1.2 Estate Operational Management Policy & Procedure PDF

ESTATEOPERATIONALMANAGEMENTPOLICYAND
PROCEDURE
DocumentationControl
Reference
ApprovingBody
DateApproved
Implementationdate
Version
Supersedes
Consultationundertaken
HS/EI/
TrustBoard
1
N/A
Directorate of Estate and Facilities
Management, Trust Health and Safety
Committee, Directors' Group and Trust
Board
Date of Completion of 1March2011
EqualityImpactAssessment
Date of Completion of We 1March2011
Are
Here
for
You
Assessment
Date
of
Environmental 18May2011
Impact
Assessment
(if
applicable)
Targetaudience
All Trust staff, occupiers of Trust premises
andcontractors
Supporting Documents and See legislation and guidance section within
References(s)
policydocument.
ReviewDate
March2013
LeadExecutive
DirectorofEstatesandFacilities
Author/LeadManager
HeadofEstatesOperations
FurtherGuidance/Information LeadExecutive/Author/LeadManager
CONTENTS
1
ESTATEOPERATIONALMANAGEMENTPOLICY ............................................................4
1.1
Introduction.................................................................................................................4
1.2
GlossaryofTerms ......................................................................................................4
1.3
Rationale ....................................................................................................................5
1.4
Aims...........................................................................................................................5
1.5
Definitions..................................................................................................................5
1.6
MethodsofDeliveryMaintenance ...............................................................................6
1.7
StatutoryComplianceAudit.........................................................................................6
1.8
PerformanceReport ...................................................................................................6
1.9
LegalDuties ...............................................................................................................7
ROLESANDRESPONSIBILITIES ......................................................................................9
2.1
TrustBoard.................................................................................................................9
2.2
ChiefExecutive...........................................................................................................9
2.3
DirectorofEstateandFacilitiesManagement .............................................................9
2.4
DirectorateManagementTeamCapital...................................................................11
2.5
DirectorateManagementTeamProcurement..........................................................11
2.6
DirectorateManagementTeamClinical&Corporate...............................................11
2.7
Infection,PreventionandControlTeam ....................................................................11
2.8
Employees................................................................................................................11
2.9
ProfessionalStructure...............................................................................................12
MAINTENANCEPRIORITIES ...........................................................................................14
3.1
ReactiveMaintenance ..............................................................................................14
3.2
PlannedPreventativeMaintenance(PPM) ................................................................15
3.3
RechargeableRepairs ..............................................................................................16
3.4
ServiceContracts .....................................................................................................16
3.5
OutofHoursEmergencyMaintenanceService .........................................................16
3.6
MaintenanceRecords...............................................................................................16
3.7
MinorNewWorks(AllWorksLessThan5,000).......................................................17
3.8
CapitalWorks(AllWorksGreaterThan5,000) ........................................................17
3.9
RiskManagement.....................................................................................................17
3.10 BusinessContinuityPlans.........................................................................................18
STATUTORYLEGISLATION ............................................................................................19
4.1
HealthandSafetyAtWorkEtc.Act1974 ..................................................................19
4.2
TheRegulatoryReform(FireSafety)Order2005 ......................................................19
4.3
ControlofSubstancesHazardoustoHealth(COSHH)Regulations(2004)................19
4.4
ConfinedSpacesRegulations(1997) ........................................................................19
4.5
ProvisionandUseofWorkEquipmentRegulations(PUWER)(1998)........................19
4.6
LiftingOperationsandLiftingEquipmentRegulations(LOLER)(1998) ......................20
4.7
Construction(DesignandManagement)Regulations(2007).....................................20
4.8
PressureSystemsSafetyRegulations(2000)...........................................................20
4.9
WorkAtHeightRegulations(2005) ...........................................................................20
HEALTHCARESTANDARDS ...........................................................................................22
5.1
GeneralDesignPrinciples(6946:0.3:England) ..........................................................22
5.2
GeneralEngineeringPrinciples(69898:0.1:England) ................................................22
5.3
PerformanceRequirementsforBuildingElementsUsedinHealthcareFacilities
(8941:0.6England).................................................................................................................22
5.4
FireCode.................................................................................................................22
5.5
PoliciesandPrinciplesofHealthcareEngineering.....................................................22
5.6
SpecialistEngineeringServices ................................................................................23
5.7
SpecialistEngineeringServicesHealthTechnicalMemorandums(HTM) ................23
5.8
SpecialistEngineeringServicesHealthBuildingNotes(HBN) .................................23
5.9
HTM00:BestPracticeGuidanceforHealthcareEngineering....................................23
5.10 HealthFacilitiesNotes(HFN's) .................................................................................24
NOTTINGHAMUNIVERSITYHOPSITALSESTATE&INFRASTRUCTUREPOLICIES..25
6.1
AsbestosManagementandControlPolicyandProcedures(NUH)............................25
6.2
BuildingandEngineeringServicesDisabilityAccessPolicy(NUH)............................25
6.3
ControlofContractorsPolicy(NUH)..........................................................................25
6.4
ControlofContractorsPolicy&GuidanceBooklet(Estates&Facilities) ....................25
6.5
ElectricityAtWorkPolicy(NUH)................................................................................26
6.6
HighVoltageSafetyProcedure(Estates&Facilities)................................................26
6.7
LowVoltageSafetyProcedure(Estates&Facilities) .................................................26
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6.8
ElectricalStandbyPolicy(NUH)................................................................................26
6.9
EnergyManagementPolicy(NUH) ...........................................................................26
6.10 EnvironmentalManagementPolicy(NUH) ................................................................26
6.11 FireSafetyPolicy(NUH)...........................................................................................27
6.12 InfectionPreventionandControlintheBuiltEnvironmentPolicy(NUH) ....................27
6.13 LegionellaManagementandControlPolicyandProcedure(NUH) ............................27
6.14 LiftsMaintenanceandManagementPassengerandGoodsLiftPolicy(NUH) .........27
6.15 MedicalGasPipelineSystemPolicy(NUH)...............................................................27
6.16 MedicalGasPipelineSystemProcedure(Estates&Facilities) ..................................27
6.17 PressureSystemsFixedInstallationsPolicy(NUH).................................................27
6.18 VentilationSystemsMaintenanceandManagementPolicy(NUH) ..........................28
6.19 WardNameManagementPolicyandProcedure(NUH) ............................................28
6.20 WasteManagementPolicy(NUH).............................................................................28
6.21 WindowManagementPolicy(NUH) ..........................................................................29
6.22 EstateStoresProcedures(Estates&Facilities).........................................................29
6.23 PreferredEquipmentReportandSchedule(Estates&Facilities)..............................29
7
RELATEDESTATESPROCEDURES...............................................................................30
7.1
FourStageRiskModelProgramme(Ultimon) ...........................................................30
7.2
SafeControlSystem.................................................................................................30
7.3
EstatesOperationsDepartmentIssuingofKeys .....................................................31
7.4
EstatesOperationsDepartmentRecordDrawings ..................................................32
7.5
EstatesOperationsDepartmentAssetRegister......................................................32
7.6
EstatesOperationsDepartmentStaffTraining ........................................................32
7.7
EstatesAnnualInspectionRequirements................................................................32
7.8
EstatesAnnualDateCollectionRequirements ........................................................34
8
ESTATEOPERATIONALPROCEDURE...........................................................................37
9
RESPONSIBILITES&WORKSUNDERTAKEN................................................................37
9.1
ElectricalMaintenance..............................................................................................37
9.2
MechanicalMaintenance ..........................................................................................37
9.3
BuildingMaintenance................................................................................................38
9.4
Security ....................................................................................................................38
9.5
Energy......................................................................................................................38
9.6
Decontamination.......................................................................................................38
9.7
VacantEstate ...........................................................................................................39
10 EQUALITYANDDIVERSITYSTATEMENT ......................................................................39
11 EQUALITYIMPACTASSESSMENT .................................................................................39
12 ENVIRONMENTALIMPACTASSESSMENT ....................................................................40
13 WEAREHEREFORYOU................................................................................................40
14 IMPLEMENTATIONPLAN ................................................................................................40
15 MONITORINGANDREVIEWING .....................................................................................40
16 APPENDIXA WORKCATEGORIESANDCONSULTATIONPROTOCOL.....................41
17 APPENDIXBASPERGILLUSINTHEENVIRONMENT .................................................43
18 APPENDIXCCONTACTINFORMATION .........................................................................45
19 APPENDIXDEMPLOYEERECORD................................................................................46
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ESTATEOPERATIONALMANAGEMENTPOLICY
1.1 Introduction
The built environment, which is used to accommodate the treatment, diagnosis and care of
patients, service users and staff andmust be provided in aform that thefabric,fixtures,fittings
andservicesminimisetheriskofHealthCareAssociatedInfections(HCAI).
The Health and Safety at Work etc Act 1974, the Management of Health and Safety at Work
Regulations1999andtheConstruction(Designand Management)Regulations2007all impose
specific duties to safeguard the health and safety of those who are and who are not in the
employmentoftheNottinghamUniversityHospitalsNHSTrust. Thesedutiesequallyapplytoa
contractor or subcontractor on Trust premises, in respect of safeguarding our employees,
patientsandvisitors fromtheiractivities.
Nottingham University Hospitals NHS Trust (NUH) is committed to fulfilling the requirements
outlined in the Health Act 2006 Code of Practice for Prevention & Control of Health Care
Associated Infections (Department of Health 2006) revised January 2008, by ensuring that a
PlannedPreventativeMaintenancesystemisinplacetominimisetheriskofHCAI.
In addition, the Trust recognises and accepts the responsibilities outlined by the Care Quality
Commission(October2010)thatitshallmeettheessentialstandardsofqualityandcare.
SpecifictoEstatesOperationsinclude:
Youcanexpecttobesafe
Youwillbecaredforinacleanenvironmentwhereyouareprotectedfrominfection.
Youwillbecaredforinasafeandaccessibleplacethatwillhelpyouasyourecover.
Youwillnotbeharmedbyunsafeorunsuitableequipment.
Youcanexpectyourcareprovidertoconstantlycheckthequalityofitsservice
Yourcareproviderwillcontinuouslymonitorthequalityofitsservicestomakesureyou
aresafe.
Ifyou,orsomeoneactingonyourbehalf,makeacomplaintyouwillbelistenedtoandit
willbeacteduponproperly.
1.2 GlossaryofTerms
AE
AP
BCP
CHC
DEL
DG
DMTO
DP
ERIC
HBN
HFN
HGN
HTM
IPCT
MGPS
MNW
NUH
PAM
PPM
PTW
QMC
SOM
VFM
AuthorisingEngineer
AuthorisedPerson
BusinessContinuityPlans
CityHospitalCampus
DirectlyEmployedLabour
Director'sGroup
DirectorateManagementTeamOperational
DesignatedPerson
EstatesReturnInformationCollection
HealthBuildingNote
HealthFacilityNote
HealthGuidanceNote
HealthTechnicalMemorandum
InfectionPreventionControlTeam
MedicalGasPipelineSystem
MinorNewWorks
NottinghamUniversityHospitalsNHSTrust
PremisesAssuranceModel
PlannedPreventativeMaintenance
PermittoWork
QueensMedicalCentre
SeniorOperationalManager
ValueforMoney
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1.3 Rationale
NUH recognises its legal obligations to take necessary measures in the provision of effective
maintenanceofbuildings,fixedorportableequipment,engineeringplant,systemsandservices.
Thekeyobjectivesofthispolicyare:
Compliancewithstatutoryrequirements
CompliancewiththeCareQualityCommission
CompliancewiththeHealthAct2006
Provisionofasafeenvironment
Toreducehospitalacquiredinfection.
Todefinethedeliveryofaneffectivemaintenanceservice.
Theconceptofprovidingandmaintainingsafeestateservicescarriesahighstatutorypriorityand
appliesacrossthe widestrangeofapplications. Itmustapplytopatients,staffandthegeneral
public, that is, all users of the healthcare environment. In a similar way, the duty of care in
operationalmaintenanceperformancecancontributetowardstheoverallsafetyandefficiencyof
ourhealthcareorganisation.
NUHshallprovideandmaintainsafeandhealthyworkingconditions,equipmentandsystemsof
workforallstaffandvisitorsandtoprovidesuchresources,instruction,training,informationand
supervisionastheyneedforthispurpose.NUHaimstodoallthatisreasonablypracticableto
manageitsbuildingandengineeringservicesandtofollowthestepslaidoutinthisPolicy.
1.4 Aims
Thispolicywill:
Provide guidance to those responsible for the maintenance of healthcare
environments
Assistinmaintainingthevalueoftheestate,extendingtheeconomiclifeofproperty
andengineeringsystemsasfaraspossible
Minimisedisruptiontoensurebusinesscontinuity
Maintainthepatientenvironmentinamannerconducivetohighqualityclinicalcare
Ensure that buildings and all associated services operate at optimum levels of
performanceandwithindesigncriteriaintheusefullifecycle.
Ensure that robust monitoring and reporting mechanisms are in place. This policy
pursuesandexpectsthegoodupkeepofbuildings,engineeringplantandequipment
by regular inspection and maintenance in line with the Department of Health
guidance documents (Health Technical Memorandum series) and other recognised
guidance,legislationandstandards.
MaintenanceofmedicaldevicesiscoveredunderaseparateTrustpolicy.
1.5 Definitions
Forthepurposesofthisdocumentthefollowingdefinitionsapply:
Maintenance: The combination of all the technical and associated administrative
actionsintendedtoretainanitemin,orrestoreitto,astateinwhichitcanperformits
required function. Given due consideration to viability and economic financial
responsibilities
Reactive Maintenance (Breakdown): Operation of restoring an item to fulfil its
original function after a failure in its performance. This is Maintenance that is
required by the customer on a day to day basis to repair faults that occur in
equipment, building fabric or the environmental system. This type of work is
undertaken by directly employed labour (DEL) supplemented by General and
SpecialistContractors.
Planned Preventative Maintenance (PPM): Maintenance carried out at pre
determined intervals or corresponding to predescribed criteria, and intended to
reduce the probability of failure, breakdown or the performance degradation of an
asset.
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Service Contracts: Maintenance carried out by an external contractor at pre

