During the design of SCART representatives from the Health & Safety Executive were very supportive of its development and its national application.

Transcription

1 LANARKSHIRE NHS BOARD QUARTERLY PERFORMANCE REPORT PERIOD TO JUNE 2009 ANNEX 5 SUBJECT: LEAD: ESTATES, PROPERTY & ENVIRONMENT I ROSS STATUTORY COMPLIANCE AUDIT AND RISK TOOL (SCART) 1. Background SCART is a new web based assessment tool which has been developed by Health Facilities Scotland (HFS) for use by NHS Boards in Scotland. It is still in developmental stage and will continue to develop under direction from HFS. The purpose of SCART is to enable NHS Boards to measure their level of compliance with a range of aspects of legal and best practice compliance and produce a prioritised high-level summary for consideration at Board level. During the design of SCART representatives from the Health & Safety Executive were very supportive of its development and its national application. 2. Current Status Version 1 of SCART is now fully operational and covers 39 topics (see appendix 1). Each topic has a question set which, when answered, provides a weighted score for that topic. This weighted score is reported as a percentage compliance with a risk rating for each topic question set (see appendixes 2 & 3 for examples of Asbestos and Legionella). Although in theory a score of 100% means full compliance, the actual score must not be considered as an absolute indicator of compliance. There are a number of valid reasons for scores below 100% which do not necessarily mean the topic is at increased risk. The score is an indicator against which improvements can be demonstrated. Also, although not government policy at this time, it is likely that SCART scores may be used as a benchmark in the future. SCART is primarily an Estates based reporting tool and although some topics apply to other disciplines within NHSL these will not necessarily be reported through SCART. NHSL commenced a SCART review of all its sites in May 2009 with the first pass completed mid July This first pass has identified those areas where a more detailed review is required before an accurate first score can be established. For the purposes of this initial report the 2 key subjects of Asbestos and Legionella are reported in detail in appendixes 2 & 3. It is intended that the number of subjects reported in detail will increase in future PSSD quarterly performance management reports to the NHSL Board. The SCART question sets require inputs from a range of persons and information sources. The approach taken by NHSL PSSD has been to appoint an Assistant August_2009_Board.doc Page 1 of 6

2 Maintenance Manager with pan Lanarkshire experience to carry out an initial first pass of answering all 39 questions sets for the 78 NHSL properties entered on the SCART database. The approach to SCART mirrors that of the national Domestic Cleaning Standards whereby an internal audit function is established. This first pass of the question sets was completed mid July 2009, and resulted in an overall score for NHSL of 43%. We are advised by HFS that this is reasonable/good score for a first pass. 3. Programme for Completion of Second Stage The second stage of the process is now for those Maintenance Managers with specific site knowledge/responsibilities to review the first pass answers and update as necessary. This is expected to be complete by September This second stage process has been applied to 2 subjects across all 78 premises. Asbestos and Legionella Scores of 88% and 95% respectively have been recorded. A number of the questions are open to interpretation and no guidance is given in SCART as to the standard of proof required in support of a positive response. The approach taken has been to assume the worst case scenario/greatest burden of proof. As PSSD becomes more familiar with SCART as an aid to demonstrating compliance, a number of questions can be answered in a more pragmatic manner which will score higher and give a truer picture of the position within NHSL than that achieved initially. 4. Future Developments Health Facilities Scotland - SCART HFS is scheduled to issue Version 2 of SCART in October/ November This will increase the number of subjects covered from 39 to over 50. It will also provide additional facilities to evidence compliance and provide an audit trail. It should be noted that SCART is at an early stage of its use within all Scottish Health Boards. 5. NHSL Management Steering Group NHSL Management Steering Group reviewed the use of SCART at its meeting on August 10 th This review will continue on a monthly basis, also Salus will liaise with PSSD to appraise the use of SCART across NHSL and how compliance monitoring of statutory duties can be assessed and reported. It should be noted that some subjects have a range of individuals with responsibility / accountability to ensure compliance. David Browning General Manager, PSSD August_2009_Board.doc Page 2 of 6

