Date Ratified 12/11/2015 Health and Safety Committee Review Date 01/11/2017 Deputy Chief Executive Expiry Date 11/11/ 2018 Withdrawn Date

Transcription

1 Policy No: RM26 Version: 4.0 Name of Policy: Ventilation Systems Protocol Effective From: 10/12/2015 Date Ratified 12/11/2015 Ratified Health and Safety Committee Review Date 01/11/2017 Sponsor Deputy Chief Executive Expiry Date 11/11/ 2018 Withdrawn Date This policy supersedes all previous issues. Ventilation Systems Protocol v4

2 Version Control Version Release Author / Reviewer Ratified by / Authorised by 1.0 April 2001 Mr S Bell Risk Management Committee /01/2009 Mr S Bell Health and Safety Committee Date April 2001 January 2009 Changes (Please identify page no.) /11/2013 Mr K Smeaton Health and Safety Committee /12/2015 Mr Tony Pratt Health and Safety Committee 14/11/2013 Rewritten in new trust OP27 policy format 12/11/2015 Revised to reflect QE Facilities (throughout doc.) Amendment to Roles and responsibilities(pg.4) Ventilation Systems Protocol v4 2

3 Contents Section Page 1 Introduction Policy scope Aim of policy Duties (Roles and responsibilities) Definitions Operational requirements Maintenance of Ventilation Systems Records Health and Safety Training Equality and diversity Monitoring compliance with the policy Consultation and review Implementation of policy (including raising awareness) References Associated documentation (policies)... 8 Appendices Appendix Ventilation Systems Protocol v4 3

4 Ventilation Systems Protocol 1. Introduction This document sets out safety responsibilities and advice associated with ventilation systems within the Trust's premises which managers are required to incorporate into their directorate/department health and safety arrangements. The protocol is based on HTM 03, local and national building regulations and relevant health and safety requirements. 2. Policy scope This policy applies to all staff and contractors employed by the Trust, and compliments the Department Of Health Policies and Principles in the Health Technical Memorandum series. 3. Aim of the policy The aim of this policy is to establish mandatory requirements for the management of Ventilation Systems. Ventilation is provided in healthcare premises for the comfort of the occupants of buildings. More specialised ventilation will also provide comfort but its prime function will be to closely control the environment and air movement of the space that it serves in order to contain, control and reduce hazards to patients and staff from air borne contaminants, dust and harmful micro-organisms. Gateshead NHS Foundation Trust recognises its obligations to take necessary measures in the provision of effective maintenance of engineering plant, systems and services. The main reasons for this policy are: Compliance with statutory requirements. Compliance with HTM03. To define the ground rules for the management of ventilation systems 4. Duties roles and responsibilities 4.1 Chief Executive The Chief Executive is responsible to the Trust Board for the effective implementation of the Ventilation Systems Protocol 4.2 Director of Estates and Facilities The Director of Estates and Facilities is responsible to the Chief Executive for the overall implementation of the policy within Gateshead Health NHS Foundation Trust. 4.3 QE Facilities Head of Estates The QE Facilities Head of Estates is the senior designated officer for estates maintenance services. This position fulfils the role of Trust Senior Operation Manager (SOM) and appoints Authorising Engineer AE & Authorised Persons (AP) for specialist engineering services. 4.4 QE Facilities, Engineering Department The QE Facilities Engineering Department have a duty to:- Advise Trust managers on the non-satisfactory performance of ventilation equipment. Ventilation Systems Protocol v4 4

5 Appoint competent persons to undertake regular thorough examination of high risk ventilation equipment. Undertake initial inspections of ventilation equipment prior to use, ensuring correct installation where there is significant risk to patients and staff. Ensure Ventilation equipment is regularly thoroughly examined by competent persons in accordance with an agreed schedule and records of examinations are kept. Undertake suitable technical inspections between through examinations where these have been agreed as necessary following the local managers risk assessment, as advised by the competent person and following manufacturer's instructions. Take appropriate action to rectify defects, which have been identified in inspection reports. 4.5 Management Responsibilities Appendix 1 identifies local management responsibilities to the: User - This is the local manager responsible for unit, e.g. the head of department, operating theatre manager, head of laboratories etc. and has the responsibilities set out in appendix 1. Plant Operator -This person will be designated by the user and will operate the equipment in a safe and correct manner in accordance with training they have received and any appropriate manufacturers' instructions. 4.6 Staff Responsibilities On no account shall a member of staff attempt the repair or maintenance of any piece of ventilation equipment. Any problems should be reported as a matter of urgency via call logging during normal office hours and Site Engineer outside these times. 5. Definition of terms For the purposes of this document the following definitions apply: The environment means the totality of a patient s surroundings when in healthcare premises. This includes the fabric of the building and related fixtures, fittings and services such as air and water supplies. Ventilation is a means of removing and replacing the air in a space. In its simplest form this may be achieved by opening windows and doors etc. Mechanical ventilation systems provide a more controllable method. Basic systems consist of a fan and collection of distribution ductwork; more complex systems may include the ability to heat and filter the air passing through them. Ventilation equipment may be required in order to remove smells, dilute contaminants and ensure that a supply of fresh air enters a space. Air conditioning is the ability to heat, cool, humidify, dehumidify, and filter air. This means that the climate within a space being supplied by an air conditioning plant can be maintained at a specific level regardless of changes in the outside air conditions or the activities within the space. Air conditioning may be required in order to provide comfort conditions within a space, or to provide temperature control for electronic equipment. Ventilation Systems Protocol v4 5