determinedintervals and intended toreduce the probability offailure, breakdown or
theperformancedegradationofanasset.
Outof Hours Emergency Maintenance Service: This service provides a 365 day
maintenance servicethat operates outside of normalworking hours. Itis accessed
through the hospital switchboard. The objective of the Out of Hours Service is to
makesafeplantorequipmentandtorepairorrectifycriticalitemstomaintainasafe
service. Calls are logged by the switch board and the on call directly employed
labour (DEL) tradesman is contacted to attend. If the call out requires assistance,
specialist advice or specialist contractor the On Call Estates Operations
Manager/Officeriscontactedtoassist.
Rechargeable Repairs: These are repairs required following wilful damage to the
Truststructure,fixturesandfittings.
MinorNewWorks:RequestsforimprovementsfromDirectorateswillbefundedvia
aMinorNewWorksrequest(MNW)andtheseformsareavailableontheEstatesand
FacilitiesWebPage. MinorNewWorkshaveacostlimitnotexceedingfivethousand
pounds (5,000). Minor NewWorks include items such as shelving,notice boards,
minordecorations,keycutting,replacementflooring,newsinks,newdatapointsand
newpowersockets.
Capital Works: Request for improvements from Directorates which will be greater
than five thousand pounds (5,000) will have to be approved by the Trusts
InvestmentGovernanceCommittee(IGC).
1.6 MethodsofDeliveryMaintenance
MaintenanceisdeliveredbythreemethodsthatmayemploytheuseofDEL,generalcontractors
orspecialistcontractors.
Thespecificworkofthesegroupsare supervisedbytheEstatesOperationsManagers,Estates
Operations Officers and Team Leaders who are accountable for obtaining quotations, placing
orders, supervising and certifying completion in accordance with the Trusts Standing Financial
InstructionsandStandingOrdersforcontractors.
ForDELlabourtheymustensureaneffectiveandefficientservicethatdemonstratesbestvalue.
Audittrailsexistforthesemethodsofdeliveryasrecordsmayberequestedtodemonstratework
undertakenforlitigationpurposes.
1.7 StatutoryComplianceAudit
On a two yearly basis a statutory compliance audit will be undertaken by external consultants
appointedbytheDirectorofEstatesandFacilities.Themethodologyoftheauditwillbetoreview
with the Directorate Management Team Operations through interviews and inspections of
recordshowtheyarecomplyingwithstatutesandhowtheyaresatisfactorilydischarged.
Arandom selectionofbuildingsareinspectedbythe EstatesOperationsManagertoverifythat
statutory maintenance has been carried out, that all documentation is available and has been
correctlycertified.Areportwillbeissuedandcorrectiveactionsheetwillbeprovided.Thiswill
bereportedtotheAuditCommitteeonanannualbasis.
1.8 PerformanceReport
Amonthly report will be providedto the OperationalManagement Team on the performance of
theOperationalServiceandprogressoncorrectiveactionsheetsissuedfollowingaudits.
Thereportwillidentifyactivitymeasuresincluding:
NumberofemergencyOutofHourscalls
Numberofreactivemaintenancerequestsreceived.
%ofreactivemaintenancerequestscompletedwithinresponsetimeframes.
Numberofstatutoryplannedpreventativemaintenancejobsissued.
% of statutory planned preventative maintenance jobs completed within response
timeframes.
Identifycriticalincidents.
Stockrotationandholding.
Complaintsandcomments.
Trainingundertaken.
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Paymentsofinvoiceswithin30days
Appraisalsundertaken
Sicknessrate
Legislativechangesandimplications.
1.9 LegalDuties
Acts:
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.
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DepartmentofHealthGuidance
HealthFacilitiesNotes
HeathBuildingNotes
HealthGuidanceNotes
HealthTechnicalMemorandums
EstateCode
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ROLESANDRESPONSIBILITIES
TrustBoard
ChiefExecutive
DirectorofEstatesandFacilities
DeputyDirectorofEstatesandFacilities
AssistantHeadofEstates
Operations(CityCampus)
AssistantHeadofEstates
Operations(QMC&Ropewalk)
EstatesOperationsManagers&
Officers
EstatesOperationsManagers&
Officers
Building
Stores
(NUH)
Electrical
Security
Mechanical
(Infrastructure)
(NUH)
Building
Energy Electrical
(NUH)
Mechanical
Decontam ination
(NUH)
2.1 TrustBoard
TheTrustBoardhasoverallaccountabilityforalltheactivitiesoftheorganisation,whichincludes
themanagementandmaintenanceoftheTrustsestate.
Thisincludesthefollowing:
landandpropertymatters
planningstrategicinvestmentintheestate
landandpropertyappraisal
assetmanagement
buildingmaintenance
engineeringmaintenance
energymanagement.
TheTrustBoarddelegatestheresponsibilityforthemanagementandmaintenanceoftheestate
totheChiefExecutive.
2.2 ChiefExecutive
The Chief Executive has the ultimate managerial responsibility for the management and
maintenanceoftheestateanddelegatestheoperationaldaytodayresponsibilityandauthorityto
the Director of Estate and Facilities Management who will manage, maintain and control the
estateassetoutinthispolicyandotherrelatedpolicies.
2.3 DirectorofEstateandFacilitiesManagement
TheDirectorofEstatesandFacilitieswilloperatethemanagementandcontrolsystemsoutlined
inthispolicyandproceduredocument.
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2.3.1 DirectorateManagementTeam Operations

TheDirectorateManagementTeamhaveoverallresponsibilityforthedeliveryoftheOperational
ServicesandBudget. ThisteamcomprisesoftheHeadofEstatesOperationsandtheAssistant
Head(s)ofEstates forCityCampusandQueensMedicalCentre/RopewalkCampuses
2.3.2 EstatesOperationalManagersandOperationalOfficers
The Estates Operational Managers/Officers have a responsibility to ensure that their staff are
instructed,trained,informedandsupervisedandaresuitablycompetenttocarryouttheirrolesin
asafe,effectiveandefficientmanner.
The EstatesOperationalManagers/Officersare the designated officersfor estates maintenance
services. This position fulfils the role of Responsible/Authorised Person (AP) for specialist
engineering and building services (these appointments are site specific). Operational
management of estates services includes building, engineering, equipment, specialist
maintenance and grounds and gardens with appropriate maintenance programmes and an
annualreviewofmaintenanceactivities
Operationalmanagementofestateservicesincludes:
building
engineering
equipment
specialistmaintenanceand
groundsandgardens.
Allserviceshaveanappropriatemaintenanceprogrammeandanannualreviewofmaintenance
activities.
The Estates Operational Managers/Officers are responsible for the implementation of the
operationalrequirementsofthispolicywhichinclude:
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&ShiftTechnician
The Team Leaders provide daytoday supervision and support to their specific discipline to
ensure that the section is able to provide give the highest level of safe, courteous and efficient
servicetothebuildingsusers.
TheDay/ShiftTechniciansareemployedtoworkacrossbothengineeringdisciplines(mechanical
and electrical). Their higher level of responsibility includes steam boilers and CHP plant, lifts,
compressors, medical gas systems, fire systems, emergency generators, electrical, heating,
cooling and water systems, drains and the sitewide air tube conveyor and security access
systems.
ShiftTechnicians(Outofhours)willalsobethekeypersoninrespondingtofirealarms,persons
trapped in lifts and mechanical and electrical engineering emergencies. They will carry out
plannedmaintenancedutiesinoperatingtheatresandotherareasoflimitedaccess,butwillalso
respondtoengineeringmaintenancefaultsandbreakdownsthroughoutthesite.
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2.3.4 Craftsmen
Thecraftsmenprovidesskilledinstallationand/ormaintenanceofspecialistservicesand willbe
directed, appointed, or authorised to work (if a contractor) by their Team Leader dependant on
the work involved. Maintenance Assistantsand Maintenance Assistants (Higher Level) provide
semiskilledsupporttothisrolewithdirectionfromTeamLeaders.
2.4 DirectorateManagementTeam Capital

The Head of Capital Projects/Procure21+CapitalProjects Director is responsibleforthe overall
programmemanagement of all Estate Capital schemes. The Directorate Management Team
Capitalwillensureallnewworksareefficientintermsofvalueformoney(VFM),energyusage,
reducing future maintenance requirements and to comply with relevant HTM/HBNs and other
legislation. The Head of Capital Projects/Procure21+Capital Projects Directorwill also monitor
progress of agreed schemes and prepare and issue reports to inform and advise Trust Senior
Managementonamonthlybasis.
2.5 DirectorateManagementTeam Procurement

TheProcurementDepartmentisresponsibleforensuringthatTrustestatesservicesareprocured
viaalegallytenderedprocurementrouteandthattheTrustsStandingFinancialInstructionsare
complied with. This includes national, regional and negotiated framework and contract
agreements. A collaborative approach is adopted between Estates and the Procurement
Department.
2.6 DirectorateManagementTeam Clinical&Corporate

Directorate Management Teams are responsible for ensuring that their staff are aware of their
dutytoreportbuildingandengineeringdefects,breakdownsandrepairsthroughtheappropriate
channels (Web Helpdesk [Non Emergency] and Switchboard [Emergency] and also to operate
the building and its equipment in a safe and appropriate way with appropriate training and
competency.
2.7 Infection,PreventionandControlTeam
It is the responsibility of the Infection Prevention and Control Team (IPCT) to provide specific
input and support for all matters relating to the hospital environment, maintenance of hospital
buildingsandengineeringsystemsandtoworkwithEstatesOperations.
Thiswillincludetheprovisionof:
Education for maintenance staff and management on infection prevention and control
andthereductioninHCAIs
Guidanceandsupportwhenadviceoncontrollingtheenvironmentisrequired
Adviceonriskassessmentsforcontrollingtheenvironment
Identifyprioritiesforaction
Assistinginreducingriskcausedbyaspergillusduringworks(SeeAppendixB).
2.8 Employees
AllTrustemployees(includingagencystaffandcontractstaff)haveadutyofcaretoeachother
assetoutwithintheHealthandSafetyatWorkActandtocooperatewiththeiremployerandnot
to tamper with safety devices and to reports defects and failures in accordance with Trust
procedures. They should also comply with reporting systems with regard to building and plant
faults.
Further information on the role of contractors can be found in the NUH Control of Contractors
Policyandthe'EFMControlofContractorsPolicy'.
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2.9 ProfessionalStructure
While the Chief Executive and the Trust Board carry ultimate responsibility for the safe and
securehealthcareenvironmentthestructurebelowrepresentstheprofessionaladoptedapproach
tothedeliveryofhighriskimpactspecialistserviceswithinNUH.Theseincludethemanagement
of high voltage electricity, low voltage electricity, decontamination, medical gas pipelines,
asbestos,watersafetyandquality,ventilationsystems,lifts,pressuresystemsetc.
Designated
Person
Appointedsenior
executive
(boardlevel)with
assigned
responsibilityfor
service
Authorising
Engineer
Authorised
Person
Appointed
independent
professionalengineer
(specifictoservice)
Appointedqualified
technicalengineer
(specificto
service)
TrustSenior
Operational
Manager
Informedclient/intelligent
customer
Competent
Person
Assessedand
qualified
craftsperson
(specifictoservice)
2.9.1 DesignatedPerson
This person provides the essential senior management link between the organisation and
professionalsupport,whichalsoprovidesindependenceoftheauditreportingprocess. TheDP
will also provide an informed position at board level. The DP will work closely with the Senior
OperationalManagertoensurethatprovisionismadetoadequatelysupportspecialistservices.
2.9.2 TrustSeniorOperationalManager(SOM)
The SOM may have operational and professional responsibility for a wide range of specialist
services.ItisimportantthattheSOMhasaccesstorobust,servicespecificprofessionalsupport
which can promote and maintain the role of the informed client within the healthcare
organisation. This will embrace both maintenance and the development of servicespecific
improvements support the provision of the intelligent customer role and give assurance of
servicequality.
2.9.3 AuthorisingEngineer(AE)
The AE acts as an independent professional adviser to the healthcare organisation. The AE
shouldbeappointedbytheorganisationwithabrieftoprovideservicesinaccordancewithHealth
TechnicalMemorandumguidance. Thismayvaryinaccordancewiththespecialistservicebeing
supported.
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The AE will act as assessor and make recommendations for the appointment of Authorised
Persons, monitor the performance of the service, and provide an annual audit to the DP. To
effectivelycarryoutthisrole,particularlywithregardtoaudit,itispreferablethattheAEremains
independentoftheoperationalstructureofthetrust.
2.9.4 AuthorisedPerson(AP)
The Authorised Person(s) have the key operational responsibility for high risk impact specialist
engineeringservicessuchasmedicalgasesandhighvoltageworks. Theappointedpersonwill
be qualified, sufficiently experienced and skilled tofully operate the specialist service. The AP
will be nominated by the AE and appointed by the SOM (or Chief Executive) and be able to
demonstrate:
his/herapplicationthroughfamiliarisationwiththesystem
attendanceatanappropriateprofessionalcourse
alevelofexperience
andevidenceofknowledgeandskills.
The Estates Operational Managers/Officers fulfil these roles and the appointments are site
specific.
An important element of this role is the maintenance of records, quality of service and
maintenanceofsystemsafety(integrity).TheAPisresponsibleforestablishingandmaintaining
the roles and validation of Competent Persons, who may be employees of the organisation or
appointedcontractors.TheTrust hasmorethanone APforaparticularservice.Administrative
duties such as recordkeeping are assigned to specific APs and recorded in the related
operationalpolicies.
2.9.5 CompetentPerson(CP)
The Competent Person(s) are skilled in the installation and/or maintenance of the specialist
service.TheCPwillbeappointed,orauthorisedtowork(ifacontractor),bytheAPandbeable
todemonstrate:
asoundtradebackground,qualificationsandspecificskillsetinthespecialistservice
he/she will work under the direction of the AP and in accordance with operating
procedures,policiesandstandardsoftheserviceasdeterminedbyNUH.
TheTeamLeaders,DayTechnicians,ShiftTechniciansandCraftsmenfulfil theserolesandthe
appointmentsaresitespecific.
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MAINTENANCEPRIORITIES
The Trust deploys specialist software to assist with the delivery, monitoring, and control of
procedures associated with maintaining and improving the provision of healthcare such as re
active maintenance and planned preventative maintenance. It is via this software that the
requestorslogforassistanceisrecordedandmanaged.
Reactive maintenance requests can be logged quickly, and the requestors have access to
interrogate the database without the need to navigate around the software. The requestor can
check the current status of any maintenance request, and review full request history enabling
queriestobeansweredimmediately.
Alibraryofstandardclientrequestsareavailabletoassistinthereportingofmaintenanceissues
andenablesfrequentissuestobeprioritisedandgroupedtogether.
Planned Preventative Maintenance iscarried out using the same software and this enables the
DirectorateManagementTeamtomonitorprogressagainststatutorylegislationandcompliance.
The specialist software enables the Directorate Management Team to maintain a plan/service
historybyrecordingworkdone,breakdownsetc,whichassistsinprioritisingplantandequipment
replacementprogrammes.
Appendix A highlights the differing type of work that the Estate Operations undertake and the
consultationprotocolthatshallbefollowed.Theworkiscategorisedasfollows:
Category1LowHazard:ReactiveMaintenance(Room)
Category2LowHazard:ReactiveMaintenance(CommonArea)
Category3LowHazardServiceShutDown:ReactiveorPlannedPreventative
MaintenanceRequiringaLocalServiceShutDown
Category4MediumHazardServiceShutDown:ReactiveorPlannedPreventative
MaintenanceRequiringServiceShutDown
Category5MediumHazard:PrePlannedLargerWork
Category6HighHazard:PrePlannedLargeScaleWorkCapitalDevelopment&
Demolition.
3.1 ReactiveMaintenance
ReactiveMaintenancecanbesummarisedunderthefollowingpoints:
Reactive maintenance can generally be defined as a single order which complies