3 Appendix 1 1 Pressure Systems Safety Regulations Control of Substances Hazardous to Health (COSHH) Regulations Electricity at Work Regulations 1989 (Incorporating SHTM 2020 and SHTM 2021) 4 Lifting Operations & Lifting Equipment (LOLER) Regulations 1998 (Incorp. SHTM 2024 (Lifts)) 5 Workplace (Health, Safety and Welfare) Regulations Personal Protective Equipment (PPE) at Work Regulations Provision and Use of Work Equipment (PUWER) Regulations Lifting Operations and Lifting Equipment (LOLER) Regulations (Lifting Equipment) 9 Manual Handling Operations Regulations 1992 (Amended 2002) 10 Asbestos - The control of Asbestos at Work Regulations Management of Health & Safety at Work Regulations 1999 (Incorporating SHTM 2050) 12 Construction, Design and Management (CDM) Regulations 13 Noise at Work Regulations (Incorporating SHTM 2045) Acoustics 14 Display Screen Equipment (Health & Safety) Regulations Ventilation in Healthcare Premises (incorporating SHTM 2025) 16 Medical Gas Pipeline Systems (MGPS) (incorporating SHTM 2022) 17 Oil Storage - The Water Environment (Scotland) Regulations Electrical Services (Abatement of) (incorporating SHTM 2014) 19 Electrical Services (Emergency) (incorporating SHTM 2011) 20 Sterilisation (SHTM 2010) 21 Firecode, Alarm and Detection Systems (incorporating SHTM 82) 22 Legionellae (Control of) in Healthcare Premises (incorporating SHTM2040 and HSE guidance document L8) 23 Hot Water & Surface Temperatures (Safe) Scottish Health Guidance Note SHGN 24 Firecode - General (incorporating SHTM80-86 bar 82) 25 Confined Spaces Regulations Patient Bearing Equipment (including slings) 27 Working at Height Regulations Statutory/Mandatory Training 29 Gas Safety (Inst & Use ) Regulations Contractors (control of) - (The Management of Health & Safety at Work Regulations 1999) 31 Decontamination of Equipment 32 Contingency Planning (Civil Contingencies Act 2004) 33 Slips, Trips and Falls - Floor Hazards34 Infection Control 34 Infection Control 35 Steam Systems 36 Dangerous Substances and Explosive Atmospheres Regulations Washer Disinfectors 38 Window Security 39 Suicide August_2009_Board.doc Page 3 of 6

4 Appendix 2 Asbestos The control of Asbestos at Work Regulations 2006 Key: LOW MEDIUM HIGH VERY HIGH MAX AVG Av erage % Comp A Do you have an asbestos plan in place? B Do you have an updated register of all locations of asbestos materials? C Are all asbestos materials identified by labelling? D Are all asbestos materials reviewed annually and results recorded Topic Average % Compliance From the INSPECTION RESULTS 88 Topic MAX RISK Topic AVG RISK 12 8 A. This is at 75% as investment plans are still being developed. This is due for completion by the end of September All other aspects of the Asbestos Plan are in place. B. Complete C. The location of all known asbestos is identified in the type 2 surveys which form part of the Asbestos Plan. A total of 52 sites have Asbestos present, all of which is in a safely contained environment. Each room within each building with the NHSL estate has a Property Information Plate (PIP). This plate has a unique number and work is underway to add a red A to the PIP in rooms where asbestos is present. This identification mark will be communicated within all Maintenance staff and contractors work instructions. Asbestos Registers will also be held locally in all relevant premises. D. Complete August_2009_Board.doc Page 4 of 6

5 Appendix 3 Legionellae (Control of) in Healthcare Premises (incorporating SHTM2040 and HSE guidance document L8) VERY LOW MEDIUM HIGH Key: HIGH MAX A VG Ave rage % Comp A Do you have a fully implemented Operational Plan? B Do you have a policy on the Control of Legionellae? C Do you keep formal records of maintenance, testing and system alterations? D Are all operational management tasks carried out (tank inspection, cleaning and disinfection)? E Do you have an Appointed Infection Control Team (Legionella)? F Do you carry out legionella water sampling tests in areas occupied by patients who are immunologically compromised? G Are new or refurbished areas commissioned as detailed in SHTM 2040 Validation and Verification? H Are temperature checks taken periodically on hot and cold domestic systems? I Do all tanks storing potable water comply with Water Bylaws? J Are hot water calorifiers drained and cleaned as necessary? L Do you have up to date record drawings of all hot and cold water systems? M Have you carried out an initial Legionella risk assessment for all properties? N Do you carry out a two yearly review of your risk assessments? O Are appliances in unused areas flushed weekly? P Can systems be fully drained down? Q Are all materials specified listed in WRAS Water Fittings and Materials directory? R Have you appointed in writing a Nominated Person (Legionellae) and Deputies where required? Topic Average % Compliance From the INSPECTION RESULTS 95 Topic MAX RISK Topic AVG RISK 12 5 August_2009_Board.doc Page 5 of 6

6 A. Complete B. Complete C. Complete D. Complete E. Complete F. Complete G. Complete H. Complete I. Complete J. Complete K. Complete L. Plant room schematic drawings are available for most sites. The provision of full record drawings, particularly for the older sites, may not be reasonably achievable. This is being investigated. M. Complete N. Complete O. Complete P. Generally systems are designed to be and can be drained down. The unpredictable nature of air locks in systems make it is extremely difficult to give an absolute guarantee. Q. Complete R. Complete FURTHER DETAILS: Full report available from / at: Managed by: Governance Committee Ian Ross, Director SIPP; David Browning, General Manager, PSSD Management Steering Group Operating Management Committees (3) and Board August_2009_Board.doc Page 6 of 6