http://www.kirklees.nhs.uk/uploads/tx_galileodocuments/Maintenance_of_PCT_premises

POLICY FOR THE MAINTENANCE OF PCT PREMISES

Responsible Directorate:

Finance, Estates & Facilities

Responsible Director:

Bryan Machin

Date Approved:

25 March 2009

Committee:

Governance Committee

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If printing a document, please check internet/intranet for most up-to-date version.

Document Title: Document number: Author: Contributors: Version: Date of Production: Review date: Post holder responsible for revision: Primary Circulation List: Web address: Restrictions:

Policy for the Maintenance of PCT premises 1 Keith Geldard 1 February 2009 March 2011 Estates Manager

Standard for Better Health Map Domain: Core Standard Reference: Performance Indicators:

First: (Safety) Sixth: (Care Environment and Amenities) C1, C21 1. ERIC Returns 2. Backlog Register 3. Estates Risk Register

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Contents

Section 1.

2.

3.

4.

5.

6.

7.

8.

9.

Page Policy Statement Introduction Associated policies and procedures Aims and Objectives Scope of Policy Accountabilities and responsibilities Equality Impact Assessments Training needs Monitoring Policy Compliance References

4 5 5 5 5 6 6 6 6 7

Appendices A B C D E F

Schedule of Properties Key Stakeholders consulted/involved in the development of the policy/procedure Equality Impact Assessment Tool Reporting Details Minor Works Cleaning requirements following maintenance works

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8 9 10 11 12 13

Policy Statement NHS Kirklees will ensure that all Premises utilised by the organisation are maintained to an acceptable standard, therefore providing a suitable environment to facilitate good quality health care.

1.

Introduction This policy has been formulated to ensure that all NHS Kirklees premises are appropriately maintained to provide a suitable environment for health care.

Current statutory legislation includes:a)

Health Act 2006

b)

Health and Safety at Work Act 1974

c)

The Management of Health and Safety at Work Regulations 1992;

d)

The Electricity at Work Regulations 1989;

e)

The Electricity Supply Regulations 1988;

f)

The Workplace (Health, Safety and Welfare) Regulations 1992

g)

Control of Pollution Regulations et seq. including but not limited to:

h)

Hazardous Waste Regulations 2005

i)

Gas Safety (Installation And Use) Regulations 1994;

j)

The Manual Handling Operations Regulations 1992;

k)

Gas Burning Installations 1994;

l)

Confined Spaces Regulations 1997;

m)

The Personal Protective Equipment at Work Regulations 1992;

n)

Health and Safety Executive Booklet HS(G)54 1998;

o)

The Provision and Use of Work Equipment Regulations 1992;

p)

Control of Hazardous Substances to Health Regulations 1994;

q)

Noise At Work Regulations 1989;

r)

Fire Regulatory Orders 2006; ;

s)

Fire Precautions (Workplace) (Amendment) Regulations 1999;

t)

The Pressure Systems Safety Regulations 2000; Page 4 of 13

u)

Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995;

v)

Food Safety (General Food Hygiene) Regulations 1995

w)

Control of Asbestos Regulations (2002)

2.

Associated policies & procedures

This policy should be read in accordance with the following Trust policies, procedures and guidance: • • • • • • • • • 3.

PCT Records Management Policy Incident Reporting Health and Safety Policy Food Hygiene Policy Water Management and Control of Legionella Policy Infection Control Policy Cleaning Policy Decontamination Policy Waste Management Policy Aims and objectives

There are legal, operational and economic reasons for introducing a maintenance policy.

The aim of this policy is to develop a system which when fully implemented, will ensure that all the properties in NHS Kirklees are maintained in a safe condition, in compliance with the latest legislation and guidance and with adequate documentation to demonstrate compliance and value for money.

4.