withstandingfinancialinstructions.
All reactive maintenance will be carried out with minimum disruption to the
DirectoratesandDepartmentsoftheTrustviagoodcommunicationlinks.
All requests are channelled via the Estates Webpage/Help Desk where they are
logged,givenauniquenumberthatisalsoprovidedtothecustomer,apriorityforthe
workisagreedagainstspecificcriteriaandtheworkloggedonthecomputersystem.
On completion of the work, costs are calculated and the date of completion is
entered.
The EstatesWebsite gives 24 hour access for the logging of reactivemaintenance
works.
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(Estatecode
Definitions),thisalsoincludesexamplesofcertainsituations(thislistisnotexhaustive):
ImmediateresponsePriority1Situationsthatcouldcausedangerordistressto
patients or prevent an essential service from being provided. Examples include
floods (either from pipework or leaking roofs), glazing (where security or safety is
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compromised),electrical(lossofpowertoanarea/buildingorbareelectricalcables),
passengerlifts(personstrappedinalift),gasleaksandfirealarms
Within 8 hours Priority 2 Situations that will degrade to an emergency if not

addressed within this time band. Examples include no heating, no water, lighting
(whereitprovidestheonlyilluminationinanarea)andlightsonstaircases
Within24hoursPriority3Situationsthatcausemajordisruptiontoservicesbut
donotcausedangerorpreventtheprovisionofpatientcare.Examplesincludeno
hotwater,Showernotworking(whereitistheonlyone),localisedelectricalfailure,
securitylighting,blockedtoiletsordrains,liftsoutofaction,corridorlightingandno
heating.
Within3daysPriority4Situationsthataffectserviceswithoutcausingdistressto
patients.
Within7daysPriority5Situationsthatwillcauseaminordisruptiontoservices.
Within 14 days or agreed deadlines Priority 6 Situations that will not directly
disruptservicesbutcauseinconvenience.
Within28daysoragreeddeadlinesPriority7Developmentwork,upgradesor
nonurgentrepairs
The Directorate Management Team Operational staff are responsible, for the quality of the
maintenance service provided and shall carry out a 1 in 10 job post inspection, to determine
satisfactory completion and acceptable workmanship and to authorise appropriate payment for
thework(Generalandspecialistcontractors).
All budgets for reactive maintenance are controlled by the Directorate Management Team
OperationalManagerswhoareresponsiblefortheirmanagement.
AllrequestsformaintenancearetobereportedthroughtheEstatesDirectorateswebsiteEstates
HelpdeskLink
3.2 PlannedPreventativeMaintenance(PPM)
Planned preventive maintenance is regular, scheduled work carried out to keep equipment in
goodworkingorderandtooptimizeitsefficiency,costeffectivenessandavailability. Thisactivity
involvesregular,routinecleaning,lubricating,testing,calibratingandadjusting,checkingforwear
andtearandeventuallyreplacingcomponentstoavoidbreakdown.
Most of the work that the Directorate Management Team Operational carry out is unseen by
Directorates and Departments and this is the planned maintenance. Planned maintenance is
carriedoutinaccordancewithschedulesarrangedbytheEstatesOperationsManagers,Estates
Operations Officers, Team Leaders and also manufacturer's recommendations and warranty
criteria.
Thisserviceisnotusuallyrequestedbyheadsofdepartments,andthemaintenanceoftheestate
iscarriedoutaccordingtotheannualprogrammewhichisreviewedannuallyorwherethereisa
major service change. However each head of department will be informed of any planned
maintenanceinorthatmayaffecttheirspecificareasofresponsibility.
If a head of department is concerned about any item in their area which is on the planned
maintenance schedule they should discuss the matter directly with the Estates Operations
Managers.
PPMworksarenormallycarriedoutduringworkinghourstotheagreedschedule.
TherearetwotypesofPPM's:
Statutory Maintenance is undertaken to comply with statutes and underpinning
regulations relating to the building/engineering elements within a building and
operationsundertakenfromthepremisessuchas5yearlyfixedwiringtests,portable
appliance testing, asbestos management, management of water systems, lift
inspections,pressuresystems.
Mandatory / Business Critical Maintenance iscarriedout under the recommendation
madebyorganisationsthatarenotenshrinedinstatutebutwillbereferredtoasbest
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practiceinacoronerscourt,acriminalorcivilactionfordamagesagainsttheTrustor
individual officers of the Trust. These include Approved Codes of Practice, British
Standards, ISO Standards, Hospital Technical Memorandum(s) and manufacturers
recommendedinstructions.
3.3 RechargeableRepairs
Thesearerepairsrequiredfollowing wilfuldamagetotheNUH structure,fixturesandfittingsby
staff,patientsandvisitors.Thiscouldincludethelossofnursecallhandsets,vandalismandloss
of keys. If required relevant authorities such as the police would be informed to investigate
furtherthroughtheSecurityManagementTeam.
3.4 ServiceContracts
Servicecontractsrequiremoreconsiderationfromtheclientside,asinherentinthefunctionofa
service contract is the partial transfer of risk and responsibility from the Estates Operations
Departmenttothecontractor.
Equipmentofacomplexorspecialistnatureisusuallycoveredbyaservicecontract.Response
timefor repairs mayvary depending on the terms of the contract. Information regarding these
termscanbesuppliedbytheEstatesOperationsManagers.
An example of a service contract for NUH is all grounds and gardens works (including snow
clearanceandgritting)whichiscarriedoutbycontractgroundsstaff.Conditionsaremonitored
duringthewintermonthstoensurethatroadsandfootpathsaremaintained. Anotherexampleis
thespecialistmaintenanceofalltheNUHlifts.
3.5 OutofHoursEmergencyMaintenanceService
There are a range of situations and activities within the Hospital that require some form of
emergencyoncallarrangementtoensurehealthandsafetyandbusinesscontinuityfor24hours
aday,7daysa week.Exampleswillbereasonablylimited,asmostsituationscanbedeferred
anddealtwithduringnormalworkinghours.
The service provided by the Estates Operations Department for out of hours emergency
maintenance is to isolate and make safe. Individuals are not expected to remain on Hospital
premiseswhilstoncall.However,theywillbeexpectedandrequired,byvirtueofthisagreement,
torespondtocallsduringtheironcallperiodandtodealwiththemappropriatelyandwithina
reasonabletimeframe,includingattendanceattheworkplaceifnecessary.Theindividualwillnot
be permitted to refer the call on to others, unless it has been directed to them inappropriately.
Individualsareexpectedtofulfilresponsibilitiesarisingasaresultofbeingoncalltoacceptable
standards.
3.5.1 SupportLevels
Therearetwotypesofsupportasfollows:
LevelOneSupport
Thistypeofsupportismanagementcoverwhenthereisaseriousuntowardincidentsuchas
amajordisaster.
LevelTwoSupport
Thistypeofsupportallowsstafftobecontactedinordertoprovidesupportoutsidethestaff
membersnormalhoursofwork. Thememberofstaffisavailableduringnonworkinghours
and the member of staff will decide whether the emergency can be dealt with, without
attendingsite,ortorequestadditionalsupportthroughcontractors.
3.6 MaintenanceRecords
Records kept by the Maintenance Section include details of the existing condition of a building
togetherwithdetailsof,servicesandpastmaintenancehistory
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AtthehandoverofanewdevelopmenttheCapitalTeamwillmakeavailableanoperationaland
maintenance manual including as built drawings to provide a description and details of
construction relevant to the design and fittings provided within a scheme, and its ongoing
maintenancerequirements.
In addition, the consultant will provide at handoverto the Trust a Health and Safetyfilefor the
respective building, in compliance with the Construction Design and Management Regulations
2007.
TheinformationforthesettingoutofmaintenanceoperationalmanualscanbefoundinSection
A37offormOTF6fromtheCapitalTeam.
AnanalysisofstatisticsandappropriaterecordsystemswillenabletheTrusttoidentifyitsfuture
maintenanceissues.Inparticularitwillhighlightanyprematurefailureofcomponents,ensuring
thatreplacement/renewalismadewithhigherqualityfixturesandfittingscapableofwithstanding
everydayuseinahealthcareenvironment.
AnapprovedlistoffixturesandfittingsisavailablefromtheEstatesOperationsTeam.
3.7 MinorNewWorks(AllWorksLessThan5,000)
Wherealterationsorimprovementsarerequiredtheserequiretobespecificallyfunded,normally
fromanappropriaterevenuebudget.ForthistypeofworkaMinorNewWorksForm(Available
fromtheIntranet)willbecompletedbytherequestingDirectorateorDepartmentandshouldbe
submittedtotheMinorNewWorksTeam(electronically).
Forexampletheworkmightcompriseofreconfiguringandredecoratingasmalloffice,providing
adjustableshelving,suspendedceilingsorachangeoffloorcoverings.Forworkofthisnaturea
site visit is organised, the Estates person will confirm the requirements, provide a specification
completewithanestimateofcostfortherequiredworks.
AllminornewworksarepricedandmanagedbytheCapitalTeamandnotEstatesOperations.
MinorNewWorksWebsiteLink
3.8 CapitalWorks(AllWorksGreaterThan5,000)
Capitalexpenditureisdefinedasexpenditureonatangibleproductiveresourcewithanexpected
life in excess of one year. The items will usually require repair and maintenance. The
capitalisationthresholdhasbeendeterminedasexpenditureof5,000(includingVATwherethis
isnotrecoverable).
AllworksandqueriesregardingcapitalworksshouldbediscussedwiththeFinanceDepartment
orInvestmentGovernanceCommitteecontacts inthefirstinstance.
3.9
RiskManagement
The associated risks with the operation of the estate will be managed by a process of
prioritisationofworkwithinavailableresources,usingprofessionalexpertise.
TheTrusthasdevelopedaRiskManagementPolicy,andaspartoftheongoingdevelopmentof
this, the Directorate Management Team Operations, in partnership with Operational Risk
Management Team, have developed risk management controls for the estates including risk
registers(DATIX),riskassessments,controlmeasuresandcontingencyplans.
The Trust accepts that due to the nature of its activities there will be risks present in those
activitiesandmonitorthese.
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3.10 BusinessContinuityPlans
Business Continuity Plans (BCP) will be maintained through training and exercise and regular
audit and review, to ensure the continuity of all estate requirements and reactivemaintenance.
Business Impact Analysis (BIA) processes will be undertaken by the Estate Managers in
conjunction with the Emergency Preparedness Team to ensure that all Estate requirements
supportandintegratewithotherdepartmentalarrangementsandtheoverarchingTrustBCP. The
Estate Business Continuity Management (EBCM) arrangements will be made available to all
membersoftheEstatesTeamandotherTrustdepartments.
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STATUTORYLEGISLATION
4.1 HealthandSafetyAtWorkEtc.Act1974
TheHealthandSafetyatWorketcAct1974,alsoreferredtoasHASAWAorHSW,istheprimary
pieceoflegislationcoveringoccupationalhealthand safetyintheUnitedKingdom.TheHealth
and Safety Executive and Local Authority is responsible for enforcing the Act and a number of
otherActsandStatutoryInstrumentsrelevanttotheworkingenvironment.
Statutory instruments are the secondary types of legislation made under specific Acts of
Parliament. These cover a wide range of subjects, from control of asbestos at work, ionising
radiationandworkingatheight.
4.2 TheRegulatoryReform(FireSafety)Order2005
ThenewOrdersimplifies,rationalisesandconsolidatesexistingfiresafetylegislation.Itprovides
forariskbasedapproachtofiresafetyallowingmoreefficientandeffectiveenforcementbythe
fireandrescueservice.
Atthecoreofthelegislationliesthefireriskassessment.Thisisanorganisedappraisalof the
Trustsworkactivitiesandtheworkplacetoenabletoidentifypotentialfirehazards,andtodecide
who(includingemployeesandvisitors)mightbeindangerintheeventoffire,andtheirlocation.
The Fire Safety Team willthen evaluate the risks arisingfromthe hazards and decide whether
theexistingfireprecautionsareadequate,orwhethermoreneedstobedone.
4.3 ControlofSubstancesHazardoustoHealth(COSHH)Regulations(2004)
Usingchemicalsorotherhazardoussubstancesatworkcanputpeopleshealthatrisk,causing
diseasesincludingasthma,dermatitisorcancer.
TheCOSHHregulationsrequireemployerstocontrolsubstancesthatcanharmworkers'health.
ForFurtherInformationSeeINDG136
4.4 ConfinedSpacesRegulations(1997)
A confined space is a place which is substantially enclosed (though not always entirely), and
where serious injury can occur from hazardous substances or conditions within the space or
nearby(e.g.lackofoxygen).
TheseRegulationscontainthefollowingkeyduties:
avoidentrytoconfinedspaces,e.g.bydoingtheworkfromtheoutside
ifentrytoaconfinedspaceisunavoidable,followasafesystemofwork
putinplaceadequateemergencyarrangementsbeforetheworkstart
The Management of Health and Safety at Work Regulations 1999 require employers and self
employed people to carry out a suitable and sufficient assessment of the risks for all work
activities for the purpose of deciding what measures are necessary for safety. For work in
confinedspacesthismeansidentifyingthehazardspresent,assessingtherisksanddetermining
whatprecautionstotake.
4.5 ProvisionandUseofWorkEquipmentRegulations(PUWER)(1998)
The Regulations require risks to peoples health and safety, from equipment that they use at
work,tobepreventedorcontrolled.InadditiontotherequirementsofPUWER,liftingequipment
is also subject to the requirements of the Lifting Operations and Lifting Equipment Regulations
1998.
TheRegulationsrequirethatequipmentprovidedforuseatworkis:
Suitablefortheintendeduse
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Safe for use, maintained in a safe condition and, in certain circumstances and
inspectedtoensurethisremainsthecase
used only by people who have received adequate information, instruction and
trainingand
accompanied by suitable safety measures, e.g. protective devices, markings,

