V2.0 November 2017
Summary The Trust shall ensure that all ventilation systems are designed, operated and maintained within the guidance in operation at the time of design or operation. All steps shall be taken where reasonably practicable to ensure all ventilation systems within the Trust meet the requirements of the latest best practice guidance. The Trust shall ensure that all staff and contractors who have responsibility for the safe operation, maintenance and installation of ventilation systems are suitably qualified and trained to undertake the tasks required. The Trust shall ensure that all training records, records of appointments and documentation relating to the management and operation of the Trusts ventilation systems are kept up to date and filed in a safe location with electronic backups regularly maintained. The Trust shall ensure that any failings or shortcomings relating to the design, operation and maintenance of their ventilation system are logged and reported to the Ventilation Management Group. Any derogation from best practice guidance shall be fully risk assessed and documented with the approval of the Trusts Directorship in line with the requirements of the current HTM 03. Page 2 of 15
Table of Contents Summary... 2 2. Introduction... 4 3. Purpose of this Policy... 4 4. Scope... 4 5. Definitions / Glossary... 5 6. Ownership and Responsibilities... 5 6.1. Role of the Chief Executive... 5 6.2. Role of the Head of Estates Operations... 5 6.3. Role of the Head of Estate Development... 5 6.5. Role of the Informed Client... 5 6.6. Role of the Authorising Engineer (Ventilation) (AE (V))... 5 6.7. Role of the Authorised Person (Ventilation) (AP (V))... 5 6.8. Role of the Competent Person (Ventilation) (CP (V))... 5 6.9. Role of the Infection Prevention Control Team... 6 6.10. Role of the Trust Associate Directors and Clinical Directors... 6 6.11. Role of Trust Staff... 6 6.12. Role of the Ventilation Management Group... 6 7. Standards and Practice... 7 7.7. Design and Installation... 7 7.8. Standards... 7 7.9. Maintenance... 8 7.10. Operational Procedures... 8 7.11. Information... 8 8. Dissemination and Implementation... 8 9. Monitoring compliance and effectiveness... 9 10. Updating and Review... 10 11. Equality and Diversity... 10 11.2. Equality Impact Assessment... 10 Appendix 1. Governance Information... 11 Appendix 2.Initial Equality Impact Assessment Screening Form... 13 Page 3 of 15
2. Introduction 2.1. Ventilation is used extensively in healthcare premises to closely control the environment and air movement of the space that it serves. This is for both the comfort of occupants in buildings and to contain, control and reduce hazards to patients, staff and visitors from airborne contaminants including, dust and harmful micro-organisms. This Policy sets out the detailed requirements for the maintenance and safe operation of all air conditioning and ventilation plant. These will be maintained so that they do not present a risk to persons either in the vicinity of the plant, in areas served by the plant, or a statutory compliance risk to the Royal Cornwall Hospitals NHS Trust (referred to as the Trust ). 2.2. This version supersedes any previous versions of this document. 3. Purpose of this Policy 3.1. This Policy requires that all ventilation and air conditioning equipment is installed, inspected, serviced and maintained in accordance with all Statutory Instruments, NHS Guidelines and Health Technical Memorandums (HTM) to ensure that such equipment does not pose a health or operational risk to either, staff, patients or visitors. 4. Scope 4.1. This Policy applies to all staff, service users and contractors associated with the Trust. Those persons with defined responsibilities should read this policy, and where applicable, read and understand the ventilation procedures manual. 4.2. This Policy covers all maintenance activities on ventilation and air conditioning plant within the Trust, and any sites which the Trust is responsible for the maintenance of ventilation equipment. This will include, but not limited to, local room extraction plants up to full air handling and conditioning systems. 4.3. This policy document and associated ventilation procedures manual cannot anticipate all eventualities, therefore professional judgement should be used to identify the appropriate course of action needed. 4.4. The on-going risk management process will enable those involved, namely, the Responsible Person Ventilation, Authorised Person Ventilation, Competent Persons and Infection Prevention Control Team to identify the level of vulnerability and risks posed to individuals; including service users, staff members and visitors, thereby ensure appropriate action will be taken. Page 4 of 15
