The Newcastle upon Tyne Hospitals NHS Foundation Trust Management and Control of Mechanical System including Pressure Systems Policy Version No.: 2.0 Effective From: 28 August 2018 Expiry Date: 28 August 2021 Date Ratified: 15 February 2018 Ratified By: Health and Safety Committee 1 Introduction It is the policy of the Newcastle upon Tyne Hospitals NHS Foundation Trust to provide a safe and healthy environment for all its patients, staff and visitors. This policy document is provided to ensure that all staff involved with mechanical systems including pressure systems understand management and individual responsibilities and methods employed by the Trust, ensuring safe operation practice of mechanical systems. The document details operational requirements and information required in the event of emergency. The Trust, in recognition of its statutory duties endeavours to comply with the Pressure Safety Regulations 2000 Approved Code of Practice. 2 Scope Failure of a mechanical system including pressure system can lead to serious injury or fatalities. Consolidation of previous legislation evolved into the Pressure Systems Safety Regulations 2000 No. 128, which deals with the risks created by a release of stored energy should the system fail and details the measures that should be taken to prevent failures and reduce risks. 3 Aims The Pressure Systems Safety Regulations 2000 applies to all plant/systems which contain relevant fluid. A relevant fluid is defined as: Steam at any pressure. Hot water at 100 degree C or above. Refrigerant within systems of input power greater than 25kW. A compressed or liquefied gas (i.e. refrigerants, LPG, air, nitrogen, acetylene, oxygen etc.) at 0.5 bar gauge or above. The extent of the plant/system covered by the Pressure Systems Safety Regulations 2000 is outlined within the Written Schemes specific to each system. The Trust s external Competent Person (Examiner) as agreed with the Director of Estates will ultimately decide which systems require inspection/ examination under the Pressure System Safety Regulation 2000. Greater detail of the scope of inspection/ Page 1 of 14
examination and frequency required is identified within the specific written scheme for each system. Examples of pressure systems and equipment are:- Steam sterilising autoclave and associated pipework and protective devices Steam boiler and associated pipework, calorifiers, heat exchangers and protective devices High Temperature Hot Water Boilers and associated pipework, calorifiers, heat exchangers and protective devices Pressure cooker Gas- loaded hydraulic accumulator, if forming part of a pressure system Portable hot water / steam cleaning unit fitted with a pressure vessel Vapour compression refrigeration system where the installed power exceeds 25 KW Medical Gas Systems pressure process plant and piping compressed air systems (fixed and portable) heat exchangers and refrigeration plant valves, steam traps and filters Pipework and hoses Pressure gauges and level indicators This policy additionally refers to items that are not covered under the Pressure Systems Safety Regulations. All mechanical systems are not included within the Pressure Systems Safety Regulations however the hazards associated for all mechanical services are extensive and are addressed under this Policy. Systems and equipment not covered by the pressure systems safety regulations 2000 include: Low Temperature Hot Water Calorifiers and heat exchangers not heated by Steam or High Temperature Hot Water 4 Duties (Roles and responsibilities) For the purposes of this Policy, the estate comprises all the premises currently occupied, owned and maintained by the Trust. The following locations have been identified as containing pressure systems and/or mechanical systems: Freeman Hospital Royal Victoria Infirmary (RVI) Page 2 of 14
Regent Point RVI Dental Hospital Northern Centre For Cancer Care Ponteland Road Health Centre Battle Hill Health Centre Benfield Park Healthcare and Diagnostic Centre Cramlington Health Centre, Manor Walks Fertility and Genetic Services at Centre for Life Campus for Ageing and Vitality The Trust s leased premises on the RVI and Freeman Hospital sites which are not maintained by the Trust s Estates Department, are the responsibility of the IFM Company (Hospital site) or Veolia (Energy Centre) who will maintain mechanical systems including pressure systems and comply with all relevant legislation, ensuring robust monitoring and the recording of information. Functional Responsibilities The Trust, as an employer has accepted and ensures the fulfilment of all its statutory duties to its employees and others who may use or access its premises. Key personnel have functional and professional responsibilities for ensuring that the Trust s pressure systems are managed and operated safely. 4.1 Chief Executive The Chief Executive has overall responsibility for ensuring that the Trust has safe systems in place and premises comply with all statutory requirements. This responsibility is delegated to the Director of Estates within the Trust. 4.2 Director of Estates The Director of Estates will provide a link with the Trust Board to ensure that appropriate management systems are put into place to address mechanical systems safety issues and ensure compliance with legislation within the Trust. The director will oversee the management arrangements and advise the Trust Board accordingly and ensure that the Trust s risk register is maintained with regard to mechanical systems including pressure systems safety management. He will appoint, in writing, an Authorising Engineer (Pressure Systems) to implement, administer and monitor the safety arrangements and will review the appointment of the Authorising Engineer (PS) on an annual basis. Where appropriate, he will seek advice from the Authorising Engineer (PS) and the Health and Safety Advisor to ensure the Trust meets its statutory obligations for the control and management arrangements for mechanical and pressure system safety. Page 3 of 14