warnings.
WorkequipmentmusthavemetalltherequirementsoftheRegulationsfrom5December1998.
ExamplesofuseofequipmentwhicharecoveredbytheRegulationsincludestartingorstopping
theequipment,repairing,modifying,maintaining,servicing,cleaningandtransporting.
4.6 LiftingOperationsandLiftingEquipmentRegulations(LOLER)(1998)
TheLOLERRegulationsaimtoreduceriskstopeopleshealthandsafetyfromliftingequipment
provided for use at work. In addition to the requirements of LOLER, lifting equipment is also
subject to the requirements of the Provision and Use of Work Equipment Regulations 1998
(PUWER)
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,safetyand welfareinconstruction.Theyplace
duties in relation to management arrangements and practical measures on a range of
construction project participants, including clients, designers, maintenance workers and
contractors
4.8 PressureSystemsSafetyRegulations(2000)
Users and owners of pressure systems are required to demonstrate that they know the safe
operating limits, principally pressure and temperature, of their pressure systems, and that the
systemsaresafeunderthoseconditions.
Theyneedtoensurethatasuitablewrittenschemeofexaminationisinplacebeforethesystem
is operated. They also need to ensure that the pressure system is actually examined in
accordancewiththewrittenschemeofexamination.
4.9 WorkAtHeightRegulations(2005)
TheWork at Height Regulations 2005 apply to all work at height where there is a risk of a fall
liable to cause personal injury. They place duties on employers, the selfemployed, and any
person who controls the work of others (e.g. facilities managers or building owners who may
contractotherstoworkatheight)totheextenttheycontrolthework.
A place is at height if a person could be injuredfalling fromit, even if itis at or below ground
level. Workincludes moving around at a place of work (except by a staircase in a permanent
workplace)butnottraveltoorfromaplaceofwork.
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HEALTHCARESTANDARDS
Overarching design and engineering principles are applicable to all health and community care
buildingsandthesewereupdatedinJanuary2011.Insomecasesthesehavenowreplacedthe
originalHTM'sandthedesigners shouldbefullyawareofthesealterations.Abriefoverviewis
suppliedherebutfurtherinformationisavailablefromthespaceforhealthwebsite.
5.1 GeneralDesignPrinciples(6946:0.3:England)
Thismanualsetsoutgeneraldesignprinciplesforhealthandcommunitycarebuildings.Specific
guidanceforindividualclinicalsettingsisavailablewithintheclinicaltopicitself.
Designers should ensure that they read this manual as a whole, since further design guidance
maybeoutlinedandcrossreferencedthroughout.
5.2 GeneralEngineeringPrinciples(69898:0.1:England)
Thistopicprovidesgeneralguidanceontheengineering,technicalandenvironmentalaspectsof
healthcarebuildingdesign.Specificguidanceforindividualclinicalsettingsisavailablewithinthe
clinicaltopicitself.
Designers should ensure that they read the manual in this topic as a whole, since further
engineeringguidancemaybeoutlinedandcrossreferencedthroughout.
5.3 PerformanceRequirementsforBuildingElementsUsedinHealthcareFacilities
(8941:0.6England)
Thismanual outlines the policy and performance requirementsfor building elements used in
healthcare facilities. These requirements are a set of essential standards of quality and safety
thatbuildingelementsmustcomplywith.
Thebuildingelementsincludedare:
Floor,finishesandskirtings
Walls/Partitions
Ceilingsand
SanitaryandPrePlumbedAssemblies
5.4 FireCode
TheFIRECODEtitlesoftheHTM'sseriescontainrequirementsontruststhataremandatory.
5.5 PoliciesandPrinciplesofHealthcareEngineering
Healthcare commissioners should expect that the facilities to which they refer patients should
provideasafe,caringenvironmentwhichaidsapatientsrecoveryanddoesnotexposethemto
undue risk. Therefore the resilience of critical engineering services and business continuity
linkedtopoliciesforemergencypreparednessandtheabilitytorespondtomajorincidentsis
highonNUH'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)
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5.6 SpecialistEngineeringServices
The following documentation will assist designers during the initial design stage of all schemes
andshallbeadheredtowhereapplicable:
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,such
as medical gas installations and fire safety requirements. The HTMs are supported by other
technicalguidance,suchastheModelEngineeringSpecifications.
HTM00PoliciesandPrinciples
HTM01Decontamination
HTM02MedicalGases
HTM03Heating&Ventilation
HTM04 Watersystems
HTM05Firesafety
HTM06Electricalservices
HTM07Environmentandsustainability
HTM08Specialistservices
5.8 SpecialistEngineeringServicesHealthBuildingNotes(HBN)
TheHBN'sareaseriesofpublicationsthatsettheDoH'sbestpracticestandardsintheplanning
and design of healthcare facilities. They inform project teams about accommodating specific
departmentorservicerequirements.
00Coreelements
01Cardiaccare
02Cancercare
03Mentalhealth
04Inpatientcare
05Olderpeople
06Diagnostics
07Renalcare
08Longstaycare
09Children,youngpeopleandmaternity
10Surgery
11Communitycare
12Outpatientcare
13Decontamination
14Medicinemanagement
15Emergencycare
16Pathology.
5.9 HTM00:BestPracticeGuidanceforHealthcareEngineering
The aim of Health Technical Memorandum 00 is to ensure that everyone concerned with the
managing,design,procurementanduse ofthehealthcarefacilityunderstandstherequirements
ofthespecialist,criticalbuildingandengineeringtechnologyinvolved.
Only by having a knowledge of these requirements can the organisations board and senior
managers understand their duty of care to provide safe, efficient, effective and reliable systems
whicharecriticalinsupportingdirectpatientcare.
By locallyinterpreting and following this guidance, NUH can demonstrate compliance with their
responsibilitiesandtherebysupportacultureofprofessionalismwhichinstilspublicconfidencein
thecapabilityoftheNHSatlocallevel.
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5.10 HealthFacilitiesNotes(HFN's)
The Health Facilities Notes (HFNs) address topical subjects, often in response to NHS driven
initiatives, and aim to provide an insight into the issues. They may draw widely from, and
challenge,trendsintheUK,EuropeandNorthAmerica.HFNsdonotincludeformalpolicyinput
from the Department of Health. In many cases, HFNs consider a wide range of alternative
options and the implications ofthose options in terms of cost consequence and acceptability to
users.
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NOTTINGHAM UNIVERSITY
INFRASTRUCTUREPOLICIES
HOPSITALS
ESTATE
&
The policies and procedures have been prepared to directly assist Estate Management staff in
thepracticalapplicationoflegislation.Theyaresimplyintendedtoactasapointofreferenceto
assiststaffintheirdaytodayroles.
Detailed below is a list of all NUH Policies and Proceduresthat are included withinthe Estates
OperationsSection:
6.1 AsbestosManagementandControlPolicyandProcedures(NUH)
Thepolicycoversthemanagementofasbestos,andappliestoallbuildingsowned,occupiedor
maintainedbyNUH.Itcoversactivitieswhereinadvertentexposuretoasbestosmayoccur(e.g.
maintenancework,refurbishmentanddemolition).
AllTrustpremiseshavehadaManagementSurveyforasbestosmaterials.Recordsareheldon
an external hosted website. Prior to demolition or alteration works a Refurbishment and
DemolitionSurveywillbeperformedasappropriate.
ForFurtherInformationSeeControlofAsbestosRegulations2006
6.2 BuildingandEngineeringServicesDisabilityAccessPolicy(NUH)
This policy underpins the principles ofthe Trust's Equal Opportunities Policy in which the Trust
anditsemployeesarerequirednottodiscriminateagainstpeople withdisabilitiesinthefieldof
employmentandintheprovisionsofgoods,facilitiesandservices.
Employeesareexpectedtobehaveinanondiscriminatorymannertowardsboththepublicand
colleagues with disabilities. All employees have the right to work in an environment free from
discrimination.
ForFurtherInformationSeeBS8300:2009DesignofBuildingsandTheirApproachtoMeetthe
NeedsofDisabledPeople
6.3 ControlofContractorsPolicy(NUH)
The aim of this policy is to establish consistent trust wide standards for the employment,
managementandcontrolofcontractorstoworkonbehalfoftheTrustandtoensurecompliance
withallrelevantlegislation.
ThetermContractor'meansanyonebroughtinbytheTrusttoworkatorontheTrustspremises
who is not an employee of the Trust. The term contractor is equally applicable to a sub
contractorbutalsoincludesthefollowing:.
Maintenance/Constructionworkers
Volunteers
Students
Agency/bankStaff
Consultants
NHSProfessionals
Locumservices
Companyrepresentatives
6.4 ControlofContractorsPolicy&GuidanceBooklet(Estates&Facilities)
Thisdocumentdefinesresponsibilitiesforthemanagementof EstatesandFacilitiescontractors
working on Trusts premises and sets out the arrangements for minimising risk. The Estates
Department recognises that the use of contractors is a necessity and that they are employed
throughouttheTrust.
WorkundertakenfortheTrustbyanEstateandFacilitiescontractormustbecoveredbyacivilor
commercial contract. Itis good practicefor health and safety requirements to be incorporated
intothecontract,anditshouldbehighlightedthathealthandsafetyresponsibilitiesaredefinedin
criminallawandcannotbedelegatedbyacontract.
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6.5 ElectricityAtWorkPolicy(NUH)
The aim of this policy is to ensure that the risks to staff and others from exposure to electrical
hazardsatworkareadequatelycontrolledandthatallelectricalsystemsaremaintainedtoahigh
standardbyperforminginserviceinspectionandtesting.
For Further Information See HTM 0601 Electrical Services Supply and Distribution (Part's A &
B) HTM 0602 Electrical Safety Guidance For Low Voltage Systems HTM 0603 Electrical
SafetyGuidanceForHighVoltageSystems.
6.6 HighVoltageSafetyProcedure(Estates&Facilities)
The aim of this policy is to ensure all Estates and Facilities staff are aware of the issues and
procedures when workingonthehighvoltagenetworkatNUH. TheTrusthastwohighvoltage
networks. There is a single ring network on the City campus and a dual ring network on the
QueensMedicalCentreCampus.
B)HTM0603ElectricalSafetyGuidanceForHighVoltageSystems.
6.7 LowVoltageSafetyProcedure(Estates&Facilities)
The aim of this policy is to ensure all Estates and Facilities staff are aware of the issues and
procedureswhenworkingonthelow voltagenetworkatNUH
Tobedevelopedin2011
B)HTM0602ElectricalSafetyGuidanceForLowVoltageSystems.
6.8 ElectricalStandbyPolicy(NUH)
Toensurethatemergencygeneratorsandfixeduninterruptiblepowersystems(BatteryOperated)
areprovidedandmaintainedtoenablecontinuityofsupplyintheeventofmainspowerfailureto
essentialservices.
Tobedevelopedin2011
ForFurtherInformationSeeHTM0601ElectricalServicesSupplyandDistribution(Part'sA&B)
6.9 EnergyManagementPolicy(NUH)
TheaimoftheTrustsenergypolicyistominimisetheuseofenergyconsistentwithoperational
needstoreduceenergyrelatedcostsandtohelpconserveenergyresourcesgenerally.
ForFurtherInformationSeeHTM0702EncodeMakingEnergyWorkinHealthcare
6.10EnvironmentalManagementPolicy(NUH)
TheNUHrecognisesandacceptsitsresponsibilitytominimise,whereverpossible,itsimpacton
theenvironmentandtocomplywithallstatutoryenvironmentalrequirements. TheTrustwishes
topromote,amongstitsstaff,patientsandvisitors,anunderstandingoftheenvironmentalissues
itfacesandinstilinthemconfidencethatittakesitsresponsibilitiesseriouslyasanenvironmental
agent.
Throughproperlydevelopedandexecutedpractices,theTrustseekstosustainandimproveits
ownenvironmentandcontributetotheprotectionofthelocal,nationalandglobalenvironments.
ForFurtherInformationSeeHTM0707SustainableHealthandSocialCareBuildings
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6.11FireSafetyPolicy(NUH)
This Fire Safety Policy document sets out the Trust Boards intent not only to comply with their
legalobligations,buttoclearlysetouttheroles,responsibilitiesandmanagementarrangements
toensureminimumimpactoffireonlife,thedeliveryofservice,theenvironmentandproperty.
ForFurtherInformationSeeHTM0503OperationalProvisions(Part'sAtoL)
6.12 InfectionPreventionandControlintheBuiltEnvironmentPolicy(NUH)
TheNUHwillensurethatallpartsofthepremisesinwhichitprovideshealthcarearesuitablefor
purpose,keptcleanandmaintainedingoodphysicalrepairandcondition.
To ensure a consistent, robust and designedin approach to infection prevention, in relation to
building and engineering projects, the Trust will adopt the Department of Health document,
HealthFacilityNote30:InfectionControlintheBuiltEnvironment2003,asitsprimaryguidance
sourcetoensureaconsistent,robustdesignedinapproachtoinfectionpreventionandcontrolin
relationtobuildingandengineeringprojects.
ForFurtherInformationSeeHFN30InfectionControlInTheBuiltEnvironment
6.13 LegionellaManagementandControlPolicyandProcedure(NUH)
The aim of the Policy and Procedure is to introduce a structured Procedure and Reporting
Schedule,for the Management and Control of Legionellosis, including Legionnaires Disease, in
compliancewithcurrentGuidelines.
AllTrustpremiseshavehadalegionellariskassessmentcarriedoutwhichisupdatedatintervals
specifiedinthelegionellamanagementplan.
For Further Information See HTM 0401 The Control of Legionella, Hygiene, Safe' Hot Water,
ColdWaterSystems(Part'sA&B)
6.14 LiftsMaintenanceandManagementPassengerandGoodsLiftPolicy(NUH)
Tosetoutthedetailedrequirementsforthemaintenanceandsafeoperationofallpassengerand
goodsliftsinNUH.Theliftsaretobemaintainedandservicedsothattheydonotpresenteither
aphysicalrisktopersonsusingtheliftsorastatutorycompliancerisktotheTrust.
Tobedevelopedin2011
ForFurtherInformationSeeHTM0802Lifts
6.15 MedicalGasPipelineSystemPolicy(NUH)
TheobjectiveofthisOperationalPolicyistoensuretheprovisionofsafeandreliablemedicalgas
pipelinesystems,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)
TheaimofthisprocedureistoensureallEstatesandFacilitiesstaffareawareoftheissuesand
procedureswhenworkingonmedicalgaspipelinesystemprocedureatNUH
Tobedevelopedin2011
ForFurtherInformationSeeHTM0201MedicalGasPipelineSystems(Part'sA&B)
6.17 PressureSystemsFixedInstallationsPolicy(NUH)
Pressurevesselsarevesselsthatcontainliquid,gas,airorsteamundersufficientpressurethata
sudden and unexpected release of contents may cause potential harm. Pressure Vessels
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operated and/or maintained by the Trust include bench top autoclaves, air compressors and
pressurisedheatingsystems.
The scope of this policy includes only fixed installation or permanently positioned pressure
vesselsandNOTtransportablepressurisedcylinders
Tobedevelopedin2011
ForFurtherInformationSeePressureSystemsSafetyRegulations2000
6.18SterilizerMaintenancePolicy(Estates&Facilities)
HTM'srequiressterilizersintheTrustconformtolegalrequirements,theminimumspecifications
set out in British and European standards, and any additional requirements of the UK health
departments (NHS Estates 1994/97). This means that the Trust must have a documented
scheme of periodictests at yearly, quarterly, weekly and (in some cases) daily intervals and to
ensurethatsterilizersaresubjecttoadocumentedschemeofpreventativemaintenance.
It is the responsibility of Estates Operations staff to conduct the tests and preventative
maintenance,butdepartmentmanagershavearesponsibilityforensuringtheEstatesOperations
staffhaveaccesstothesteriliserssothatthiscanbecompleted.
The Trust must also ensure that there are procedures for quality control and safe working are