Scope of the policy

This policy must be followed by all NHS Kirklees employees who are involved with the Maintenance of Properties NB This policy does not cover the maintenance of Medical Devices/Clinical Equipment The policy covers

Planned Preventative Maintenance Reactive Maintenance (i.e. fault rectification) Minor Works

NHS Kirklees does not currently employ maintenance staff directly and all Maintenance activities are undertaken by Contractors or Service Providers in accordance with the relevant Service Level Agreements (SLA’s) Appendix A details the properties covered by this policy and indicates the Tenancy arrangements for the sites.

Appendix D details the reporting mechanisms for the various sites.

Independent Contractors are responsible for the development and management of their own procedural documents and for ensuring compliance with relevant legislation and best practice guidelines. Independent Contractors are encouraged to seek advice and support as required.

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5.

Accountabilities and Responsibilities

The Chief Executive is responsible for the Trust wide implementation of this policy. The Chief Executive has delegated the day to day responsibility for the Maintenance of Properties and Services to the Assistant Director (Estates and Facilities).

The Assistant Director (Estates and Facilities) will appoint a Designated Officer (on behalf of the Chief Executive) with relevant Estates Management experience to monitor the various Service Providers who undertake the maintenance of the properties and services in accordance with the respective SLA’s KCHS, Clinical Managers and Service Managers are responsible for the correct reporting of faults and to manage the site/situation until the repair is effected. They must inform the Service Provider, Assistant Director Estates and Facilities / Estates Manager if work is not undertaken within a reasonable timescale.

6. Equality Impact Assessment This Policy was found to be compliant with this philosophy (see appendix C).

7. Training Needs Analysis All personnel involved in maintaining NHS Kirklees Properties and Services, must be trained in all the latest relevant updates:• • •

Department of Health, Health and Safety Executive or any other relevant bodies.

Manufacturers/technical training

8. Monitoring Compliance with this policy The compliance of the policy will be monitored in three elements I. Financial II. Quality III. Legislation The monitoring of the all three elements of the policy will be undertaken by Estates and Facilities.

Customer Satisfaction surveys will be undertaken as part of the SLA by the Service Provider.

Service Providers will provide Activity Reports at predetermined periods and an annual summary of performance against the SLA.

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9. References DH Policy and Best Practice Guidance material:•

Estatecode,

•

Fire Code Suite of documents.

•

Encode,

•

Health Building Notes (HBN) and Health Technical Memoranda (HTM)

APPENDICES Page 7 of 13

Appendix A NHS Kirklees Liversedge HC Savile Town HC Shaw Cross HC` Broughton House Clinic Beckside Court

Tenancy

Comments Covered by MITIE

F F F F

Covered by MITIE Partial Occupancy by West Yorkshire Police Covered by MITIE Owned by PCT leased to GP’s Covered by MITIE

TIR

Building maintenance undertaken by JT Ltd

F

Covered by C&HFT

F

Covered by C&HFT

F

Covered by C&HFT

F

Covered by C&HFT

F

Covered by C&HFT

Holme Valley Memorial Hospital

F

Covered by C&HFT

Fartown HC

F

Covered by C&HFT

Ringway Community Store

FIR

Covered by C&HFT

F

Covered by C&HFT

Almondbury Clinic

TIR

Covered by C&HFT

New Brewery Lane

FIR

Covered by MITIE

Keldregate Surgery

F

Covered by C&HFT

Moorfield Community Centre

FIR

Covered by C&HFT

Whitehouse Centre

FIR

Covered by C&HFT

TIR

Owned by Mid Yorkshire Hospitals

TIR

PFI Building

Mill Hill HC Marsden HC Slaithwaite HC Skelmanthorpe HC Thornton Lodge Clinic

Golcar Clinic

Woodkirk House Batley HC Cleckheaton HC Dewsbury HC

TIR

PFI Building

TIR

PFI Building Page 8 of 13

Eddercliffe ICC Ravensthorpe HC

TIR

PFI Building

TIR

PFI/TIR

PFI Building

Princess Royal CHC

TIR

Owned by C&HFT

St Lukes House

TIR

Owned by C&HFT

Laura Mitchell HC

TIR

Owned by C&HFT

The status of the Tenancy agreement is indicated by the following key:F FIR TIR

= = =

Freehold Full Internal Repair (leased buildings) Tenants Internal Repair (leased buildings)