The Director of Estates will ensure that sufficient resources are made available to the Estates Department to comply with their duties outlined in this policy and in the Safety Rules and Procedures for Work on Mechanical Systems including Pressure Systems. To help with such responsibility, Authorised Person(s) will help with the dayto-day management and control of the Mechanical Systems including Pressure Systems Policy. 4.3 Authorising Engineer The Authorising Engineer will take on the duties, roles and responsibilities as outlined in the Safety Rules and Procedures for Work on Mechanical Systems including Pressure Systems. They will be an independent appointee to the Trust, reporting directly to the Director of Estates. They will hold Authorising Engineer qualifications in line with Pressure Systems Safety Regulations 2000 and will assess and recommend, in writing, an appropriate number of Authorised Persons. They will carry out regular audits of the management and control procedures and provide technical assistance where necessary. Refer to the Safety Rules and Procedures for Work on Mechanical Systems including Pressure Systems for a full description of duties 4.4 Authorised Persons (Pressure Systems): AP(PS) The Authorised Person (Pressure Systems) will be appointed by the Director of Estates following assessment and recommendation of the Authorising Engineer (PS). The role of the Authorised Person (Pressure Systems) is to manage and oversee all work relative but not limited to PSSR 2000 and the Trust s Safety Rules and Procedures for Work on Mechanical Systems including Pressure Systems. The AP(PS) will work in collaboration with the appointed Competent Person to maintain compliance with the Trust s Written Scheme of Examination. It is essential that they inform the Competent Person of any change to systems to allow update of the Written Scheme. Authorised Persons (PS) will be responsible for investigating any incidents reported on Datix. Any lessons learned will be shared with the Pressure Systems Safety Group and disseminated to all relevant staff. The Authorised Persons (PS) will inform the Competent Person(s) of any changes to systems to allow update of the Written Scheme. Page 4 of 14
4.5 Competent Person (Examiner) The term Competent Person (Examiner) refers not to the individual employee who carries out the duties under the Regulations, but to the body which employs the person charged with those duties. Thus, the definition of Competent Person makes it clear that the legal duty to comply rests with a Competent Person s employer and not with an individual. The Trust employs a Risk Services company to undertake the role of Competent Person (Examiner). This role has two distinct functions: (a) drawing up and certifying schemes of examination (Regulation 8) (b) carrying out examinations under the scheme (Regulation 9) Although separate guidance is given on these functions, this does not mean that they have to be carried out by a different Competent Person (Examiner). From time to time, the Trust (Trust/Owner) may seek advice from a Competent Person (Examiner) on other matters relating to the Regulations. In such circumstances, a Competent Person would be acting solely as an advisor, rather than a Competent Person as defined. It is the responsibility of the Trust (User/Owner) to select a Competent Person capable of carrying out the duties in a proper manner with sufficient expertise in a particular type of system. A Competent Person, who has available a team of employees with the necessary breadth of knowledge and expertise, should be chosen. 4.6 Maintenance Staff (Skilled Persons) Only Trust staff/contractors with the relevant system knowledge, experience and training will be allowed to undertake maintenance duties of mechanical and pressure systems. These works must be undertaken as per the agreed systems of work to ensure: (a) (b) (c) Systems are operated within their safe operating limits Incidents of note are escalated as outlined in section 6.3 and 6.4 below Systems included within the Pressure Systems Safety Regulations 2000 are only operated whilst included within an accurate written scheme and with a valid examination certificate Any remedial actions, upgrades and/or repairs will be undertaken by the Trust. staff (person in charge/skilled person). They are required to fulfil their statutory duties and use all work items provided by the Trust correctly, in accordance with their training and the instructions they receive to enable them to use the items safely. The Trust, or those they appoint to assist them with health and safety matters, therefore must be informed without delay of any work situation within the Trust Page 5 of 14
