indicators to assess the performance of a TrustsEstatesandFacilitiesServices.OvertimethesewillpermitTruststodemonstrateyearonyearimprovement.

The guidance document, 'A riskbased methodology for establishing and managing backlog',provides trusts with guidance on how to review the estate and indicate immediate and futureinvestment requirements. The guidance was produced in response to Standards for BetterHealth and National Standards, Local Action which set out a new approach to improvingstandardsintheNHS,includingthereductionofbacklogmaintenanceforNHSfacilities.

Theguidancedocumentimprovesonpreviousmethodologiesbytakingintoaccountthedifferentlevelsofrisktopatients,visitorsandstaffarisingfromdeficienciesinstatutorysafetyandphysicalconditionofthebuiltenvironment.Themethodologycontainedinthedocumentthusprovidesarepresentationoftheprioritiesinwhichinvestmentisneeded.AllreturnscanbeviewedagainstothersimilaracuteTrusts.

7.8.2 SixFacetInformationInaccordancewithDepartmentofHealthrequirementsaSixFacetSurveyhasbeenundertakenin2008andisamultifacetedsurveywhichenablesanappraisalofanNHSTrust'sEstateandprovidesasnapshotofthephysicalconditionofindividualbuildings,whichcaninformtheEstatesStrategy.

Theresultsof thesurveyareused todetermineandmanagebacklogmaintenance,alongwithmeasuringriskinrelationtosubstandardassetssothatinvestmentcanbeprioritised.Oncetheriskassociatedwithsubstandardelementshasbeenassessed,capitalandrevenueinvestmentcanbetargeted.

InordertoensureconsistencythesurveyusesthedefinitionsusedbyEstatecode.Theseare: PhysicalConditionSurvey(Fabric&M&E) StatutoryComplianceAudit(incl.Fire) SpaceUtilisationAudit FunctionalSuitabilityReview QualityAudit EnvironmentalManagementAudit

The stock condition survey data is updated on a regular basis to identify and quantify theprojectedworkloadandprovidedetailedinformationonboththeinternalandexternalelementsofthebuilding.

It is envisaged that a continuous rolling programme of stock condition surveys is the mostappropriatemethodforcollationofinformation. Everypropertywillhaveanannualsurvey,bothinternallyandexternallyandacompletesurveyeveryfiveyears.


Suchdataallows for the rapid retrievalof information,permittingexpenditure forecasts,budgetpreparation,andresourcesmoothing.Inadditionitenablesexpendituretobetargetedatareasofgreatestneed.

FurtherdevelopmentsoftheSixFacetSurveyarecurrentlyunderwayinpartnershipwithexternalconsultants.

CopiesoftheSixFacetSurveyDocumentisavailableonrequest,brokendownbyDepartmentsandDirectorates.

Thesixfacetsurveyis reviewedregularlyandupdatedby theDirectorateManagementTeam Operations.

7.8.3 PremisesAssuranceModel(PAM)TheNHSPremisesAssuranceModel (PAM)hasbeendevelopedtosupport thedeliveryof the(QIPP)qualityandproductivity challenge,publicvalueandcarbon reductionprogrammes.Theintention being to introduce a methodology for cross NHS provider

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