Within buildings owned Freehold by the PCT all the maintenance requirements are the responsibility of NHS Kirklees Within Leased (including PFI Buildings) and Third Party Development properties, there will be a requirement to provide a partial maintenance service for identified equipment/furnishings belonging to the Tenant FIR indicates that the Tenant (NHS Kirklees) is responsible for all planned and reactive maintenance to the internal building fabric/fixtures, engineering services and the Tenants equipment/furnishings. The Landlord is responsible for the external fabric and structures.

With a TIR lease the Tenant is only responsible for the cost of maintaining the Tenants own furniture and fixtures.

NB Leased properties may include buildings with Partial occupancy whereby the Tenant’s (NHS Kirklees) responsibility for maintenance will be detailed in the lease agreement.

Appendix B - Key stakeholders consulted/involved in the development of the policy/procedure

Stakeholders name and designation Head of Estates and Facilities Estates Manager Hotel Services Manager Estates Support Officer Policy Development Group

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Key Participant Yes/No Yes Yes Yes Yes

Feedback requested Yes/No Yes Yes Yes Yes Yes

Feedback accepted Yes/No

Appendix C - Equality Impact Assessment Tool To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval.

Insert Name of Policy / Procedure Maintenance of PCT Properties 1.

Yes/No

Does the policy/guidance affect one group less or more favourably than another on the basis of: • Race

NO

• Ethnic origins (including gypsies and travellers)

NO

• Nationality

NO

• Gender

NO

• Culture

NO

• Religion or belief

NO

• Sexual orientation including lesbian, gay and bisexual people

NO

• Age

NO

• Disability - learning disabilities, physical disability, sensory impairment and mental health problems

NO

2.

Is there any evidence that some groups are affected differently?

NO

3.

If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?

NO

4.

Is the impact of the policy/guidance likely to be negative?

NO

5.

If so can the impact be avoided?

N/A

6.

What alternatives are there to achieving the policy/guidance without the impact?

N/A

7.

Can we reduce the impact by taking different action?

N/A

APPENDIX D Reporting arrangements Page 10 of 13

Comments

For all Building/Engineering Services and Non Medical Equipment Repairs/Faults in Health Centres and Clinics in the previous South and Central Kirklees – Contact Estates at Calderdale and Huddersfield Foundation Trust (C&HFT) on extension 2805 (external 01484 342805) A unique reference number must be provided for each call and must be noted by the caller This phone is manned Monday/Friday from 08:00am to 05:00pm. An Answer Phone operates outside these hours, for non urgent requests, to be picked up the next working day Outside the above hrs and for emergencies only, please ring Huddersfield Royal Infirmary switchboard on 01484 342000. The operator will put you through to the Estates Officer on call, who will deal with the request accordingly. As indicated the on call service is for emergencies only.

Almondbury Clinic Community Store (Ringway) Elmwood Clinic Fartown Clinic Golcar Clinic Holme Valley Memorial Hospital Keldregate Laura Mitchell Health Centre Marsden Health Centre Mill Hill Community Health Centre Moorfield Primary Care Centre

Princess Royal Community Health Centre Slaithwaite Health Centre Skelmanthorpe Health Centre St Lukes House Thornton Lodge Clinic Whitehouse Centre

For all Building/Engineering Services and Non Medical Equipment Repairs/Faults in Health Centres/Clinics in the North Kirklees, contact MITIE Services on 01924 351569 (internal 1569) Again a unique reference number must be provided for each call and must be noted by the caller This phone is manned Monday/Friday from 08:30 to 16:00.but outside this hrs and for emergencies only,. the above number is diverted to the Engineer On Call, who will deal with the request accordingly.

