BASINGSTOKE AND NORTH HAMPSHIRE HOSPITALS NHS FOUNDATION TRUST SUMMARY This policy provides guidance for providing safe maintenance procedures for assets and buildings owned by the Trust. 1
BASINGSTOKE and NORTH HAMPSHIRE HOSPITALS NHS FOUNDATION TRUST Planned Preventative Maintenance and Building Refurbishment Policy CONTENTS ~~~~~~~~~~ Section Page 1. EXECUTIVE SUMMARY 4 2. INTRODUCTION 4 3. AIMS OF POLICY 5 4. OBJECTIVES 6 5. SCHEDULES AND PRIORITIES 7 6. PROCESS 7 7. AIR HANDLING SYSTEMS 8 8. CONTRACTORS 10 9. POLICY LINKAGE 10 10. RESPONSIBILITIES 11 11. REFERENCES 11 12. CONTRIBUTERS 11 13. POLICY REVIEW 11 2
BASINGSTOKE and NORTH HAMPSHIRE HOSPITALS NHS FOUNDATION TRUST Planned Preventative Maintenance and Building Refurbishment Procedures Implementation Plan Invitation for comment by key stakeholders. March 2010. Submission to Infection Control Committee. March 2010. Submission to Divisional Governance Boards. March 2010. Submission to Executive Committee March 2010. Implementation. TBC Summary of changes Revision 1.1 Amendment made by Andrew Bowler to include section on Air Handling systems 26/02/2010. Reviewed in accordance with: - The Health and Social Care Act 2008: Code of Practice for health and adult social care on the prevention and control of infections and related guidance as published 16 December 2009. 3
1. EXECUTIVE SUMMARY. All of the building and the equipment within the boundaries of the land owned by Basingstoke and North Hampshire NHS should be subject to Planned Preventative Maintenance programmes to ensure that the safety of patients, staff and visitors are maintained at all times. Refurbishment of any areas of the Estates should also take into account the need for future maintenance requirements and ensure that these issues have been identified as part of the project. The Planned Preventative Maintenance programmes should be based around the requirements identified within Health Technical Memorandums, Health and Safety guidance documents and to ensure compliance all statutory requirements. All Trust General Managers are responsible for the area they manage to ensure safety of staff, patients and visitors. They should be aware, by Estates, of what is and is not being regularly maintained in their department. They should make the business cases for servicing of high risk building services and equipment with support from the Estates Department. The Estates Department is responsible for central services in plant rooms. It is essential all Planned Preventative Maintenance is recorded and that records are available to be scrutinised if required. This process is all managed by EFM helpdesk and a dedicated Estates software package called Eclipse. All Planned Preventative Maintenance carried out under a service contract will be managed by the Supplies department, Supplies will receive service sheets and inform the relevant managers of any rectification works identified as part of their visits. Supplies department will also ensure that Planned Maintenance visits take place against the schedules issues on appointment. All equipment to be maintained by Estates will be logged as assets and set up within the Estates Information Management IT system with specific maintenance tasks set at the correct time intervals as identified either by legislation, guidance or manufacturers recommendations. All equipment to be maintained by Medical Equipment Department will be logged within the MED Planned Preventative Maintenance Program with specific maintenance tasks set at the correct time intervals as identified either by legislation, guidance or manufacturers recommendations. In the event of staff shortages, exceptional periods of excessive defects and or revenue shortfalls the Planned Preventative Maintenance program may not be fully completed. The % completed will be reported to Corporate Governance each month, resources will be applied on a risk based rational, with activities that relate to statutory compliance and patient safety being of paramount importance when assessing risk. 2. INTRODUCTION The Trust attaches the greatest importance to the Health, Safety and Welfare of its staff, patients, contractors and visitors, and considers it essential that management and staff should work together to achieve an environment compatible with an acceptable provision of services to patients and visitors to reduce risks to the lowest reasonably practicable. 4