documentedandthatthereareproceduresinplacefordealingwithmalfunctions,accidentsand
dangerousoccurrences,shouldtheseoccur
Tobedevelopedin2011
For Further Information See HTM 0101 Decontamination of Reuseable Medical Devices and
HTM2010Sterilization
6.19 VentilationSystemsMaintenanceandManagementPolicy(NUH)
NUH is committed to ensuring that all ventilation/air conditioning equipment is installed,
inspected, serviced and maintained in accordance with all of the statutory legislation to ensure
that such equipment does not pose a health or operational risk to either, staff, patients or
membersofthepublic
Tobedevelopedin2011
ForFurtherInformationSeeHTM0301SpecialisedVentilationForHealthcarePremises(Part's
A&B)
6.20 WardNameManagementPolicyandProcedure(NUH)
ThepolicycoversthemanagementoftheTrustsBuilding/Department/WardNames,andapplies
toallbuildingsowned,occupiedormaintainedbyNUH.
ForFurtherInformationSeeNHSWayfindingDocument
6.21 WasteManagementPolicy(NUH)
NUH will ensure that the requirements, both legislative and best practice,for the management,
handlinganddisposalofwaste,areobservedinallareasforwhichitisresponsible. TheTrustis
committedtorecycling(andinsomecasesreusing)asmuchofitswasteaspracticallypossible,
recognisingthatsome wastes when sold(e.g.leadacidbatteries,metalsand electricalwastes)
canprovideasourceofincomeforthehospital.
TheTrustrecognisestheimportanceofcorrectwastedisposalandthepartthatallstaffmustplay
to achieve this. Staff will be given training, both at induction and regularly thereafter, in the
segregationandhandlingofwaste.
TheTrustwillinstallandmaintainanadequatelevelofwastedisposalinfrastructure,designedto
encourage a safe working environment that safeguards patients, staff and visitors. Wards and
departmentswillallhaveasuitablewastestoragefacilitywhichiseasilyaccessedbywardstaff
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andwasteporters.Eachareawillhavesufficientwastereceptaclestoensurethatanywastecan
besegregatedanddepositedeasilyandcorrectlybystaffwhileworking.
ForFurtherInformationSeeHTM0701SafeManagementofHealthcareWasteHTM0705The
Treatment,RecoveryRecyclingandSafeDisposalofWasteElectricalandElectronicEquipment
6.22 WindowManagementPolicy(NUH)
The window installations in NUH properties are of varied types of construction, materials and
performance. NUHintendstosetstandardsandproceduresrelatingtowindowsformaintenance
and operating purposes. It will assist building users, maintenance contractors and others in
respectofcreatingasafeenvironmentandsafeoperationofthewindows.
TheobjectiveofthisPolicyistogiveclearguidanceonmaintenanceandsafeuseespeciallyof
openingwindows.ItisintendedtogiveaclearstatementofbestpracticeintheirusewithinNUH
properties.
Tobedevelopedin2011
ForFurtherInformationSeeHTM55Windows
6.23 EstateStoresProcedures(Estates&Facilities)
This procedural document is designed to allow the stores staff to operate the Estates Stores
correctly.Itcoversthevariousareasofoperationsuchasreceiving,orderingandtheissuingof
stockandtheoperationofthecomputersystem.Thisalsoincludesstockcounts,theproduction
ofthevariousreports,storesaccessandsecurityarrangements.
6.24 PreferredEquipmentReportandSchedule(Estates&Facilities)
Thepurposeofthisdocumentistoidentifythepreferredequipmentandsuppliers,servicingNUH
EstatesandFacilitiesManagementDirectorate.
The key requirement has been to collate a schedule that will identify what equipment/materials
andsuppliersarepreferredforuseontheEstates,thisdocumentshallthenbeissuedtodesign
teamsandcontractorsforreferenceonprojectsand/ormaintenancevisits.
In addition tomaking reference to standards and guidelines, the document also confirms some
general requirements regarding the environment in which the equipment may be installed,
generatingsomebestpracticeprinciples.
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RELATEDESTATESPROCEDURES
7.1 FourStageRiskModelProgramme(Ultimon)
The Four Stage Risk Model was developed in 2001, it has been successfully been used in a
number of Trusts, as it overcomes the major problems associated with the 5x5 criticality grid.
With employing a series of Utility Functions it provides a fully auditable robust and repeatable
trail for the assessment and scoring of risk. This resulting score is then, transferred into the
standardNHS5x5gridfordirectinclusionintoatrustsriskregister.
As part of their mandatory governance responsibilities, Boards of NHS organisations need to
conduct a review of the effectiveness of their managerial systems of internal control. As
compliancetotheNHSLitigationAuthoritystandardstogetherwithotherprocessesandsystems,
gives assurance to all stakeholders that a Trusts managerial systems are meeting the national
codesofpracticeasaminimum.Thesystemofinternalcontrolshouldbebasedonanongoing
risk management process, and monitoring system via a multiprofessional team. Estatecode
clearlystatesthatfailuretodosocouldleadtocorporateand/orpersonalliability.
Fromtheaforementioned,thereisaneedformanagerstobegintoidentifyinatransparentand
auditablemannertherisksthatarebeinggeneratedwithintheirspheresofactivity.Andtoadvise
their trust senior managers and others of the identity and scale of their findings together with
detailed risk treatment plans giving options, manpower, costs and timeframes for the control
and/orreductionoftherisks.
National codes of practice provide a framework for trusts to assess their managerial systems
against,andtoidentifythoseareasofweaknessthatcouldproduceunacceptablelevelsofriskto
the organisation, staff and patients. However they can only provide a very high level of
assessment,foragreaterdegreeofappraisalamoreindepthandmeaningfulanalysismustbe
undertaken.
ThemanagementsoftwareiscalledUltimon.
7.2 SafeControlSystem
SafesystemsofworkarecrucialinmanyaspectsoftheworkthatEstates&Facilitiescarryout.
Anumberofactivitieshavebeenidentifiedwherethepotentialrisksarehighandthecarefulco
ordinationofactivitiesandprecautionsisessentialtosafeworking.Inthesesituationsandothers
ofsimilarriskpotential,thepermittowork(PTW)procedurewillbedeployedtoensurethereisa
safesystemofworkinplace.
An'Isolation'PTWisrequired,forsituationswhereworkonthefollowingsystemswouldexpose
personsto specifichazards,whereisolationisnotlocal,orisofacomplexnature(twoormore
sourcesofsupply)orwhereisolationwouldhaveanimpactonotherusers.
Theareascoveredare:
HotWorks
ServiceIsolations
Asbestos
AccesstoConfinedSpaces
WorkingatHeights
ElectricalHighVoltage
ElectricalLowVoltage
MedicalGasPipelinesSystems
GroundExcavations
FurtherinformationisavailablewithintheDirectorateofEstatesandFacilitiesManagementSafe
ControlSystem(PermittoWork)DocumentVersion18February2010.
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7.2.1 AccesstoServiceAreas
Accesstoallserviceareas such asboilerhouses,calorifierhouses,plantrooms,electricmeter
houses,subways,ductsarecontrolledbytheEstatesDepartmentengineeringandbuildingstaff.
AllcontractorsandTruststaffenteringsuchplacesshallcomplywiththeprotocolprescribedfor
thearea,andanylocalrulesprevailingatthetime.
Installation of all cables, pipe work, service distribution networks and the like, shall only be
undertakenfollowingliaisonwiththeEstatesDepartmentandfollowingapprovalofanappropriate
riskassessmentandmethodstatementinaccordancewiththeControlofContractorsGuidance.
7.2.2 AccesstoConfinedSpaces
The definition of a confined space is one that is substantially enclosed and in which there is a
reasonably foreseeable risk to the health and safety of persons from hazardous substances or
conditionswithinthespaceornearby.
NoworkshallbecarriedoutoraccessmadeintoconfinedspacesbyoronbehalfofNUHunless:
Itisnotreasonablypracticabletoavoidit
Suitableandsufficientriskassessmenthasbeencarriedout
Itisinaccordancewithanapprovedsafesystemofworkand
Itmeetstherequirementsofavalidpermittowork
Where working within a confined space is unavoidable NUH will take all reasonable steps to
securethehealthandsafetyofthoseinvolvedinconfinedspacesworking.NUHacknowledges
thesafetyhazardsinherentinconfinedspacesworkingandwillensurethatanyrisksarereduced
toaminimumbycarryingoutriskassessmentsandprovidingsafesystemsofwork.
7.2.3 WorkingatHeights
Roof work and work at heights has consistently given rise to a substantial number of fatal and
seriousincidentseachyear. Thecauses ofroofwork incidentsandpreventativemeasuresare
widelyknownandpublicised.NUHwilltakeallreasonablestepstosecurethehealthandsafety
ofthoseinvolvedinroofwork.NUHacknowledgesthesafetyhazardsinherentinroofworkand
will ensure that any risks are reduced to a minimum by carrying out risk assessments and
providingsafesystemsandplacesofwork.
7.2.4 GroundExcavations
Excavation is defined as any surface removal, compaction, indentation, penetration or
disturbance of any ground surface or any subground surface to a depth greater than 200mm
(approximately8inches)andincludesanydisturbancesofgroundwhetherbyhandtools,power
toolsandequipmentorbymobiletools,mobilemachineryormobileequipment.
NUHwilltakeallreasonableprecautionstoavoidaccidentsandtosecurethehealthandsafety
of all its employees and also third parties (contractors, visitors, public etc) from the risks
associatedwithexcavations.
7.2.5 AccessaboveSuspendedCeilings,RoofandCeilingVoids
Whenaccessisrequiredtoinstallservicesabovesuspendedceilingsorinroofandceilingvoids
thismustbenotifiedtotheEstatesDepartment. Workshallonlybeundertakenfollowingliaison
withtheEstatesDepartmentandfollowingapprovalofariskassessmentandmethodstatement
inaccordancewiththeControlofContractorsPolicy(EstatesandFacilities).
The cost of any reinstatement and remedial work required on completion of the work will be
rechargedtothescheme.
7.3 EstatesOperationsDepartmentIssuingofKeys
LoanofkeysisavailablethroughtheSecurityDepartmentlocatedonBFlooratQMCandTrust
HeadquartersatCity.
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7.4 EstatesOperationsDepartmentRecordDrawings
Records and drawings shall be kept up to date and records completed for all maintenance
actions.AtthehandoverofanewdevelopmenttheEstatesOperationalManagers/Officersshall
ensure that all statutory asfitted information is received with log books implemented for new
systems.
ThelayoutandproceduresofOperationalandMaintenanceManualsissetoutinSectionA37of
theTrustsContractPreliminarieswithallexternalcontracts.
7.5 EstatesOperationsDepartmentAssetRegister
Anassetregisterisupdatedforallsites,buildings,levels,departments,majorengineeringplant,
systemsandequipmentviaasoftwaresystemtoenablelifecyclecoststoberecorded.
Currentinformationheldis:
AutomaticDoors
BuildingManagementSystems
Chillers
FireAlarmPanels
Lifts
LockingSuite
Macerators
NurseCall
SecuritySystems(IntruderAlarms)
CCTVCameras
SwipeCardAccess
7.6 EstatesOperationsDepartmentStaffTraining
The DMTO are to ensure that their staff are trained to the standard for the relevant task
undertakenandtheoperativesaretobecompetentpersonsintheirdiscipline.Regularreviews
of training requirements shall be undertaken and refresher training shall be implemented as
necessary.
TheNUHrecognisesthatEstatesOperationsisaspecialistareaoftheservicewithaneedfor
continuingprofessionaldevelopment(CPD). Trainingrecordsshallbekeptuptodateforallstaff.
7.7 EstatesAnnualInspectionRequirements
7.7.1 AnnualFireRiskAssessments
To satisfy compliance with the Regulatory Reform (Fire Safety) Order 2005 this particular
statutory requirement is the annual risk assessment that captures evidence that all the other,
morefrequentfireriskcontrolmeasures,alsopartofthestatutoryrequirement,areinplace.
Annual fire training for all staff, weekly fire bell testing, regular fire alarm and emergency light
testing,firedrills,firelogbookateachsite,portablefirefightingequipmentchecksetc. TheFire
Risk Assessments will identify actions required to bring the estate to a level of acceptable risk
status
7.7.2 GasApplianceTesting
Annualtestandcertificationofallgasappliancesshallbecarriedoutbypersonswhoareonthe
GasSafeRegister.
7.7.3 ElectricalTesting
Each site requires a mains electrical (circuit) test every five years by a certified (NIC/EIC/ECA
approved)engineer.Actionsarisingfromeachtestwillidentifytheelectricalrisksandremedial
works required to ensure compliancy. Alterations to any circuits within a premise carried out
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betweeneach5yeartestrequiresa newcertificatetobeissuedforthosecircuitswhichshould
berecordedonfilewiththeoriginaltestcertificate.
7.7.4 PortableElectricalApplianceTesting(PAT)
Thelevelofinspectionandtestingrequiredisdependentupontheriskoftheappliancebecoming
faulty, which is in turn dependent upon the type of appliance, the nature of its use and the
environmentinwhichitisused.
7.7.5 AsbestosSurveys
Everynondomesticbuildingisrequiredtohaveanasbestosregister,containingtheasbestosrisk
assessment. The register is required to be updated every year with a survey identifying the
currentstatusoftheasbestoscondition.Eachsurveywillidentifythepresenceandconditionof
anyasbestoswithinthebuildingandanyactionsrequiredtoreducetheriskofcontamination.
Theriskregistershouldbeheldonsiteand shouldbebroughttotheattentionofanyoperative
whoistocarryoutinvasiveworkonthepremisestoenableariskassessmenttobecarriedoutof
the risk of disturbing the asbestos during the works and the precautions required to close out
thoserisks.Priortoanymajorinvasiveworks, aRefurbishmentandDemolitionsurveymustbe
carried out on the premises prior to handover to a contractor. A Refurbishment and Demolition
surveycanonlybecarriedoutonavacatedbuildingorsealedpartthereof
7.7.6 WaterSafety(LegionellaandTemperature)
Afullwaterservices(Legionella)riskassessmentisdueeverytwoyears. However,therearea
number of more frequent tests required to be carried out to ensure that premises are being
maintained to reduce the risk from either contaminated water or water temperature. Some of
thesetestingregimesarerequiredtobecarriedoutweeklyandformpartoftheTrustsPlanned
Preventative Maintenance (PPM) schedules which are then tested for compliancy under due
diligencetesting
7.7.7 LiftsandHoists
Anannualtestandinsuranceinspectionforallliftsandportableliftingequipmentisrequired.Any
liftorpieceofliftingequipmentwhichfailsitsannualtestshouldbetakenoutofactionuntilthe
defectisremedied.LiftswillbeinspectedannuallybyanindependentCompetentPerson.
7.7.8 PressureVessels
SchedulesofregularmaintenanceandinspectionshallbedeterminedforeachPressureVessel
havingregardtothevesselstype,operatingpressure,frequencyofuseandstatutoryobligations.
Where appropriate, Pressure Vessels will be inspected annually by an independent Competent
Person.
7.7.9 AirConditioningEnergyEfficiencyAudit
TomeettherequirementsoftheEuropeanEnergyPerformanceofBuildingsDirective(EPBD)all
airconditioning systems with an effective rated output greater than 12KWmust now have their
energyefficiencyassessedannually.
The reports give information about each individual air conditioning units performance and
identifies opportunities to reduce CO2 emissions by improvements to the maintenance regime,
how the system is operated and recommendations on the specification of a more efficient
replacementsystem.
7.7.10 Audits
The Trust also has statutory independent audits undertaken on a yearly basis (or less) of the
followingareas:
LowVoltageNetwork
Legionella/WaterManagement(Quarterly)
HighVoltageNetwork
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MedicalGasPipeworkSystems
DecontaminationCompliance
AsbestosManagement
TheseareavailableforreviewthroughtheDirectorateManagementTeam