5. Definitions / Glossary HTM Health Technical Memorandum 6. Ownership and Responsibilities 6.1. Role of the Chief Executive The Chief Executive Officer has overall responsibility for ensuring that suitable and sufficient procedures are in place to manage and maintain the Trust s ventilation and air conditioning equipment. 6.2. Role of the Head of Estates Operations The Head of Estates Operations is responsible for ensuring this Policy is implemented and a Senior Engineer, as Authorising Engineer (Ventilation) (AE (V)), is appointed. That all Estates related work is carried out by competent and trained staff, including checks on contractors. All appointments are to be made in writing. 6.3. Role of the Head of Estate Development The Head of Estate Development is responsible for ensuring that the requirements of this policy are observed and adhered to during projects and other contract works. 6.4. Role of Private Finance Initiative Services Providers/Lease Plus Arrangement They will appoint in writing their own Authorised and Deputy Persons; who will ensure that adequate arrangements are in place to achieve compliance with this policy and associated procedures. Details of such persons shall be notified in writing to the Trust s Director of Estates & Facilities. 6.5. Role of the Informed Client The Informed Client is responsible for ensuring that the PFI/ Lease plus Arrangement partner is compliant with this policy including the maintenance of appropriate records. 6.6. Role of the Authorising Engineer (Ventilation) (AE (V)) The AE (V) is responsible for providing advice on ventilation systems and to audit via critical maintenance audits, review and witness documentation on system validation. 6.7. Role of the Authorised Person (Ventilation) (AP (V)) The Ventilation Engineer for the Trust is the appointed AP (V) responsible for the implementation and operation of safety policies and procedures relating to the engineering aspects of air conditioning and ventilation systems. 6.8. Role of the Competent Person (Ventilation) (CP (V)) The Senior Estates and Facilities Manager is responsible for maintaining site lists of CP(V), who have received appropriate training, in order to carry out maintenance, validation and periodic testing of Air conditioning and ventilation systems. Page 5 of 15
6.9. Role of the Infection Prevention Control Team The Infection Prevention Control Team will nominate a point of contact to advise on the monitoring of microbiological performance of the air conditioning and ventilation systems. 6.10. Role of the Trust Associate Directors and Clinical Directors The Trust s Associate Directors or delegated managers shall attend the Trusts Ventilation Management Group meetings, where they will provide information relating to the divisional clinical risk assessments in place and update the group on any changes to clinical procedures that require a specific ventilation strategy or may present an elevated risk to patients and staff if the ventilation strategy is not reviewed. 6.11. Role of Trust Staff All Trust staff members are responsible for reporting defects and faults with any ventilation systems, as they occur, via the Estates Department Helpdesk. To inform their clinical directors/managers to provide information to the Trust ventilation management group or directly with the Estates department when areas of the ward or department are planned to change use, this will then require an engineering review prior to the planned changes taking place. 6.12. Role of the Ventilation Management Group 6.12.1. The Group will monitor the ventilation safety testing within the Trust and report monthly on issues arising from non-compliance. 6.12.2. Submit quarterly reports and make recommendations to the Hospital Infection Control Committee in relation to ventilation testing and any issues. 6.12.3. Identify and agree the strategic direction each year for review and implementation of the Ventilation Safety Action Plan 6.12.4. Monitor compliance against the Health and Social Care Act & Department of Health guidance 6.12.5. Review any new methods to ventilation and make recommendations relating to their use. 6.12.6. Receive and review incoming guidance from outside areas and ensure an appropriate response is initiated by the Trust. Page 6 of 15
7. Standards and Practice 7.1. The Trust shall ensure that all ventilation systems are designed, operated and maintained within the guidance in operation at the time of design or operation. 7.2. All steps shall be taken where reasonably practicable to ensure all ventilation systems within the Trust meet the requirements of the latest best practice guidance. 7.3. The Trust shall ensure that all staff and contractors who have responsibility for the safe operation, maintenance and installation of ventilation systems are suitably qualified and trained to undertake the tasks required. 7.4. The Trust shall ensure that all training records, records of appointments and documentation relating to the management and operation of the Trusts ventilation systems are kept up to date and filed in a safe location with electronic backups regularly maintained. 7.5. The Trust shall ensure that any failings or shortcomings relating to the design, operation and maintenance of their ventilation system are logged and reported to the Ventilation Management Group. 7.6. Any derogation from best practice guidance shall be fully risk assessed and documented with the approval of the Trusts Directorship in line with the requirements of the current HTM 03. 7.7. Design and Installation 7.7.1. All new ventilation and air conditioning equipment will be designed, installed and commissioned by suitably qualified Engineers and Tradespersons. 