The purpose of the Planned Preventative Maintenance Program and Building Refurbishment policy is to: Meet Health and Safety and Statutory requirements Protect the assets of the installation and building Continue to provide the specified service /working environment. Provide a safe environment for staff and patients Ensure adequate investment into the Trust Estate The Planned Preventative Maintenance program will reflect best practice, manufacturer s recommendations or Hospital Technical Memoranda (HTM s) which provide additional guidance, that if not followed could be used against the Trust in a legal case. Revisions to HTM s and Health and Safety Executive guidance issued after plant was installed, generally require more stringent checks which require more resources and modifications. Therefore there is a need to review the plan annually to take into account any changes. The Health and Safety at Work etc Act 1974 requires the Trust to provide a safe environment and planned Preventative Maintenance schedules would be used by HSE in an investigation in action against the Trust, and lack of regular maintenance and checks on any equipment or service could be held to be a contributory issue. Many legal claims against the Trust for accidents can require evidence of regular checks of plant and equipment. Where Planned Preventative Maintenance is carried out these records are required to be made available from the Estates IT system. All Trust General Managers are responsible for the area they manage to ensure safety of staff, patients and visitors. They should be aware, by Estates, of what is and is not being regularly maintained in their department. They should make the business cases for servicing of high risk building services and equipment with support from the Estates Department. The Estates Department is responsible for central services in plant rooms. The age of the building stock can make it very difficult to fully implement PPM programmes. For example there is a lot of plant and equipment throughout the Trust that is obsolete and spares are no longer available. Therefore it is essential that a risk based backlog maintenance capital program is linked to the (Draft) Estates Strategy and (Draft) Estates Development Control plan is in place to address such issues, via a replacement or refurbishment program. A system for risk based Planned Maintenance procedures will be followed and a reporting procedure adopted to provide information to Governance boards. 3. AIMS OF POLICY The aim of this procedure is:- 1. To raise awareness of the need for Planned Preventative Maintenance programs for all equipment purchased throughout the Trust 2. To ensure those procuring diagnostic, medical and other electronic equipment consider Planned Preventative Maintenance implications at an early stage and consult with the appropriate technical department(s). 5
3. To ensure that the Trust operates a fair and consistent process in assessing requests for the Planned Preventative Maintenance of equipment and services 4. To ensure that the building services infrastructure of Trust properties is not put at risk by the uncontrolled introduction of equipment and plant 5. To ensure that adequate revenue is provided to allow for changes in legislation and thus to allow modification to Planned Preventative Maintenance schedules. 6. To ensure plant and building maintenance schedules are recorded. 7. To ensure that adequate service contracts are in place for equipment where specialist training and test equipment are required. 8. To identify through Planned Preventive Maintenance tasks, areas that require refurbishment. 9. To ensure that Infection Control issues are included in both Regular maintenance tasks and building refurbishments. 10. To provide a strategic link to address backlog maintenance and implement building refurbishment via the Capital Investment Group, (Draft) Estates Development Control plan and the (Draft) Estates strategy 4. OBJECTIVES 1. To provide a safe and energy efficient environment for staff, patients and visitors 2. To ensure, as far as practicable, that Building Infection Control issues are addressed during Planned Preventative Maintenance tasks and building refurbishments 3. To ensure maximum life cycles of plant and equipment are achieved. 4. To predict, monitor and prevent equipment failures by replacement or refurbishment of equipment. 5. To monitor plant performance against design parameters 6. To compile a comprehensive maintenance record for plant and equipment. 7. To ensure all new plant and equipment is adequately funded for Planned Preventative Maintenance before purchasing. 8. To ensure Estates staff are provided with adequate training and documentation to ensure correct maintenance is carried out. 9. To ensure best value is delivered for maintaining the plant and equipment. 10. To ensure equipment and plant is made available to maintain at correct intervals. 11. To ensure condemned and obsolete equipment is removed from the Planned Preventative Maintenance program 6
12. To ensure the Planned Preventative Maintenance program is updated following area and equipment. 13. To ensure the Planned Preventative Maintenance program is regularly updated to reflect new legislation and guidance. 5. SCHEDULING AND PRIORITY 1. All planned maintenance tasks are to be annually risk assessed and given a priority scored against compliance to legislation, guidance and Health Technical Memorandums. 2. The Estates Infection Control Committee will review any processes or procedures relating to Planned Preventative Maintenance, Building repair or refurbishment. 3. All Planned Maintenance tasks will be reported against a traffic light scoring system to indicate high, medium and low risk. 4. All statutory Planned Maintenance tasks (identified as Red using the traffic light system) are to be completed within 1 month of issue. 