Estates & Works Department

Transcription

1 Estates & Works Department Statutory Compliance Strategic Plan

2 INDEX 1. INTRODUCTION 2. SUMMARY 3. CONTROL OF CONTRACTORS 4. ELECTRICAL 5. GAS SAFETY 6. VENTILLATION 7. LEGIONELLA 8. MEDICAL GAS 9. ASBESTOS 10. RESOURCING OF ESTATES DEPATMENT APPENDICES Please refer to separate file 2

3 1. INTRODUCTION This strategy paper has been developed at the request of the HSE following a meeting between Sarah Baldwin-Jones (HSE) and Bob Hudson CEO of Powys teaching Health Board (PtHB) on 4th February The purpose of this document is to provide the HSE with details and timeframe of the strategy PtHB has adopted to move its built estate to a position of broad statutory compliance. The areas of statutory compliance which PtHB is currently engaged include: Control of Contractors Electrical Safety Gas Safety Ventilation Medical gases Asbestos Legionella Staff Resource in Estates & Works Department 2. SUMMARY PtHB can demonstrate considerable progress in moving the PtHB estate towards a level of broad compliance over the last 6 months. Whilst the speed with which the strategy can be rolled out is limited to the corresponding limits of PtHB resource, PtHB believes it is demonstrating commitment to achieving estate compliance and will continue with the tempo of the workload until a level of steady state property maintenance can be established. 3. CONTROL OF CONTRACTORS 3.1 Control of Contractors Policy PtHB has drafted a policy for the effective control of contractors across the estate portfolio (Appendix 1.1). This is to ensure that the contractors are adequately resourced and competent to undertake work to Health and Safety best practice. All contractors working on PtHB premises will be required to conform to the provisions of the PtHB Code of Contractors policy. The policy is currently being administered through PtHB corporate governance processes to enable formal adoption by the organisation. The target date for the policy being formally adopted is 1st May Control of Contractors Policy Implementation The contents of the policy are in the course of being implemented and full implementation will take place with effect from 1st May

4 The Estates & Works Department has also developed a code of safe practice and also a pre-qualification questionnaire for all contractors who are engaged by PtHB. (Appendices 1.2 & 1.3). 4. ELECTRICAL 4.1 Electrical Policy PtHB has drafted a corporate policy for the safe working with electricity (Appendix 2.1). The policy is currently being administered through PtHB s corporate governance process to enable its formal adoption by the organisation. The target date for the policy being formally adopted is 1st May The contents of the policy are in the course of being implemented within the Estates & Works Department and full implementation will be effected from 1st May Electrical Policy Implementation Actions taken to date: Under HTM 06-02, PtHB appointed an Authorising Engineer AE on 8th January 2013 to oversee the management of electricity within the estate. (Appendix 2.2). The Estates & Works Department has identified and initiated a maintenance management programme for the safe and efficient management of the electrical infrastructure within the estate. This includes Portable Appliance Testing P.A.T. Testing. Further documentation of PtHB s progress towards electrical compliance is documented in Appendix 2. The data at Appendices 2.3, 2.4 and 2.5 provides samples of qualified personnel from PtHB Works Department and external contractors respectively. This format of documentation will be used on all electrically biased personnel who work for PtHB as per the requirements of HTM Electrical Inspection & Testing The Estates & Works Dept. has commenced the implementation of a revised maintenance programme which will ensure that all buildings within the PtHB estate are periodically inspected and tested to comply with: BS7671 (IEE Wiring Regulations) including Guidance Note No 3 Inspection and Testing. (The IEE On Site Guide for use by competent electricians is not considered solely appropriate for this work). Electricity at Work Regulations 1989 Health and Safety at Work Act 1974 Health Technical Memorandum 06-01: Electrical services supply and distribution 4