7.7.2. They will be compliant with the requirements of Health Technical Memorandum (HTM) 03, HTM05 and other legislation; such as, the Health and Safety at Work Act 1974, the Control of Substances Hazardous to Health Regulations 2002, the HSE Control of Legionella Approved Code Of Practice L8, Regulatory Fire Reform Order and specific requirements under the Medicines Act 1968. Copies of all HTM s can be found online at the Government Library Webpage. 7.7.3. Such a system must be appropriate for the area for which it was designed and is only installed where absolutely necessary and by agreement with the Infection Prevention Control Team. 7.7.4. Information for all new equipment, concerning its installation, designed mode of operation together with full details of maintenance procedures, shall be provided as part of the commissioning process. 7.7.5. In areas undergoing refurbishment, advice will be sought from the Infection Prevention Control Team to determine the requirements of the existing ventilation and air conditioning systems. Where systems will not meet current HTM 03 standards, equipment will be upgraded or replaced. 7.8. Standards Operational Standards applied during the design and installation of ventilation Page 7 of 15
and air condition systems will not to be reduced during the operation and life of the equipment. This will be evidenced through the use of planned maintenance records held within the Estates Department. Assessment of the suitability of older ventilation systems shall be made with the assistance of the Authorising Engineer (Ventilation) and the Infection Prevention Control Team. 7.9. Maintenance All service and maintenance procedures shall conform to the principles set out in Specialised Ventilation for Healthcare premises HTM 03-01, and the Approved Code of Practice on the Prevention of Control of Legionella published by the Health & Safety Commission and The control of Legionella, hygiene, safe hot water, cold water and drinking water systems HTM 04-01 and any subsequent legislation or guidelines. 7.10. Operational Procedures The operational procedures relating to the safe operation and maintenance of ventilation systems within the Trust are defined and explained within the ventilation procedures document. 7.11. Information 7.11.1. Maintenance and routine inspections records shall be maintained for ventilation plant, and kept within the Estates Department electronic database. 7.11.2. For the safety of contractors and maintenance staff the following information shall be provided adjacent to the plant to which it refers: a) General information regarding the intended operation of the plant together with a schematic diagram of the equipment and its distribution system. b) Information concerning the purpose of the plant and details of those departments and/or personnel served by the plant and who should be informed prior to switching off or carrying out maintenance activities. c) Information required for the safety of the personnel carrying out the service and maintenance activities. 8. Dissemination and Implementation This document will be available on the Trust Documents Library and disseminated to all staff and departmental groups listed here: Divisional Directors and Directorate Managers Estates Department Contractors Estates Intranet Site Project Co [PFI Services Providers] (via Contracts office) Page 8 of 15
9. Monitoring compliance and effectiveness Element to be monitored Lead Compliance with this document will be monitored via the Estates Department, through annual audits, inspections and the Ventilation Management Group. Nominated Lead AP Ventilation with guidance from AE Ventilation Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Appendix A to E detail the monitoring and control documentation required for compliance with this policy. Advise and annual Audits from the AE Ventilation will confirm compliance. Compliance with this policy is required for all new equipment or projects concerning Ventilation systems. Independent Annual Audits will confirm compliance. All issues and reports relating to this policy will be sent to the Infection Prevention and Control committee, via the Ventilation Management Group. Reports submitted to this committee will detail the actions required to ensure compliance with HTM guidance where possible and will detail actions required to remedy any defects or faults. Meetings are to have minutes. Estates Department will undertake subsequent recommendations and action planning for any or all deficiencies and recommendations within reasonable timeframes. The Estates lead for this will be the nominated AP Ventilation Required actions will be identified and completed in a specified timeframe Required changes to practice will be identified and actioned by the nominated AP Ventilation, within the appropriate time frame, this will be coordinated under the guidance of the nominated AE Ventilation. Lessons will be shared with all the relevant stakeholders Page 9 of 15