As indicated the on call service is for emergencies only.

Broughton House Liversedge HC Saviletown Shaw Cross New Brewery Lane

Batley Cleckheaton Dewsbury Eddercliffe Ravensthorpe

For repairs/service at Woodkirk House contact Mid Yorkshire Estates on 01977 606939 For Medical Equipment Repairs in all properties, contact Medical Physics at Mid Yorks on 01924 212298

Appendix E Minor Works Page 11 of 13

South/Central Kirklees For all Minor Works in Health Centres/Clinics in the South/Central Kirklees (listed below), contact Estates Support Officer Sue Heeley by Email. The email must contain al relevant information for the request including:¾ ¾ ¾ ¾ ¾ ¾

Name of requester (if different from the email) Site Department Cost Code Access arrangements Preferred timescale for work

NB

The work will be actioned without providing a cost unless this is specifically requested (Estates will screen all jobs and if the cost is likely to be above an agreed level, the requester will be contacted Almondbury Clinic Community Store (Ringway) Elmwood Clinic Fartown Clinic Golcar Clinic Holme Valley Memorial Hospital Keldregate Marsden Health Centre Mill Hill Community Health Centre Moorfield Primary Care Centre Skelmanthorpe Slaithwaite Health Centre Thornton Lodge Clinic Whitehouse Clinic Requests for Minor Works at St Lukes House (including Nurse Training School) and Laura Mitchell will be requested through the C&HFT SWR System.

North Kirklees For all Minor Works in Health Centres/Clinics in the North Kirklees (listed below), contact MITIE Services on 01924 351569 (internal 1569) The MITIE Helpdesk operative will talk through the procedure and obtain the relevant information from the caller. ¾ Name of requester (if different from the caller) ¾ Site ¾ Department ¾ Cost Code ¾ Access arrangements ¾ Preferred timescale for work A unique reference number will be provided for each call and must be noted by the caller.

MITIE will provide a cost and seek approval from the Budget Holder prior to commencing the work.

MITIE are producing a flow chart in April 2009 which will be appended to this policy.

Broughton House Batley Liversedge HC Cleckheaton Saviletown Dewsbury Shaw Cross Eddercliffe New Brewery Lane Ravensthorpe

Appendix F Page 12 of 13

Cleaning and evaluation of standards of cleanliness following maintenance, repairs, refurbishment, floods, building work etc Contractors are responsible for cleaning up after themselves, removing their equipment and leaving sites safe each day when working in NHS Kirklees premises. The cleaning contracts provide for each room to receive an appropriate clean each day, which ensure appropriate standards of cleanliness are achieved.

Should work be undertaken in clinical rooms after they have received their daily clean, whoever is organising the work, must ensure that appropriate arrangements have been made for rooms to be cleaned as necessary prior to them being used for clinical services. Depending on the extent of the work (as categorised below) the standards of cleanliness should be audited using methods outlined below to ensure appropriate standards of cleanliness are maintained.

1. Minor repairs to loose equipment, services and furnishings • Ensure scheduled daily clean is sufficient to restore appropriate standards of cleanliness 2. Repairs to building fabric, for example, repair minor leaks, damaged woodwork, paintwork, flooring: • Clean area in line with identified risk category and to the standard of the National Specification for Cleanliness 2007 and undertake audit.

3. Major repair (requiring closure of facility) for example: structural damage of walls, floors, ceiling; flooding or leak requiring repair to fabric; minor alterations to building fabric • Builders clean followed by full clean of area, • Visual audit using NSC audit tool or equivalent • Environmental air sampling of clinical areas 4. New builds or refurbishment to facilitate alteration to room use, from non clinical use to clinical use, requiring major alteration or disturbance to fabric • Builders clean followed by deep clean • Visual audit using NSC audit tool or equivalent • Environmental air sampling

Major incidents will be addressed by individual assessment.

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