5 o Part A: Design Considerations Health Technical Memorandum 06-01: Electrical services supply and distribution o Part B: Operational Management Periodic Inspection Contract In April 2014 PtHB awarded electrical contractors John Bulpin Electrical a contract for carrying out the periodic inspection and testing for the freehold PtHB estate, across Powys. Please ref also to Appendix 2.6 for the John Bulpin Electrical company profile; this also presents the evidence of John Bulpin Electrical staff as Competent Persons to work on the PtHB estate. The duration of the Periodic Inspection & Testing is approximately 29 weeks with an anticipated completion date of 4 th of July Please ref Appendix 2.9 for details of the programme of works. The programme of works shows the 9 main PtHB community hospital sites. The Compliance and Maintenance Manager will require the contractor to complete the testing of all PtHB freehold premises, including clinic premises, within the 29 week schedule. 4.4 Maintaining Electrical Compliance The Compliance and Maintenance Manager has programmed an annual Electrical Infrastructure PPM into the Department s IFM system to ensure that of the electrical periodic & inspection testing is continuously carried within the entire estate in the future (Appendix 2.11). The Head of Estates and Property (HoEP) will be responsible for ensuring that this PPM is undertaken. The Electrical Compliance Working Group sits on a monthly basis with the aim of moving the PtHB estate into compliance in terms of HTM06, to establish a steady state of best practise across the portfolio, plan for the replacement / overhaul of electrical distribution assets when necessary and to effectively manage risk for this aspect of compliance. Attendees include HoEP who chairs the group, the Compliance and Maintenance Manager, Estate Officer (M&E) (AP Electrical), the Health and Safety Manager and the PtHB Infection Control lead. The Action Tracker from this Working Group is tabled at the monthly Compliance Committee. The HoEP has responsibility to ensure that PtHB is in a position of acceptable compliance within a reasonable timeframe and to ensure that appropriate maintenance regimes are put in place. The Action tracker from the most recent Working Group can be referenced at Appendix GAS SAFETY 5.1 Gas Safety Policy PtHB has drafted a corporate policy for Gas safety (Appendix 3.1). The policy is currently being administered through PtHB s corporate governance process to enable its formal adoption by the organisation. The target date for the policy being formally adopted is 1st May The contents of the policy are in the course of 5

6 being implemented within the Estates & Works Department and full implementation will be effected from 1st May Gas Safety Policy Implementation Actions taken to date: PtHB has engaged and is working in partnership with a Gas Safe registered company Amroc Heating Services Ltd. The Compliance and Maintenance Manager has been overseeing a fast track servicing work stream across the PtHB estate. To date, Amroc has already serviced over 90% of the PtHB gas fired asset (heating and hot water) and has completed any necessary remedial work to these assets. Assets which have not yet been serviced have been excluded from the work due to ongoing asbestos removal contracts. These assets are located at the Newtown Hospital boiler house and the Bronllys Hospital Courtyard boiler house. This has prevented 100% achievement of compliance for gas servicing to date. The asbestos removal contracts are currently programmed to complete 14th April It is intended that this servicing will be undertaken as soon as reasonably possible after the completion of the asbestos removal work. At service level, the Estates & Works Department has produced a fully comprehensive file to demonstrate the partnership working between PtHB and Amroc (as retained contractor) (Fig 1). This file includes, the tendering documents, contract details, company profile, R.A.M.S., service sheets for all gas appliances, asset list, etc. Amroc s file is held in the Compliance & Maintenance Managers office and can be viewed upon request. Fig 1 Amroc File Front Works/Service Sheets 6