5. The Trust will aim to complete A minimum of 75% of all planned maintenance tasks each year. 6. Performance against planned maintenance activity will be reported to Corporate Governance Boards monthly 6. PROCESS 1. All new equipment is to be subject to Pre Purchase Questionnaire, (Via Supplies), to ensure that maintenance; training and energy requirements can be funded by the purchaser prior to procurement. For major schemes this process will be managed by the Capital Investment Group. 2. Any additional revenue consequences due to future changes in legislation must be met by the Trust. 3. For any equipment requiring specific training, the training is to be carried out at the time of commissioning or prior to the equipment being taken into use. 4. Revenue costs for new equipment to be identified and funded by the purchaser prior to purchase. This will include any refresher training requirements identified at the time of purchase 5. All equipment to be maintained by Estates will be logged as assets and set up within the Estates Information Management IT system with specific maintenance tasks set at the correct time intervals as identified either by legislation, guidance or manufacturers recommendations. 6. All equipment to be maintained by Medical Equipment Department will be logged within the MED Planned Preventative Maintenance Program with 7
specific maintenance tasks set at the correct time intervals as identified either by legislation, guidance or manufacturers recommendations. 7. At the pre determined dates the Planned Preventative Maintenance sheet will be allocated to an appropriately trained tradesman, any logbooks will be completed and the time spent will be recorded in the Estates Information Management IT system. 8. All spare parts or consumables replaced will be recorded against the job specific docket number to ensure full maintenance records are maintained. 9. The user will notify the Maintenance Manager (Estates) or the Medical Equipment Manager if there is any change of use of the equipment or areas. 10. Any breakdowns or equipment performance issues will be reported by the user via Facilities Helpdesk (Extension 3523), or Medical Equipment Department (Extension 3520) depending on equipment type. Significant equipment failures should also be reported by the Health and Safety Incident reporting process. 11. Planned Preventative Maintenance Programs will be reviewed annually, against budgets, by the Senior Engineer for Estates or Medical Equipment Manger. Any changes will be discussed with the Managers of the specific areas and Infection Control prior to any changes being made. 12. In the event of staff shortages, exceptional periods of excessive defects and or revenue shortfalls the Planned Preventative Maintenance program may not be fully completed. The % completed will be reported to Corporate Governance each month, resources will be applied on a risk based rational, with activities that relate to statutory compliance and patient safety being of paramount importance when assessing risk. 13. Estates will manage a dedicated rapid response team (Environmental Team) to specifically deal with minor wall damage, replacement of curtain rails etc, which may present an Infection Control risk to Patients, staff and Visitors. 14. Estates staff are to ensure that areas are kept clean during and following any works within the buildings, this will involve liaison with other Facilities Management staff to provide additional cleaning etc as required. 7. Air Handling Systems 1. All ventilation systems should be inspected on an annual basis, with systems associated with critical systems inspected on a quarterly basis. 2. The performance of all critical ventilation systems (such as those servicing operating theatres) need to be verified on an annual basis. 3. Local exhaust ventilation systems (extract systems) should be inspected and tested at least every 14 months. 4. The inspection should confirm that the system meets the following minimum requirements: - a. Safe access is possible whilst carrying out routine maintenance activities 8
b. The risks associated with Legionella and other potentially hazardous organisms have been managed c. The system remains fit for the purpose it was originally intended d. The system performance is adequate to the functional requirement eg air flow and air quality checks etc. e. The fire containment has not been breached 5. The maintenance frequency of the plant will be assessed according to the function of the system, it s location and the consequence of failure. 6. Air handling unit drainage systems should be inspected to ensure that they are clean and operating correctly. 7. Care should be taken whilst changing the air filters to avoid inhaling the dust, properly disposing of the used filters and vacuuming the dust residue from the filter housing to avoid contamination of the system. 8. Filters used in an extract system for the containment of hazardous substances or organisms should incorporate design provision for their safe removal. 