7.8 EstatesAnnualDateCollectionRequirements
7.8.1 EstatesReturnInformationCollection
ERIC enables the analysis of Estates and Facilities information from NHS Trusts and PCTs in
England. This is a mandatory response to the DH required annually at the end of April
(EmergencyPlanningrequiredattheendofFebruary
ItisacompulsoryrequirementthatNHSTrustssubmitanEstatesReturn.ThisissotheDHcan
provide an indication of the status of Estates and Facilities services in the NHS for the
DepartmentofHealth.
ThedevelopmentofthePriorityandPlanningFrameworkandnewNationalStandardshasledto
the data now being used to inform a set of indicators to assess the performance of a Trusts
EstatesandFacilitiesServices.Overtimethese willpermitTruststodemonstrateyearonyear
improvement.
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 future
investment requirements. The guidance was produced in response to Standards for Better
Health and National Standards, Local Action which set out a new approach to improving
standardsintheNHS,includingthereductionofbacklogmaintenanceforNHSfacilities.
Theguidancedocumentimprovesonpreviousmethodologiesbytakingintoaccountthedifferent
levelsofrisktopatients,visitorsandstaffarisingfromdeficienciesinstatutorysafetyandphysical
conditionofthebuiltenvironment.Themethodologycontainedinthedocumentthusprovidesa
representationoftheprioritiesinwhichinvestmentisneeded.
AllreturnscanbeviewedagainstothersimilaracuteTrusts.
7.8.2 SixFacetInformation
InaccordancewithDepartmentofHealthrequirementsaSixFacetSurveyhasbeenundertaken
in2008andisamultifacetedsurveywhichenablesanappraisalofanNHSTrust'sEstateand
providesasnapshotofthephysicalconditionofindividualbuildings,whichcaninformtheEstates
Strategy.
The results of the survey are used to determine and manage backlog maintenance, along with
measuringriskinrelationtosubstandardassetssothatinvestmentcanbeprioritised.Oncethe
riskassociatedwithsubstandardelementshasbeenassessed,capitalandrevenueinvestment
canbetargeted.
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 the
projectedworkloadandprovidedetailedinformationonboththeinternalandexternalelementsof
thebuilding.
It is envisaged that a continuous rolling programme of stock condition surveys is the most
appropriatemethodforcollationofinformation. Everypropertywillhaveanannualsurvey,both
internallyandexternallyandacompletesurveyeveryfiveyears.
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Such data allows for the rapid retrieval of information, permitting expenditure forecasts, budget
preparation,andresourcesmoothing.Inadditionitenablesexpendituretobetargetedatareasof
greatestneed.
FurtherdevelopmentsoftheSixFacetSurveyarecurrentlyunderwayinpartnershipwithexternal
consultants.
CopiesoftheSixFacetSurveyDocumentisavailableonrequest,brokendownbyDepartments
andDirectorates.
The sixfacet surveyis reviewed regularly and updated by the Directorate ManagementTeam
Operations.
7.8.3 PremisesAssuranceModel(PAM)
The NHS Premises Assurance Model (PAM)has been developed to support the delivery of the
(QIPP) quality and productivity challenge, public value and carbon reduction programmes. The
intention being to introduce a methodology for cross NHS provider and commissioner
discussions.
Themodelisintendedtopromotethesharingofbestpracticeandlessonslearntacrossproviders
with a common aim of improving the performance ofpremises utilised in the delivery of clinical
servicesanddeliveringonpremisesaspectsofthequalityandproductivitychallenge
The NHS PAM seeks to align local provider needs and priorities with Departmental policy to
supportdeliveryon:
HighQualityCareforAll,publishedinJune2008,settingoutthevisionforputtingquality
attheheartofeverythingtheNHSdoes
TheQuality,Innovation,ProductivityandPrevention(QIPP)challenge
TheNHSConstitution
TheNHSOperatingFramework2010/11
QualityAccounts.
Thefocusofthemodelisonfivekeydomains
Finance/ValueforMoney
Safety
Effectiveness
PatientExperienceand
BoardGovernance.
7.8.4 DrinkingWaterReturns
The Trust has to submit water samples to the Local Authority under the private water supply
regulationstoensurethatthewaterisacceptabletodrink. ThisisbecausetheLocalauthorityis
responsibleforregulatingprivatewatersuppliesused bytheTrustandtheTrustusesborehole
extraction.
7.8.5 EnvironmentalPermit
The Environmental Permitting Regulations 2010 means that the Trust has to have an
environmental permit to be able to use the Combined Heat and Power Plant at theQMC. The
permithastoberenewedannually/
7.8.6 WaterAbstractionLicence
TheTrustabstractsmorethan20cubicmetresofwateradayfromitsboreholessowehavean
abstractionlicencefromtheEnvironmentAgencywhichisrenewedannually.
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7.8.7 DisplayEnergyCertificates
DisplayEnergyCertificates(DECs)showtheactualenergyusageofabuilding,theOperational
Rating,andhelpthepublicseetheenergyefficiencyofabuilding.Thisisbasedontheenergy
consumptionofthebuildingasrecordedbygas,electricityandothermeters.TheDECshouldbe
clearlydisplayedatalltimesandclearlyvisibletothepublic.ADECisalwaysaccompaniedby
anAdvisoryReportthatlistscosteffectivemeasurestoimprovetheenergyratingofthebuilding.
Display Energy Certificates are only required for buildings with a total useful floor area over
1,000m2 andarevalidforoneyear. TheaccompanyingAdvisoryReportisvalidforsevenyears.
The requirement for Display Energy Certificates came into effect on 1 October 2008, they are
doneannuallyandrunouteveryOctober.(FromthisdatetheTrusthasthreemonthstorenew)
7.8.8 EuropeanUnionEmissionTradingScheme(EUETS)
The European Union Emissions Trading Scheme (EU ETS) was introduced across Europe to
encourage businesses to reduce greenhouse gas emissions. The Department for Energy and
Climate Change (DECC) has appointed the Environment Agency to regulate the scheme in
EnglandandWales,aswellastomaintainthetradingRegistriesonbehalfoftheUK.
The cost of ongoing regulation of a permit is recovered through the annual subsistence charge
andcoverstheongoinguse oftheregistryandallowstheTrusttobuyemissionunitsduetoit
havingcentralisedboilerhousesoneachsite.
Charges are based on annual emissions and are payable on 1 April each yearfor thefinancial
yearahead. TheTrustbuysallowancesonthebasisofpredictedemissionsandwheretheTrust
canmakeefficiencysavingsthenexcessallowancesmaybetradedforafinancialreturn.Atthe
otherendofthespectrum,iftheTrustisunabletoremainwithintheirbudgetedallowancesthey
willhavetobuyadditionalallowancesfromthescheme.
7.8.9 PollutionInventoryReporting
ThePollutionInventory(PI)isanannualrecordofpollutioninEnglandandWalesfromselected
activities the Environment Agency regulate. It is the annual mass releases of specified
substances to air, water and land, and offsite transfers of waste by the Trust which has to be
submitted.
The PI now includes seven years of datafrommajorindustrial sitesand the main objectives of
thepollutioninventoryareto:
tell the public about pollution from industrial and other sources in their local area and
nationally
helpenvironmentalregulatorstoprotecttheenvironment
help the Government to meet national and international commitments and reporting
obligations
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ESTATEOPERATIONALPROCEDURE
The procedure document within this policy aims to show the responsibilities and requirements
undertheremitoftheOperationalEstatesDepartment.
RESPONSIBILITES&WORKSUNDERTAKEN
TheEstatesOperationsDepartmentexiststodealwithongoingoperations,faultsandproblems
withthebuildingfabricandengineeringservicesacrossalltheTrust'scampuses.Thisincludes
flickeringlights,faultyheatingorcooling,blockeddrains,brokenpavingslabsandleakingroofs.
All sections also carry out planned preventative maintenance. There is no direct charge for
maintenancerepairs(unlesstheyaretenant'sservicecharges).
Each section will respond to a report or request for maintenance in accordance with the
Departments standard priority code system as detailed in Maintenance Priorities. If there is a
reason why this cannot be achieved the person making the original request will be informed of
thatreason.Wherethereisanoutstandingsafetyissueassociatedwithsuchajobwewillensure
thattemporarymeasuresareimplementedtoensurethesafetyofallstaffandpatients.
Toensurestandardsarebeingmaintainedallstaffemployedbyeachsectionarekeptuptodate
with technical and Health and Safety related issues through a combination of in house and
boughtintrainingandapprovedprocedureshavebeenformulatedforallactivities.
AswellasatechnicalassessmentallspecialistcontractorsundergoaninitialHealthandSafety
vetting procedure (IOSH Managing Safely) to ensure that their standards at least reach those
expectedbytheTrustandthattheirlevelofpublicliabilityinsuranceissufficientforthetasksthey
aretoperform,thisprocedureisrepeatedevery3years.
Alsoongoingandregularspotchecksandsafetyauditsarecarriedoutonbothemployeesand
contractors, to quickly identify and correct any poor practices and to ensure that the work
providedbythesectionremainsofagoodstandard.
9.1 ElectricalMaintenance(Infrastructure)
To ensure that the electrical infrastructure of the Trust owned properties is maintained and
operatedinasafeandefficientmannerandincompliancewithallrelevantandcurrentlegislation
usingacombinationofdirectlyemployedstaffandspecialistcontractors.
TheDepartmentundertakesbothplannedandreactivemaintenancework,whichincludes:
Periodic inspection and test program of electrical infrastructure in accordance with
BS7671
Periodictestingandmaintenanceofemergencylightingsystems
Periodictestingandmaintenanceoffirealarmsystems
Periodictestingandmaintenanceoflightningconductorsystems
Maintenanceofinternalandexternallighting
Maintenanceofpowercircuitsuptothepointofuse,(localisolatororsocketoutlet)
SupportandadviseallothersectionsofEstates
Daytodayoperationsonthe11,000voltnetwork
Provision of a 24 hour 365 days a year emergency call out service. This service is
providedtomakesafeuntilthenextworkingdayonly.
In addition to these activities the section manages central contracts for the service and
maintenanceofotherequipmentandplant.
The work is carried out by fully qualified inhouse craftsmen, supported by a team of carefully
selectedandapprovedcontractors.
9.2 MechanicalMaintenance
TheMechanicalMaintenancesectionofEstatesandFacilities(E&F)isresponsiblefortheoverall
designandsafe,efficientoperationalcontroloftheMechanicalServicesinstallations.
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Allplumbinganddrainage
Domestichotandcoldwatersystems
Fullorpartcomfortcoolingairconditioningsystems
Generalheatingandventilationsystems
Passengerliftsandliftingequipment
SupportandadviseallothersectionsofEstates.
Provision of a 24 hour 365 days a year emergency call out service. This service is
providedtomakesafeuntilthenextworkingdayonly.
Specialist equipment is maintained under Service Contracts between E&F and the specialist
providers,withinhousetechnicalstaffprovidinginitialresponseandcontractmanagement.
9.3 BuildingMaintenance
Theteamareresponsiblefortheupkeepandmaintenanceofalltrustbuildingsandsurroundings.
Brickwork&plastering
Carpentry&joinery
Doors&windows
Ceilingrepairsandfinishes
Externaldrainage
Floorrepairs&finishes
Lockingsystems
Painting&decorating
Roads&pavings
Roofworks
Signage
9.4 Security
TheEstatesteamwillensurethatallelectronicsecuritysystems(intruderalarms,CCTVinuse)
are serviceable and covered by appropriate maintenance and monitoring contracts at all times
andensurethatsuitablerecordsofsuchmaintenancearekept.
9.5 Energy
TheEstatesteamareresponsibleforenergyservicesinthefollowingkeyspecialistfields:
EnergyManagementandrelatedregulatorycompliance.
ManagementdutiesoftheEnergyProductionunits.
BuildingEnergyManagementSystems(BEMS)
Contractmanagementforthirdpartyserviceandfuelsuppliers
PromotionofeffectiveandefficientuseofutilityresourcesacrosstheTrust
9.6 Decontamination
Operational Estates organise the planning, programming, implementation, supervision and
controlofengineeringmaintenanceandoperationsinrelationstoalldecontaminationservices.
Thisincludestheresponsibilityofthemaintenanceandtestingofsterilisersanddisinfectors.All
inaccordancewithHTM2010,2030,2031andwhen,supersededwithHTM0101(PartsAD).
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9.7 VacantEstate
Thefinancialimplicationsofhavingvacantpropertyareaswithoccupiedestate:capitalcharges,
rates and maintenance however the added risk with vacant property is that of security breach
anddamageresultingfromvandalism,potentiallyillegaloccupationandfire.
10 EQUALITYANDDIVERSITYSTATEMENT
All patients, employees and members of the public shall be treated fairly and with respect,
regardless of age, disability, gender, marital status, membership or nonmembership of a trade
union,race,religion,domesticcircumstances,sexualorientation,ethnicornationalorigin,social
&employmentstatus,HIVstatus,orgenderreassignment.
11 EQUALITYIMPACTASSESSMENT
NameofPolicyorService
ResponsibleManager
JohnSimpson
NameofPersonCompletingtheEIA
MarkJackson
DateEIACompleted
1March2011
DescriptionandAimsofPolicy/Service(includingrelevancetoequalities)
This Policy and Procedural Document provides the infrastructure for the implementation of the
Trusts Maintenance Programme. It is expected that this Document be complied with by Trust
employees, on all Trust sites, and by all appointed contractors, in whatsoever capacity, with or
withoutcontractualagreements.
BriefSummaryofResearchandRelevantData
Thereisnoresearchorrelevantdataatthepresenttime
MethodsandOutcomeofConsultation
Consultationshavebeencarriedoutwiththefollowing:
EstatesandFacilitiesDirectorate
RiskManagementCommittee
TrustHealthandSafetyCommittee
Directors'Group
TrustBoard
ResultsofInitialScreening
EqualityGroup
Age
Gender
Race
SexualOrientation
Religionorbelief
Disability
DignityandHumanRights
WorkingPatterns
SocialDeprivation
AssessmentofImpact
None
None
None
None
None
None
None
None
None
ResultsofInitialScreening
From the information contained in the policy, it is my decision that a full assessment is not
requiredatthepresenttime.
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EqualityActionPlan(ifrequired)
N/A
MonitoringandReviewArrangements(includingdateofnextfullreview)
ItisrecommendedthatthispolicyandEIAbereviewedyearlyinlinewiththerequirementsinthis
policy.
12 ENVIRONMENTALIMPACTASSESSMENT
AstageoneEnvironmentalImpactAssessmenthasbeencarriedoutonthispolicyandprocedure
documentandbasedontheinformationsetoutintheTrustProcedure,ithasbeenconfirmedthat
anenvironmentalimpactassessmentisnotnecessary.
13 WEAREHEREFORYOU
ThisTrustiscommittedtoprovidingthehighestqualityofcaretoourpatients,sowecanpledge
to them that we are here for you. This Trust supports a patient centred culture of continuous
improvement delivered by our staff. The Trust established the Values and Behaviours
programme to enable Nottingham University Hospitals to continue to improve patient safety,
outcomesandexperiences.Thesetoftwelveagreedvaluesandbehavioursexplicitlydescribeto
employees the required way of working and behaving, both to patients and each other, which
wouldenablepatientstohaveclearexpectationsastotheirexperienceofourservices.
14 IMPLEMENTATIONPLAN
Reference
Title
Version
Date
LeadOfficer
TargetAudience
HS/
EstateOperationalManagementPolicyandProcedure
1
TBC
MarkJackson
All Clinical Areas, Estates and Facilities and all other
occupiersonTrustPremises
TrainingandEducationRequirements
OngoingtrainingassetoutbytheLeadOfficer
ImplementationPlan
Insertion of notice in Trust Briefing, accompanying the