10. Updating and Review 10.1.This policy will need to be reviewed every 3 years, or subject to any industry and Government guidance and best practice updates. 10.2.Revisions can be made ahead of the review date when the procedural document requires updating. Where the revisions are significant and the overall policy is changed, the author should ensure the revised document is taken through the standard consultation, approval and dissemination processes. 10.3.Where the revisions are minor, e.g. amended job titles or changes to the procedures in the Appendices, approval can be sought from the Executive Director responsible for signatory approval, and can be re-published accordingly without having gone through the full consultation and ratification process. 10.4.Any revision activity is to be recorded in the Version Control Table as part of the document control process. 11. Equality and Diversity 11.1.This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website. 11.2. Equality Impact Assessment 11.3. The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 10 of 15
Appendix 1. Governance Information Document Title Date Issued/Approved: March 2018 Date Valid From: March 2018 Date Valid To: February 2021 Directorate / Department responsible (author/owner): James Tinsdeall, Head of Estates Operations Contact details: 01872 25 3400 Brief summary of contents Policy for the maintenance, control and assurance of all ventilation plant and equipment within the Trust. Suggested Keywords: Target Audience Executive Director responsible for Policy: Ventilation RCHT CPFT KCCG Director of Finance Date revised: November 2017 This document replaces (exact title of previous version): Approval route (names of committees)/consultation: v1.1 Hospital Infection Control Committee Divisional Manager confirming approval processes Name and Post Title of additional signatories Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Director of Estates & Facilities Not Required {Original Copy Signed} Name: Governance Lead, Estates & Facilities {Original Copy Signed} Internet & Intranet Intranet Only Estates / General Page 11 of 15
Links to key external standards Related Documents: Training Need Identified? Health Technical Memormandum Local procedures Yes Authorised Person training and Competent Person training. Version Control Table Date Versio n No 16 Apr 13 V1.0 Initial Issue 20 Apr 15 V1.1 Policy Review Summary of Changes Changes Made by (Name and Job Title) Steven Carter, Energy and Environment Officer Steven Carter, Estates Operations Manager 02 Nov 17 V2.0 Policy Review and Updated with Ventilation User Group TOR and Clinical management responsibilities defined. AE Ventilation GPJ Consulting Engineers All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 12 of 15
Appendix 2.Initial Equality Impact Assessment Screening Form Name of Name of the strategy / policy /proposal / service function to be assessed Ventilation System Policy Directorate and service area: Estates & Facilities Name of individual completing assessment: James Tinsdeall Is this a new or existing Policy? Existing Telephone: 01872 25 3400 1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at? To set out the detailed requirements for the maintenance and safe operation of all air conditioning and ventilation plant within the Trust 2. Policy Objectives* Ensure compliance with Statutory instruments, industry best practice guidance. To ensure that such equipment dose not pose a health and operational risk to either staff, patients or members of the public. 3. Policy intended Outcomes* 4. *How will you measure the outcome? Guidance for the best practice maintenance of ventilation plant and equipment Compliance with Statutory instruments. Compliance with industry best practice guidance Annual plant and equipment inspections Regular audits from the independent AE Ventilation Detailed remedial action plans together with evidence based remedial actions, approved by the AE Ventilation and signed off as completed by the AE Ventilation. 5. Who is intended to benefit from the policy? 6a Who did you consult with b). Please identify the groups who have been consulted about this procedure. What was the outcome of the consultation? All Trust staff, patients and members of the public Estates and Facilities Department Workforce Patients Local groups Hospital Infection Control Committee Approval External organisations Other Page 13 of 15
7. The Impact Please complete the following table. If you are unsure/don t know if there is a negative impact you need to repeat the consultation step. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence Age Sex (male, female, trans-gender / gender reassignment) Race / Ethnic communities /groups Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions. Religion / other beliefs Marriage and Civil partnership Pregnancy and maternity Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major this relates to service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please explain why. There is no impact Page 14 of 15
Signature of policy developer / lead manager / director Phil Bond Date of completion and submission 13/04/2018 Names and signatures of members carrying out the Screening Assessment 1. 2. Human Rights, Equality & Inclusion Lead Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD This EIA will not be uploaded to the Trust website without the signature of the Human Rights, Equality & Inclusion Lead. A summary of the results will be published on the Trust s web site. Signed Date Page 15 of 15