7 5.3 Maintaining Gas Safety Compliance A 12 monthly PPM has been created on the Estates & Works Department IFM system. This PPM will then give the department an annual prompt to contact the preferred gas safe contractor at that time to come to the given site to carry out the gas safe maintenance service. HoEP is responsible for ensuring that this work is undertaken in the future at the required intervals. Appendix 3.2 shows a copy of this PPM. 6. VENTILATION 6.1 Ventilation Policy PtHB has drafted a corporate policy for the safe management of ventilation across the estate portfolio (Appendix 4.1). The policy is currently being administered through PtHB s corporate governance process to enable its formal adoption by the organisation. The target date for the policy being formally adopted is 1st May The contents of the policy are in the course of being implemented within the Estates & Works Department and full implementation will be effected from 1st May A member of the Estates staff has recently completed AP Ventilation training at Eastwood Park, completed 17th Match 2014.Procedures have been put in place towards delivering a safe and robust maintenance programme on all critical ventilation systems. HoEP chairs a monthly Ventilation Compliance Working Group which is also attended by Compliance and Maintenance Manager, Building Officer (Mechanical & Engineering) and the PtHB Health and Safety Manager. The Action Tracker from this working group is tabled at the monthly Compliance Committee. Please ref Appendix 4.7 for a copy of the most recent action Tracker from the Working Group. Further documentation of PtHB s progress towards ventilation compliance is documented in Appendix Ventilation Policy Implementation: Actions taken to date: Please find below a list of milestones that PtHB Estates & Works Department has achieved in the last 2 months preceding date of this document: Ventilation policy has been written in draft form and is now waiting for approval from the board. Authorising Engineer (AE) for ventilation systems has been appointed by PtHB Mr Kevin Ridge of NHS Wales Shared Services Partnership In adherence with HTM 03-01an Authorised Person (AP) has been identified Mr Steve Watkins, Engineering Estates Officer. Steve has successfully carried his AP training and is currently waiting for his certificate and formal articles of appointment from Mr. Kevin Ridge. Tool box talks held with D.E.L. on how to maintain the critical ventilation plant at both Brecon and Llandrindod theatre suites. 7

8 Weekly PPM, with procedure in place, for checks on the critical ventilation plant. Appendix 4.5. Filter itinerary identified for the efficient ordering of ventilation filters. To complete the programme for the compliance of the ventilation systems, PtHB within PtHB Estates & Works Department needs to complete the following tasks: Mr Steve Watkins to receive his certificate/qualification to become an Authorising Person (AP) under HTM Authorising Engineer (AE), Mr Kevin Ridge of Shared Services to officially appoint Mr Steve Watkins as the Authorising Person for ventilation systems for PtHB. PtHB Estates & Works Department must identify and engage a specialist contractor to assist with the maintenance of all critical ventilation systems within the PtHB. PtHB Estates & Works Department must set up a pertinent maintenance contract for all critical ventilation systems within the PtHB. PtHB Estates & Works Department must develop the PPM s for all ventilation systems via IFM to ensure more control of the maintenance programme. The table in Appendix 4.6 provides a programme of when these milestones will be achieved. It is envisaged that PtHB ventilation systems will be fully complaint by the end of May Maintaining Ventilation Compliance The Ventilation Working Group will continue to sit on a monthly basis with the aim of moving the PtHB estate into compliance in terms of HTM03, to establish a steady state of best practise across the portfolio, plan for the replacement / overhaul of ventilation assets when necessary and to effectively manage risk for this aspect of compliance. HoEP has responsibility to ensure that PtHB is in a position of acceptable compliance within a reasonable timeframe and to ensure that appropriate maintenance regimes are put in place. 7. LEGIONELLA 7.1 Legionella Management Policy PtHB has had Legionella management policy in place since February PtHB has a written Legionella Management Plan which is currently being reviewed and updated by the Compliance and Maintenance Manager. The update will be completed by 31st May