9. The intake section of a ventilation system should be vacuumed-out to remove visible particles, the frequency of the cleaning operation will depend on the use of the system. 10. If the HEPA filters are changed on a ventilation system then an entrainment test needs to be carried out before the system is put back into service. 11. Critical ventilation systems should meet the following operating constraints during the verification process:- a. Achieve not less than 75% of the original design air-change rate b. Achieve not less than 75% of the original design pressure regime c. Sounds levels should not exceed levels specified in HTM 03-01 Part B d. If the area is an horizontal ultra clean operating theatre the discharge velocity should not be less than 0.4 m/s e. If a critical system should fail to meet the above mentioned parameters it should be taken out of service 12. Pharmacy aseptic suites should conform to the requirements of the European guide to manufacturing practice and the requirements of the Medicine Inspectorate if a licensed manufacturing unit. 13. Sterile services inspection and packing rooms should conform to the requirements of BS EN ISO 14644. 14. Inspection and maintenance regimes should be carried out in accordance with HTM 03-01. 15. Records of inspection and maintenance should be kept for at least five years 16. Any major issues associated with the status, operation or maintenance of the ventilation system should be discussed at the Decontamination & Estates Sub Committee. 9
17. When areas are being refurbished the use of negative pressure will be considered as a means of dust control for infection control management. This will be part of the Infection control team leads remit to advise of any practical methods that can be employed. Any other ventilation systems will also need to be assessed to ensure that any positive pressure effects are taken into account when works are being undertaken, this may involve the plant being isolated for the duration of the works. 8. CONTRACTORS 1. All contractors will be inducted in Trust procedures in accordance with the Management of contractor s policy. 2. All contractors will provide risk assessments and method statements in advance for all planned maintenance tasks to be carried out. 3. The contractor will be allocated a link Infection Control lead for the works as described in the management of Contractors policy. 4. The Trust must ensure that contractors employed to carry out planned maintenance and emergency support must be suitably qualified. 5. Contractors must be fully trained in the systems installed 6. Service contracts will be reviewed by Supplies prior to renewal and advice sought from the appropriate persons within the Trust to ensure full compliance with legislation is attained through the contract. 7. Supplies will ensure that all scheduled service visits occur as per contract and tat records are maintained for all works carried out. 8. Appropriate test equipment must be supplied by the contractor, as required, and be fully tested and calibrated 9. Copies of valid calibration certificates to be provided with any reports as required. 10. Contractors must have access to an adequate supply of spares to ensure that plant and equipment can be maintained correctly. 11. Service record sheets must always be provided following each service or breakdown visit. 9. POLICY LINKAGE This Policy is to be linked with the 1. Trust Procurement Policy. 2. Management of contractors policy 3. Hygiene Code 4. (Draft) Estates Strategy document 5. (Draft) Estates Development Plan Policy 10
6. Governance and Risk Management policy 7. Infection Control Manual 8. Business Continuity Plans 9. Incident, near miss hazard reporting policy 10. RESPONSIBILITIES a. The Trust will provide adequate funding to provide a full Planned Preventative Maintenance Program. b. The Trust will provide adequate capital investment to ensure refurbishment or replacement of plant or buildings as identified by condition monitoring. c. EFM helpdesk to log all contractors entering and leaving site. d. Supplies to ensure that companies providing service contracts are aware of the document and its requirements. e. Estates / Supplies to ensure that all Contractors complete relevant plant log books f. Designated Infection Control lead to ensure all infection control procedures are adhered to. 11. REFERENCES Health and Safety at work Act 1974 Standards for Better Health (DH 2006) NHSLA 2007 12. CONTRIBUTERS Paul Bond Andrew Bowler Chris Vowell Andrew Long Gary Turner David Gurd Tsambika Jeffries Tammie Purdue Hazel Gray Nigel Parker Corporate Governance Board MACH Governance Board Emergency Governance Board Elective Governance Board Infection Control Committee Head of EFM Maintenance Manager Building Supervisor Estates Electrical Supervisor Estates Mechanical Supervisor Estates Health and Safety Advisor Risk Manager Head of Supplies and Purchasing Infection Control Nurse Medical Equipment Manager 13. DOCUMENT REVIEW The Head of EFM and Maintenance Manager will conduct an annual review of the Procedure and its application. 11