6 6. Operational requirements 6.1 Maintenance of Ventilation Systems All ventilation air handling units (AHU), plant, ductwork and systems shall be included in the planned preventative maintenance (PPM) system Inspections and maintenance shall be carried out in accordance with the following: Heating and ventilation systems Health Technical Memorandum 03-01; specialised ventilation for healthcare premises Part A & B Health and Safety Commission s Approved Code of Practice and guidance document Legionnaires disease; the control of Legionella bacteria in water systems (L8) Health Technical Memorandum The control of Legionella, hygiene, safe hot water, cold water and drinking water systems The general frequency of inspections and verification for ventilation systems shall consist of: All ventilation systems to be subject to inspection and maintenance annually Ventilation systems servicing critical care areas shall be inspected and maintained quarterly with actual performance measured and verified annually Local Exhaust Ventilation (LEV) systems to be examined and tested every 12 months. Annual tests to be carried out in order to demonstrate the continuing efficiency of the fire detection and containment systems. 6.2 Records In order that ventilation systems can be correctly operated and maintained it is essential that as-fitted drawings, operating manuals, maintenance instructions and commissioning manuals are available. Log books should be kept for each ventilation system consisting of maintenance records, test and validation data. 6.3 Health and Safety All work shall be undertaken in accordance with the Trusts health and safety policies, Department of Health guidance, relevant Codes of Practice, Health and Safety Executive guidance and departmental health and safety procedures. Safe systems of work shall be used for all personnel working on ventilation systems. 7. Staff Training Personnel carrying out maintenance of Ventilation Systems must receive suitable training, which includes information about any significant hazards arising due to their maintenance activities which may either affect them personally or any other person who may be affected by their actions or omissions. Training record shall be kept up to date for all staff. 8. Equality and Diversity The Trust is committed to ensuring that, as far as is reasonably practicable, the way that services are provided to the public and the way staff are treated, reflects their individual needs and does not discriminate against individuals or groups on any grounds. This policy aims to ensure that no employee receives less favourable treatment on the grounds of a protected characteristic in accordance with the Equality Act 2010.This policy has been appropriately assessed. Ventilation Systems Protocol v4 6

7 This policy when implemented should reflect anti-discriminatory practice. Any services, interventions or actions must take into account any needs arising from race, gender, age, religion and belief, language, communication, sensory impairment, disability and sexuality. 9. Monitoring compliance with the policy The overall protocol will be monitored by the QE Facilities Department and Health and Safety Team using the Datix Incident Reporting System and the QE Facilities Department Call Logging System and any relevant incidents will be reported to the Health and Safety Committee. Standard / process / issue Regular review of incidents using the Datix Incident Reporting System and the QE Facilities Department Call Logging System Monitoring and audit Method By Committee Frequency Regular review of QE Health and Annually incidents Facilities Safety Head of Committee Estates and H&S Adviser 10. Consultation and review The policy has been reviewed by QE Facilities Department staff and the Health and Safety Team, in consultation with members of the Health and Safety Committee. It has been reviewed and approved by the Health and Safety Committee and will be regularly reviewed according to OP27 Policy or more frequently depending on updates in health and safety legislation or building regulations. 11. Implementation of policy (including raising awareness) This policy reflects the Trust s stance on the Management of Risk and the provision of good health and safety standards. The individuals named in Appendix 1 have responsibilities as specified in the Duties section. 12. References HTM03 Heating and ventilation systems in Healthcare Premises. HBN 21 Maternity Care Facilities Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR) Water Supply (Water Fittings) Regulations HTM 04 (previously dealt with in HTM2027 Hot and Cold water supply, storage and mains services ) Health & Safety at Work Act 1974 Ventilation Systems Protocol v4 7

8 Health & Safety Executive (HSE) Approved Code of practice and Guidance Document L8 The Control of Legionella Bacteria in Water Systems. 13. Associated documentation and policies RM02 Health and Safety Policy RM25 SAFE hot water and surface temperature protocol RM04 Incident reporting and investigation policy Ventilation Systems Protocol v4 8

9 APPENDIX 1 TITLE NAME DUTIES Authorised Person Tony Pratt Energy Manager Verify new system design complies with standards. Validate, audit and advise on installations and their application. Test Person Approved Contractor To carry out testing on system performance as directed by authorised person. Maintenance person Mr S Hancock Assistant Operational Engineer (Mechanical) To ensure planned maintenance schedules are carried out and maintenance staffs are capable of carrying out duties. Maintain log books on individual ventilation systems. Infection Control Officer Dr S Hudson Consultant Microbiologist Advise on monitoring infection control and microbiological performance of systems. To carry out or authorise the carrying out by an accredited laboratory, the microbiological tests as required. Liaise with authorised person on system design. Plant Operator To operate equipment. To 'Call Log' any faults with the system. User Person with Unit responsibility Ensure operators are familiar with system operation, controls, functions, faults and safety procedures. Ensure maintenance is carried out as laid down in log book. Ventilation Systems Protocol v4 9