9 7.2 Legionella Policy Implementation Michael Cope, Compliance and Maintenance Manager has been formally appointed as Responsible Person and Steve Watkins, Estates Officer (Mechanical & Engineering) has been appointed as Deputy Responsible Person for PtHB. Both of these individuals have received adequate training to fulfil this position and will continue to receive refresher training at appropriate intervals. The Works Supervisors for both the North and the South DLO Works Teams have also recently completed training trained to fulfil the Authorised Person role. The Estates & Works Department are currently considering the appointment of Competent Persons, from internal staff resource or external contractors. Risk assessments were undertaken by Oakleaf consultants early in 2013 and are due for review in A recent audit was undertaken by Oakleaf which reported on the effectiveness of the administration of PtHB legionella policy, PtHB training needs, and performed a check of the log book maintenance system. The findings of the audit were satisfactory and PtHB will look to continue with the implementation of the policy accordingly. A log book system is currently in place covering requirements of legionella maintenance under L8 Approved Code of Practice. This is monitored by the RP/DRP and AP s for performance and remedial actions. Legionella awareness training has been given to the Estates & Works Department staff and Steve Watkins, Estates officer Engineering is rolling this out across the entire estate, including a water flushing regime. Nursing staff at each site have been required to attend the training and are undertaking flushing regimes at the various PtHB sites as part of their duties. JD Water Consultants are contracted to PtHB to undertake legionella sampling, temperature monitoring, disinfection of water system and tank cleaning as required to fulfil our obligation under L8 Approved Code of Practice. PtHB is currently approaching appropriately experienced contractors to provide fee quotes for undertaking Thermostatic Mixing Valve TMV, maintenance across the PtHB estate, to comply with WRAS and TMV3 scheme. I this mean time this work is being undertaken, incrementally, using in-house maintenance staff resource. In Brecon and Llandrindod Hospitals, PtHB has installed Chlorine Dioxide systems to continuously dose the water system with a chemical solution which will inhibit legionella growth. The pipework in these hospitals are very old and the method of shot disinfection was not working therefore a more permanent solution was sought following advice from Oakleaf and the HSE. Additional works are being undertaken across the whole of the estate to identify suitable drinking water outlets, removal of non-compliant water vending machines and remedial works as identified in the risk assessments. Maintenance Assistants are being required to develop their knowledge of the estate and seek out and report braded hoses and dead legs during their day to day working activities. 9

10 7.3 Maintaining Compliance with Legionella Policy and best Practise The Water Safety Working Group sits on a monthly basis with the aim of moving the PtHB estate into compliance in terms of HTM04, to establish a steady state of best practise across the portfolio, to plan for the replacement / overhaul of relevant estate assets when necessary and to effectively manage risk for this aspect of compliance. Attendees include HoEP who chairs the group, the Works and Compliance Manager (RP Legionella), Estate Officer (M&E) (ARP Legionella), the Health and Safety Manager and the PtHB Infection Control lead. HoEP has responsibility to ensure that PtHB is in a position of acceptable compliance within a reasonable timeframe and to ensure that appropriate maintenance regimes are put in place. The Action tracker from the 8. MEDICAL GASES 8.1 Medical Gas Policy PtHB has drafted a policy for the management of medical gas policy. The policy is currently being administered through PtHB corporate governance processes to enable formal adoption by the organisation. The target date for the policy being formally adopted is 1st May A copy of the draft policy can be seen at Appendix Medical Gas Policy Implementation The AE for Medical Gas for PtHB is John Tidball from the All Wales Shared Services Facilities Services. They were appointed in December Two of the PtHB Works staff have successfully completed their initial training to become APs in medical Gas. They are currently undertaking the vocational element of their training. The Compliance and Works Manager is currently overseeing these staff in their progression to become APs in Medical gas and is hopeful that the formal appointment will be made after a period of assessment and training, before the end of The next milestones that PtHB need to undertake are: Complete the appointment of APs in Medical Gas who will take responsibility for overseeing the management and maintenance of Medical Gas at PtHB. Timescale by 1st January For the trainee APs to work with the AE for the review and updating of risk assessments associated with Medical Gas. Timescale by 31st August To revitalise / re introduce log books for permits to work where medical gas assets are located across the PtHB estate. Timescale by 1st June Compliance and Maintenance Manager to oversee the procurement of updated drawings for medical gas infrastructure at relevant PtHB sites. Timescale by 1st June