promulgationofVersion1.
Traininghasalreadybegunandwillcontinueonayearly
basis.
SeparatemeetingswithTrustoccupiers
Forums will be held at Matrons Meetings, ICOG etc.

throughouttheyear.
Timetable
for
Completion
of Ongoing
Implementation
15 MONITORINGANDREVIEWING
Thisprocedure willbereviewedinayear'stimeorwhentherearechangestolegislationwhich
impactsontheprocedureseffectiveness.
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16 APPENDIX A WORK CATEGORIES AND CONSULTATION

PROTOCOL
Category1LowHazard(Room)
ReactiveMaintenance
ThisisthetypeofworkrequestedbytheWardSister/HeadofDepartment/Occupier/Stakeholder,
usuallyfor an item which has failedin service such as a door lock not operating properly, or a
lightbulbwhichhasfailed. Theproblemisusuallyconfinedlocallytoanareaorroom,anddirect
arrangementsforaccess/repaircanbemadebetweentheoriginatoroftherequestforrepairand
EstatesOperationstoundertakethework.
Prior to the work being carried out, theWard Sister/Department Manager/Occupier/Stakeholder
willbeconsultedbytheoperativeundertakingthetaskandaskedforanyspecialproceduretobe
adopted.
Theareawillbespotcleanedbythecraftsmenoncompletionofthetask.
Category2LowHazard(CommonAreas)
ReactiveMaintenance
ThisisworkrequestedbytheWardSister/HeadofDepartment/Occupier/Stakeholder,butisnot
confined to a room, and may require work to be undertaken in common areas of a Ward or
Departmentsuchasacorridorbutwillbeofashortdurationsuchasreplacingadefectivelight
fitting or adjustment of a fire door. If the work can be carried out safely with little disruption,
arrangementswillbemadebetweentheoriginatorofthecallandtheTradePersonforaccessto
carryouttherepair. TheEstatesDepartmentwillundertaketherepairataconvenienttimetothe
Usersoftheservicewherepossible.
Theareashallbespotcleanedbythecraftsmenoncompletionofthetask.
Category3LowHazardServiceShutDown
ReactiveorPlannedPreventativeMaintenanceRequiringaLocalServiceShutDown
WhereworkinitiallyrequestedbytheWardSister/HeadofDepartment/Occupier/Stakeholder,on
closerexaminationismoreextensiveinnaturetocorrect,andrequiresalocalserviceshutdown
such as turning off the water supply to a wash basin to change taps or to facilitate a planned
preventativemaintenanceactivity,thefollowingprocedureshallbeobserved:
Thefullextentoftheworkshallbeassessedandtheminimumshutdowntimerequired
determined.
The Ward Sister/Department Manager/Occupier/Stakeholder shall be informed of the
extentandnatureoftheproblemandwhatneedstobedonetocorrectthedefect.
Anagreedstrategyforundertakingtheworkshallbedeterminedincorporatinganysafety
and control ofinfectionmeasures deemed necessary and approvalto proceed shall be
givenbytheabove.
DMTO, Estates Operational Officer, Supervisors and Capital Project Managers ensure
thattheagreedmethodiscarriedout,andanytimeconstraintsto shutdownofservice
areadheredto.
Theareashallbespotcleanedbythecraftsmenorcontractoroncompletionofthetask.
Category4MediumHazardServiceShutDown
ReactiveorPlannedPreventativeMaintenanceRequiringServiceShutDown
WorkaffectingawholeWardorDepartmentthefollowingprocedureshallbeobserved:
The full extent of the repair or planned preventative maintenance activity shall be
assessedandtheminimumshutdowntimerequireddetermined.
TheWardSisterandServiceManager,OccupierorStakeholdershallbeinformedofthe
extentandnatureoftheproblemandwhatneedstobedonetocorrectthedefect.
Oneofthefollowingproceduresshallthenbeadopted:
a) An agreed strategy for undertaking the work shall be determined incorporating
anysafetyandinfectionpreventionandcontrolmeasures agreedasnecessary,
andapprovaltoproceedshallbegivenbytheWard/ServiceManagerwiththose
listedbelowbeinginformedoftheworkasnecessarybytheEstatesDepartment.
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b) The Estates Operations Staff / Project Manager shall arrange a coordinating