which might present a serious and imminent danger. Whether the danger could be to the employee concerned or, if it results from the employee s work, to others. Staff must also notify any shortcoming in the health and safety arrangements to their line manager, even when no immediate danger exists, so that management in pursuit of their duties under the HSWA and other statutory provisions can take such remedial action as may be needed. Any incidents or near misses must be reported on the Trust incident system Datix. Health and safety issues will be escalated as required, to the relevant Estates site specific Health and Safety group and/or to the Estates Risk Management and Governance Group. 4.7 Plant/Equipment Operator The Trust will provide appropriate training to ensure that plant and equipment is operated in a safe manner. This will be support by a risk assessment and standard operating procedure where appropriate. 4.8 Pressure System Safety Group An Estates Pressure System Safety Group has been formed that will oversee all relevant aspects of the safe management of mechanical systems including pressure systems trust-wide. Terms of reference (see Appendix 1) will be reviewed on an annual basis. 5 Definitions A list of definitions is included in the Safety Rules and Procedures for Work on Pressure Systems manual. 6 Work on Mechanical Systems Including Pressure Systems 6.1 Safety Rules and Procedures for Work on Mechanical Systems including Pressure Systems The Safety Rules and Procedures for Work on Mechanical Systems including Pressure Systems manual outlines the safety requirements to allow competent Trust staff to operate the various pressure systems owned by the Trust. The Safety Rules and Procedures manual shall not be interpreted as over-riding any legislation in force at the time of issue, or any which may come into force at a later date. It provides detailed guidance on: Compliance with safety regulations; Management arrangements; Operating procedures; The requirements of the Permit to Work system and the content and information that should be included; The training requirements of the members outlined within the document Page 6 of 14
The extent and responsibilities of the roles identifiable within the Trust The management arrangements implemented to ensure adequate control and monitoring of the relevant systems; The responsibilities and escalation procedure for incidents that include explosions, dangerous occurrences or defects that affect the safety of the plant/ system. 6.2 Written Scheme of Examination and Report of Examination A certified Written Scheme of Examination is available for all systems covered under the Pressure Systems Safety Regulations 2000 owned by the Trust. The Trust ensures the scope of the Written Scheme of Examination is appropriate; however, advice may be sought from the Competent Person (Examiner) if necessary. The written schemes owned and maintained by the Trust will be reviewed annually to ensure they are comprehensive in their extent. After defining the scope of the mechanical and pressure systems, the competent person will specify the nature and frequency of examinations and any special measures needed to prepare the system for safe examination. No plant or equipment shall be operated without an over-arching Written Scheme, outside the scope of safe operation or beyond the further examination date requirements identified on the current report of examination. 6.3 Escalation process as a result of defects that affect the safety of the plant: In the event that a defect of any part affects the safety of the operation of a mechanical systems including pressure system, the following escalation process will occur: The Authorised Person (Pressure Systems) will withdraw the plant from use. The Director of Estates will be notified by the Authorised Person (Pressure Systems), Where the plant is subject to their examination, the Authorised Person (Pressure Systems) will notify the Competent Person (Examiner). If service delivery is affected. Senior managers of affected departments will be notified, The plant will only be returned to use following completion of repairs to the satisfactory of the Authorised Person (Pressure Systems), Director of Estates and where applicable Competent Person (Examiner) Page 7 of 14
6.4 Responsibilities as a result of explosions and dangerous occurrences. In the event of either an explosion or dangerous occurrence within the Mechanical System the following escalations process will occur: 7 Training Notification shall be given to the Emergency Services (If applicable) The Authorising Engineer (Pressure Systems) will be informed, The Trust Health & Safety Adviser will be Informed, so that they can notify the HSE as soon as possible, but within 24 hours of an occurrence, The Director of Estates will be informed, The Competent Person (Examiner) will be notified, AP - City & Guilds Authorised Person Mechanical & Pressure Systems course and will attend refresher courses every 3 years Skilled Person - City and Guilds Competent Person Pressure System course and will attend refresher courses every 3 years Contractors Companies will demonstrate correct training levels before undertaking works as agreed with Authorising Person. 8 Equality and Diversity The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This document has been appropriately assessed. 9 Monitoring compliance Standard / process / issue Management and control procedures, including risk assessments, Task Method Statements, Safety Programme, Permits to Work (PS) including appropriate issue, acceptance & cancellation, Operational restrictions, RIDDOR, registers of APs is current, statutory/regulatory warning Monitoring and audit Method By Committee Frequency Audit Report Authorising Pressure Annual Engineer (PS) Systems Safety Group Page 8 of 14