11 Compliance and Maintenance Manager to require the trainee APs in medical gas to review the annual report provided to PtHB by the AE Medical Gas and to formulate a plan to overhaul the equipment as necessary. Timescale by 1st August Compliance and Maintenance Manager to work submit any priority Capital works to the Capital Works Programming Manager. Timescale by 1 st August Compliance and Maintenance Manager to review the Maintenance contract. Timescale by 1st June HoEP has required the Workforce Development Directorate to arrange for the Porters to undertake appropriate medical gas training, consummate with the normal activities they are asked to undertake in their roles. Timescale by 31st May Maintaining Compliance with Medical Gas Policy and Best Practise The Medical Gas Working Group sits on a monthly basis with the aim of implementing this work stream to move the PtHB estate into compliance under HT02, to establish a steady state of best practise across the portfolio, to plan for the replacement / overhaul of relevant estate assets when necessary and to effectively manage risk for this aspect of compliance. Attendees include HoEP who chairs the group, the Works and Compliance Manager (RP Legionella), Estate Officer (M&E), the Health and Safety Manager and two staff whom are currently undertaken training to be AP Medical Gas for PtHB. HoEP has responsibility to ensure that PtHB is in a position of acceptable compliance within a reasonable timeframe and to ensure that appropriate maintenance regimes and mechanisms for risk management are put in place. The Action Tracker from this meeting is tabled at the Monthly compliance Committee. The Action tracker from the most recent Working Group is referenced at Appendix Asbestos 9.1 Asbestos Policy PtHB has an Asbestos Policy which was formally adopted by the organisation in June The Asbestos Management Plan is currently being reviewed and revised by the HoEP (Appendix 6.1). The final draft will be tabled at the next Asbestos Group Meeting (Appendix 6.2) on 20th May Asbestos Policy Implementation The implementation of the Asbestos Policy is through the contents of the Asbestos Management Plan. 11

12 Most of the Works Staff and key members of the Estates Staff within the Works & Estates Department at PtHB have now completed Asbestos awareness training and are trained up to Category B standard. HoEP has ensured the timely procurement of appropriate PPE and the majority of the Works staff have undertaken full face fitting for masks. The appointed Asbestos Manager for PtHB has recently completed several capital projects for the removal of asbestos at sites across Powys including Llandrindod Hospital, Brecon Hospital, Llanidloes Hospital and Newtown Hospital. Asbestos removal works currently remain outstanding at Bronllys Hospital (Courtyard) due to the requirement for Licensing under European law for the protection of Bat species. Over the next financial year, there will be further projects to remove asbestos from PtHB sites and this work will generally be rolled up with other works of refurbishment / reroofing. e.g Bronllys Hospital Concert Hall re-roofing / window replacement. HoEP is arranging for the Works & Compliance Manager to undertake full training so they are able to take on the responsibilities of Asbestos Manager and increase the staff resource able to manage permits to work and oversee the dissemination of data about Asbestos on the PtHB estate to relevant parties. Timescale by 1st July Maintaining Compliance with Asbestos Policy and Best Practise The Asbestos Management Group sits on a monthly basis with the aim of implementing this work stream to maintain adherence to the PtHB Asbestos Policy. The Group aims to ensure a regime of best practise across the portfolio and plan for the removal of asbestos whilst safeguarding operational outputs of the estate and to effectively manage risk for this aspect of compliance. Attendees include HoEP who chairs the group, the Compliance and Maintenance Manager, Estate Officer (M&E), Estate Officer (Buildings) (Asbestos Manager) and the PtHB Health and Safety Manager. The Action Tracker from this meeting is tabled at the Monthly compliance Committee. The Compliance Committee is held monthly and is chaired by the CEO of PtHB. The Action tracker from the most recent Working Group is referenced at Appendix Resourcing of the Estates & Works Department at PtHB Current position The Estates and Works Department consists of 30 1/2 no staff at the present time. The current staff structure can be referenced at Appendix 8.1. The current HoEP commenced in post mid August 2013 and since this time, 2 permanent staff and 2 interim staff have been recruited to the Estates Department to support the service function. These include: Permanent staff: Compliance and Maintenance Manager Capital Programming Manager 12

13 Interim temporary staff: Fire Adviser (18 hours per week) Building Surveyor (full time) Contractors which have/are been engaged by PtHB via HoEP over the last few months to boost the strategy towards compliance include: Amroc (Gas works) M & M Medical David Waters (Review of Estates & Works safe ways of working.) Joe Taylor (Fire Procedures) Activate Fire (Fire Consultancy advice) John Bulpin (electrical works) HoEP is mindful that the implementation of the compliance strategy is limited to the limits of available staff resource and funding for interim staff resource. HoEP is also mindful that the size of Powys as a region also frustrates speedy progress as does also the procurement regime adopted by PtHB, wherein tenders can routinely take several months to come to a result. HoEP is committed to expand and develop the Estates Department at PtHB to overcome these limiting factors Future Position Section to be re-written by CEO 13