meeting of those listed below (if appropriate) not less than 14 days before the
requiredshutdown:
Ward/DepartmentManagers
ServiceManagers
RiskManagement
InfectionPreventionandControlTeam
FireSafetyTeam
EstateServices
HotelServices
Security
Switchboard
OccupationalHealth
InformationTechnology
HealthandSafety
Anagreedstrategyforundertakingtheworkshallbedeterminedincorporatingallsafety
and infection prevention and control measures deemed necessary or temporary service
neededtobeprovided.
DMTO, Estates Operational Officer, Supervisors and Capital Project Managers ensure
thattheagreedmethodiscarriedout,andanytimeconstraintsto shutdownofservice
areadheredto.
Category5MediumHazard
PrePlannedLargerWork
Smallpreplannedalterations/refurbishmentorlargermaintenancetaskswhichrequirestructural
work or will present significant inconvenience to the users of the Ward/Department whilst the
workisinprogress.
The full extent of the work shall be determined, and a method statement prepared. The
responsible officer shall call a prestart meeting not less than 14 days before the planned
commencementdatewith(ifappropriate):
Ward/DepartmentManager
ServiceManagers
RiskManagement
InfectionPreventionandControlTeam
FireSafetyTeam
EstatesServices
HotelServices
Security
Switchboard
OccupationalHealth
InformationTechnology
HealthandSafety
AnagreedstrategyforundertakingtheworkshallbedeterminedinaccordancewiththeInfection
preventionandcontrolriskassessmentduringconstruction/refurbishmentofahealthcarefacility
protocol (Appendix 2 Infection Control in the Built Environment Design and Planning). The
agreed strategy will incorporate any safety and infection prevention and control measures
deemed necessary, e.g. temporary screening, dustmats, negative air pressure to the area and
thetimescaleinvolved.
DMTO,EstatesOperationalOfficer,SupervisorsandCapitalProjectManagersshall ensurethat
theagreedmethodiscarriedout,andanytimeconstraintstoshutdownofserviceareadhered
to.
Category6HighHazard
PrePlannedLargeScaleWorkCapitalDevelopment&Demolition
Large scaleprojectshavethepotentialtopresentmajorhealth&safetyandcontrolofinfection
risks, disruption or nuisance. It is essential that this type of work is subject to detailed
consultation and planning. It will be subject to a full range of the health & safety and infection
prevention and control requirements together with statutory obligations and guidance published
byawiderangeofsources,e.g.HealthTechnicalMemorandaandHealthBuildingNotes.
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17 APPENDIXBASPERGILLUSINTHEENVIRONMENT
Theairbornerouteoftransmissionisimportantforanumberofpathogenicmicroorganismssuch
asaspergillus,andeveryattemptshouldbemadetomaintainanenvironmentasfreefromdust,
aerosols and spores as possible during building and engineering works carried out in the
healthcareenvironment.Sourcesofairbornemicrobesinclude:
Fungalspores
Waterdroplets
Skin scales directly shed from skin, or indirectly distributed from clothes or patient
equipment
Mechanicalactionthroughcleaning,demolitionandconstructionwork
Respiratorytractcoughing,sneezing(alsoindirectviatissuesandfabrics)
AtRiskPatients
Patients who are most at risk are those who are immunocompromised or suppressed for
extended periods of time, especially those who have prolonged periods of neutropenia. These
include:
Haematology
BoneMarrowTransplants
OrganTransplants
Oncology
ICU/HDU
Burns
Otherpatientgroupswhoareatanelevatedlevelofriskare:
Patientsonhighdosesteroids
HIVpositivepatients
Patientsaftermajorsurgery
Due to the extent and prevalence of aspergillus in the environment, a two stage protection
protocol should be considered. The first stage is good housekeeping and hygiene measures to
minimise the release of spores. The second is to provide specific protection to known areas of
highriskbytheuseofpositiveHEPAfiltrationventilationsystems.
RiskAssessment
Due to the nature of microbiological infections and the patients at risk from infection a risk
assessmentprocessshallbeemployedtoestablishtheextentandnatureofprecautionsrequired
throughconsultationwiththeInfectionPreventionControlTeam.
PermanentProtection
Someclassificationofpatientswillrequirepermanentprotectionduetothenatureoftheirillness
or treatment.These patients will be identified by clinical stafffollowing liaison with the Infection
PreventionandControlTeamwhoareresponsibleforagreeingthedegreeofprotectionrequired
with professional advicefrom the responsible Estates Technical Staff / Project Manager on the
practicalsolutionsavailable.
TemporaryProtection
All technical officers/project managers are responsible for liaising with the Infection Prevention
andControlTeamandjointlyassessingtherisksfrominfectiononanyworkswhichareplanned
tobeundertaken.TheEstatesTechnicalStaff/ProjectManagerwillassesstheworksanddetail
anyriskareasandtheprecautionstobeadoptedpriortoanyworkscommencing.Thetechnical
officer/projectmanagerisavailableforspecificadviceandisaccountabletoseniormanagement
forauditingcompliancetotheagreedprecautionsforallandanyworksonTrustpremises.The
degree of precautions will be dependent on the area involved, nature of works and the risk of
dustreleaseandspread.
MinorDemolition/Refurbishment
If undertaking limited demolition or renovation works within the confines of an existing building,
e.g. ward upgrade, the area must be effectively sealed off from other occupied areas of the
hospital and thoroughfares. Dedicated access and egress routes need to be established.
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Access/exit routes need to be established to minimise the spread of dust and contact with
patients,visitorsandstaff.
The use of dedicated staircases or lifts for trade staff should be considered with use of sticky
mats or changing/transition areas for personnel entering or leaving a works construction area.
Provision for separate toilet facilities for the use of construction staff must be made. If such
precautionsaredeemednecessary,thentheymustbesubjecttoregularauditandmaintenance
toensureeffectiveness(defineroleofdomesticmonitoringteam/supervisors).
MinorRepairs
Numerous maintenance activities can give rise to the creation of dust (drilling, sanding,
plastering,etc). Ifsuchworksarelimitedtoasmallareaorarerequiredtobedoneinahighrisk
patientarea,thentheuseofLEVsystemsarerecommended. Thesecantaketheformofeither
ahepafilteredvacuumcleanerormobileextractfansystem. Theextentandnatureoftheworks
willdeterminethetypeofsystemrequired. Nonhepafilteredvacuumcleanersdonoteliminate
aspergillus particles and therefore cannot be used in high risk areas. In practice all areas may
havepatientsfromtheriskcategoriesabove,soallclinicalareasshouldbeclassedashighrisk.
CleaningProtocols
InadditiontominimisingthespreadofdustthroughEstatesprecautions,considerationshouldbe
given to increasing the existing cleaning regimes during the course of any prolonged or major
redevelopmentworktopreventdustaccumulationonsurfaces,ceilingsandairductgrilles.This
should be built into the initial planning stage of works. Damp dusting and not dry cleaning is
recommended. Any air filtration system should be regularly checked and maintained, including
adjoiningtheatresandatriskareas.
PedestrianTraffic
Pedestrian traffic from the construction area should be directed away from patient areas, with
tradesmen having a separate entrance to the construction site and where possible, patients
shouldavoidenteringthehospitalviaentrancesadjacenttomajorconstruction/demolitionworks
wheredebrisordustisbeingremovedfromtheworkareas.
OtherConsiderations
CleaningEquipment
A known area of aspergillus growth and contamination is the use of nonhepa filtered vacuum
cleanersandthecrossinfectionrisksofnondedicateddevicesforcriticalareas.
RefuseSkips
Allskipsusedforthetemporarystorageanddisposalofwastematerialshouldbefullycovered
andlockabletopreventdustreleaseandunauthoriseddisturbance.
Wherethisisnotpracticable,skipsmustbecoveredbymeansofasecureintacttarpaulinatall
times,whennotbeingfilled.
If filling a skip via mechanical plant or when using heavily dust laden materials, consideration
should be given to prevailing wind direction and dust suppression techniques such as damping
downorenclosure.
MonitoringProtocols
Priortothecommencementofmajordevelopment,maintenanceordemolitionworks,monitoring
countsbefore,duringandafterworkscanhelpinestablishingthenormalbackgroundandaction
levelsshouldbeconsidered.SuchmonitoringistheresponsibilityoftheInfectionPreventionand
Control Team and liaison between the Estates Technical Staff / Project Manager and Infection
PreventionandControlTeamwilldeterminewhenandifsuchmonitoringisnecessary.
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18 APPENDIXCCONTACTINFORMATION
EstatesandFacilities Website
Estates&FacilitiesWebsiteLink
EstatesHelpdesk
EstatesHelpdeskLink
EstatesWebsite
EstatesWebsiteLink
MinorNewWorksRequests
MinorNewWorksWebsiteLink
MarkJackson
AssistantHeadofEstatesOperations(City)
AndrewCamina
AssistantHeadofEstatesOperations(QMC)
EstatesOperationsManagerEngineering(City)
EstatesOperationsManagerEngineering(QMC)
GarethJones
EstatesOperationsManagerBuilding(City)
GrahamPugh
EstatesOperationsManagerBuilding(QMC)
RaymondStanton
AccessControlManager(Infrastructure)(NUH)
MarkBoothroyd
EnergyManager(NUH)
PaulHeaton
DecontaminationManager(NUH)
GeoffLeafe
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19 APPENDIXDEMPLOYEERECORD
CERTIFICATIONOFEMPLOYEEAWARENESS
DocumentTitle
Estate Operational Management Policy and

Procedure
1
Version(number)
Version(date)
IherebycertifythatIhave:
Identified (by reference to the document control sheet of the
above policy/ procedure) the staff groups within my area of
responsibilitytowhomthispolicy/procedureapplies.
Madearrangementstoensurethatsuchmembersofstaffhave
the opportunity to be aware of the existence of this document
andhavethemeanstoaccess,readandunderstandit.
Signature
Printname
Date
Directorate/
Department
The manager completing this certification shall retain it for audit
and/or other purposes for a period of six years (even if subsequent
versionsofthedocumentareimplemented).
Thesuggestedlevelofcertificationis:
ClinicalDirectoratesGeneralManagers
NonClinicalDirectoratesDeputyDirectororEquivalent
InfectionPreventionandControlTeamAllmembers
Estates and Facilities Directorate Operational Department
StaffandCapitalProjectManagers.
The manager may, at their discretion, also require that subordinate
levels of their directorate / department utilize this form in a similar
way,butthiswouldalwaysbeanadditional(notreplacement)action.
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ESTATEOPERATIONALMANAGEMENTPOLICYAND

Service Contracts: Maintenance carried out by an external contractor at pre

2.3.1 DirectorateManagementTeam Operations

2.4 DirectorateManagementTeam Capital

2.5 DirectorateManagementTeam Procurement

2.6 DirectorateManagementTeam Clinical&Corporate

Reactive maintenance can generally be defined as a single order which complies

Within 8 hours Priority 2 Situations that will degrade to an emergency if not

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

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

Insertion of notice in Trust Briefing, accompanying the

Forums will be held at Matrons Meetings, ICOG etc.

16 APPENDIX A WORK CATEGORIES AND CONSULTATION

b) The Estates Operations Staff / Project Manager shall arrange a coordinating

Estate Operational Management Policy and

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