notices are displayed where relevant. Authorising Engineer (PS) report Action plan Chair of the Pressure Systems Safety Group(PSSG) /Trust Engineer (lead AP) Pressure Systems Safety Group Quarterly until actions are completed Compliance with: Quarterly PPM review, AP training and appointments, record keeping, repairs, improvements, AE report and action plan review, risk register review and incidents of note. Annual review of the Terms of Reference for the Pressure Systems Safety Group, Safety Rules and Procedures for Work on Mechanical Systems including Pressure Systems. Training, competence and appointments including: AE (E) APs (E) CP (E) Updates according to the TNA Planned Preventative Maintenance Compliance: Testing of High risk BMS mixing valves BMS function test of all critical vent plants BMS function test of all non-vent plants Ceiling heated/radiators system Fan coil areas A/C areas Chiller Bedpan checks Audit/review report on compliance with the requirements listed with Executive summary Report on compliance with requirements Report Head of Compliance Chair of the PSSG/Trust Engineer (lead AP) Chair of the PSSG/Trust Engineer (lead AP) Pressure Systems Safety Group Health and Safety Committee (for (Executive summary) Pressure Systems Safety Group Pressure Systems Safety Group Annual Annual 6-monthly Quarterly Page 9 of 14
Tea boiler check Inspections as dictated by the written scheme: calorifiers, air receivers, pressure reducing valves, air/oil separators, autoclaves, pressurisation vessels, pressure relief valves etc. Pressure systems risks Incidents concerning mechanical or pressure systems (including investigation and actions/ lessons learned) Datix risk register report Datix incident analysis report Trust Lead AP/Engineer Head of Compliance Pressure Systems Safety Group Pressure Systems Safety Group Quarterly (at each meeting) Quarterly 10 Consultation and review This policy has been reviewed by all relevant Estates staff qualified in Pressure Systems. It has been approved by the Pressure Systems Safety Group and ratified by the Health and Safety Committee. It will be reviewed in line with the Trust policy on policy management or when there is significant change. The review shall focus on, but not be exclusively restricted to, the following.- Legislation Guidance Best Practice Responsibility and management structure Personnel Training Changes to site details Work Practices. Active and Reactive monitoring Effectiveness of management action 11 Implementation The policy will be available via the Trust intranet. 12 References Health and Safety at Work Act 1974 (HSW Act) Management of Health and Safety at Work Regulations 1999 (MHSWR) Confined Spaces Regulations 1997 Page 10 of 14
A Guide to Pipeline Safety Regulations 1996 Regulation L82 Pressure Systems Safety Regulations 2000 (SI 2000 No 128) inc Written Scheme of Examination Regulation 8 Provision and Use of Work Equipment Regulations 1998 Safety in pressure testing GS4 Workplace health, safety and welfare Regulation 1992 13 Associated documentation Health & Safety Operational Policy Safety Rules and Procedures for Work on Mechanical Systems including Pressure Systems Written Scheme of Examination (Trust-wide) Incident management and Reporting Policy Page 11 of 14
Appendix 1 Estates Directorate Pressure Systems Safety Group Membership: (Titles) Estates Manager (Engineering) - Freeman (Chair) Estates Manager (Engineering) - RVI Deputy chair Authorised Person (FH) Authorised Person (RVI) Authorised Person (CAV) Pressure Systems Authorising Engineer AE(PS) User Representative e.g. CSSD Trust Health and Safety Lead/Advisor Veolia (Energy Centres) Newcastle University representative PFI representative (Identify deputies where appropriate) Quorum Frequency By Invitation: Accountable to: Liaison with: A quorum will consist of not less than four members of the Group including the Chair and/or deputy, two other Authorised Person(s) from alternative sites, (and one other member if required in the absence of the chair or deputy). It is expected that members of the group attend at least 75% of meetings per year. If members are not able to attend they should nominate a deputy to attend. Quarterly. Other meetings will be convened as necessary. Individuals or groups as and when required to enable informed decision making. The Health and Safety Committee. Estates Risk Management and Governance Group. Estates Health and Safety Groups via membership. Overall Purpose: A specialist working group in the Estates directorate to assess and oversee all aspects of pressure systems safety required for the safe management and operation of the premises and to inform the following areas: the design process for new healthcare premises and modifications to existing premises; commissioning; operational management; maintenance; de-commissioning and removal of equipment. Page 12 of 14
Terms of Reference The Group s responsibilities will include: 1. To provide assurance to the board of directors for the safe provision of pressure systems to support the premises/organisation; 2. To undertake effective ownership of the pressure system safety management for the organisation and inform the required business continuity risk assessments; 3. To ensure that the policy for the Management and Control of Mechanical Systems Including Pressure Systems and the Safety Rules and Procedures for Work on Pressure Systems manual are reviewed appropriately and kept up to date. 4. To ensure new builds, refurbishments, modifications and equipment are designed, installed, commissioned and maintained to the required pressure systems standards and the needs of the healthcare organisation; 5. To ensure that a Written Scheme of Examination is produced and certified by the Competent Person (Examiner); 6. To ensure maintenance procedures are undertaken appropriately; 7. To ensure adequate monitoring of the status of pressure systems and any issues of note; 8. To ensure any risks pertaining to pressure systems safety and quality of the supply of steam, compressed air, heating and hot water are addressed; 9. To ensure that a Permit To Work system is in place and operational; 10. To record any relevant risks on the risk register and review regularly; 11. To discuss and review any incidents relating to pressure systems; 12. To determine best use of available resources; 13. To monitor the training and communication to relevant staff on pressure systems issues; Page 13 of 14
14. To accept ownership of and to be accountable for Pressure System Safety Management in accordance with all current legislation and guidance documentation; 15. To undertake an annual review of the Terms of Reference. Approved by: Pressure Systems Safety Group 20 th Dec 2017 Ratified by: Health and Safety Committee February 2018 Review date: December 2018 Page 14 of 14
The Newcastle upon Tyne Hospitals NHS Foundation Trust Equality Analysis Form A This form must be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. PART 1 1. Assessment Date: 9 th July 2018 2. Name of policy / guidance/ strategy / service development / Investment plan/board Paper: Management and Control of Mechanical Systems including Pressure Systems Policy 3. Name and designation of author: Anthony Spoor, Engineering Estates Officer 4. Names & Designations of those involved in the impact analysis screening process: Colin Addison, Estates Compliance and Risk Manager, Lucy Hall, Equality and Diversity Lead and Anthony Spoor Estates Officer 5. Is this a: Policy Is this: Who is affected: Revised Employees 6. What are the main aims, objectives of the document you are reviewing and what are the intended outcomes? The aim of this policy is to ensure that all staff involved with mechanical systems including pressure systems understand management and individual responsibilities and methods employed by the Trust, ensuring safe operational practice of mechanical systems. The document details operational requirements and information required in the event of emergency. The Trust, in recognition of its statutory duties endeavours to comply with the Pressure Safety Regulations 2000 Approved Code of Practice. 7. Does this policy, strategy, or service have any equality implications? No If No, state reasons and the information used to make this decision, please refer to paragraph 2.3 of the Equality Analysis Guidance before providing reasons: The policy applies to all staff involved with pressure systems. The Policy sets out safe use of systems for staff who are deemed competent to carry out this work. There is no evidence of any negative effects in relation to any protected characteristics.
8. Summary of evidence related to protected characteristics Protected Characteristic Evidence What evidence do you have that the Trust is meeting the needs of people in all protected Groups related to the document you are reviewing please refer to the Equality Evidence within the resources section at the link below: http://nuthvintranet1:8080/cms/supportservices/equalitydiversityhumanrights.aspx Does evidence/engagement highlight areas of direct or indirect discrimination? For example differences in access or outcomes for people with protected characteristics Are there any opportunities to advance equality of opportunity or foster good relations? If yes what steps will be taken? (by whom, completion date and review date) Race / Ethnic origin (including gypsies and travellers) None relevant to this policy No No Sex (male/ female) None relevant to this policy No No Religion and Belief None relevant to this policy No No Sexual orientation including lesbian, gay and bisexual people None relevant to this policy No No Age None relevant to this policy No. No Disability learning difficulties, physical disability, sensory impairment and mental health. Consider the needs of carers in this section None relevant to this policy No No
Gender Reassignment None relevant to this policy No No Marriage and Civil Partnership None relevant to this policy No No Maternity / Pregnancy A risk assessment is carried out for all pregnant staff in relation to their duties. No No 9. Are there any gaps in the evidence outlined above? If yes how will these be rectified? No 10. Engagement has taken place with people who have protected characteristics and will continue through the Equality Delivery System and the Equality Diversity and Human Rights Group. Please note you may require further engagement in respect of any significant changes to policies, new developments and or changes to service delivery. In such circumstances please contact the Equality and Diversity Lead or the Involvement and Equalities Officer. Do you require further engagement No 11. Could the policy, strategy or service have a negative impact on human rights? (E.g. the right to respect for private and family life, the right to a fair hearing and the right to education?) No PART 2 Name of author: Anthony Spoor Date of completion 9 th July 2018 (If any reader of this procedural document identifies a potential discriminatory impact that has not been identified, please refer to the Policy Author identified above, together with any suggestions for action required to avoid/reduce the impact.)