STATUTORY COMPLIANCE REPORT

Transcription

1 BOARD MEETING 25 JUNE 2014 AGENDA ITEM 2.7 STATUTORY COMPLIANCE REPORT Report of Interim Director of Planning Paper prepared by Head of Estates & Property Purpose of Paper To provide the Board with a summary of the Estates Compliance report which was provided to the Health and Safety Executive in May 2014 Action/Decision required The Board is asked to NOTE the contents of this paper Link to Doing Well, Doing Better: Standards for Health Services in Wales : Link to Health Board s Corporate Plan Acronyms and abbreviations This paper supports Standards: 1. Governance & Accountability 12. Environment 22. Managing Risk and Health and Safety 23. Dealing with concerns and managing incidents Striving for Excellence Making Every Pound Count HoEP Head of Estates and Property AE Authorised Engineer AP Authorised Person PPM Planned Preventive Maintenance HSE Health and Safety Executive FRA - Fire Risk Assessments Statutory Compliance Progress Report Page 1 of 10 Board Meeting

2 STATUTORY COMPLIANCE REPORT Background In June 2012 the executive team received a report on Estates Compliance prepared by the then Head of Estates and Property. This report highlighted the risks in relation to providing assurance to the organisation in respect of statutory compliance across the estate. As a consequence of receiving this report, the overall issue of estates compliance risk was placed on the thb Corporate Risk Register. At that time the thb was also managing two improvement notices from the Health and Safety Executive in respect of Asbestos management. These notices have subsequently been discharged. Subsequent to the June 2012 assessment a number of incidents that re-inforced the risk assessment that had been undertaken, including the lack of control of legionella bacteria on a number of sites and a series of reports including a No Assurance audit report on Fire Safety that the Interim Director of Planning had requested to be undertaken. Following the earlier of these incidents the table of risks was re-assessed and approved through Risk Management Committee as follows: The level of risk associated with Compliance has been recognised by the Executive Team and in October 2012 two additional posts within the Estates Team were approved. These included a Compliance & Maintenance Manager and a Capital Programming Manager, to ensure the availability of the appropriate staff resource to improve performance of the estate in terms of compliance. The appointment of a new Head of Estates and Property in August 2013 to replace the previous appointee, coupled with the receipt of the Fire Procedures Audit triggered further rapid review of the arrangements for programming and monitoring progress on compliance related works across the estate. Strategically these were in two categories: Visibility of Estates Compliance at Executive and Board Level The measure of risk in terms of Statutory Estates Compliance had previously been reported to the Board through the risk register. There have been reports to the Quality and Safety committee on individual live issues, most notably regarding asbestos and Legionella and this was strengthened through the following actions: An Estates Compliance Committee (ECC) has been established and this replaces the previous compliance working groups. The Committee takes a programme approach and since January 2014 is chaired by the Chief Executive. A clear line of reporting has been established on a monthly basis to Executive Team and to Quality and Safety Committee from the ECC High level reporting remains in place to the Board through the Risk Register Resources The pace of progress with actions to improve compliance had not been kept within previously estimated timeframes. Progress with recruitment to bring additional capacity within the Estates Department had been slow. Additional emphasis on resourcing the team was put in place as follows: Statutory Compliance Progress Report Page 2 of 10 Board Meeting

3 With the departure of the previous post-holder in August 2013 a new Head of Estates and Property was recruited rapidly. The new post-holder, commenced in August enabling a week of handover from the previous post holder The Estates Compliance Manager was appointed and commenced in post in November The Capital Programming Manager was appointed and commenced in January An interim Fire Safety Manager has been appointed on an agency basis to develop and take forward all aspects of estate Fire Safety and NHS Fire code compliance across the thb, and further interim capacity has been sourced The appointment of a more robust Estates leadership team, supported by specialist advisors, and training and development of existing staff has enabled a further review of the Estates and works teams structure and capacity. A business case has been considered by executive team for the future structure of the team. Current position This summary report provides a summary of an Estates Compliance strategy report which was provided to the HSE in May 2014 following a meeting with the Chief Executive and senior team e4arlier in the year. This document has been compiled by Health Board s Head of Estate & Property (HoEP) with input from the Compliance & Maintenance Manager and Estates Officer (Engineering) and provides a snap shot of the current position in terms of general estates compliance as at 28th May The report is split into 8 general compliance topics:- Medical Gas Ventilation Water Electrical Fixed Wire Inspection & Testing Portable Appliance Testing Asbestos Gas Maintenance Control of Contractors Medical Gasses The Medical gas installations across the PtHB portfolio require a considerable amount of attention before they will become fully compliant with the current NHS HTM standards. It is planned that that full compliance will be attained within the next 12 months and a programme of work has been put in place by the Head of Estates and Property. Statutory Compliance Progress Report Page 3 of 10 Board Meeting

4 The current medical gas policy has been drafted and is due for approval at the next Executive Team meeting. The Authorising Engineer (AE) for Medical Gas for PtHB is John Tidball from the All Wales Shared Services Facilities Services. He has already been appointed by PtHB Two of the PtHB Works staff have successfully completed their initial training to become Authorised Person s (AP s) in Medical Gas. They are due to be authorised by the AE in June The Estates Department recently requested the AE for medical gases to carry out a thorough audit on how the Department is managing PtHB s medical gas systems. In conjunction with this report the AE has also carried out individual site inspections on all 6 hospitals which have medical gas systems. Therefore both the audit report and individual site inspection reports are currently being reviewed by the Estates Department and actions are in the process of being planned. To ensure progress is being made with both reports the Estates Department has requested the AE to carry out a 6 monthly review in July The AE will evaluate the Department s performance to date and from this audit they will compile an action plan to provide the Department further guidance on how to complete all outstanding actions within an acceptable timeframe. Ventilation The management of all ventilation systems within the PtHB is in development. Specialist staff training has recently been completed and procedures have been put in place to deliver a safe and robust maintenance programme on all critical ventilation systems. Ventilation policy has been written in draft form and is now waiting for approval from the Executive Team. Authorising Engineer (AE) for ventilation systems has been appointed by PtHB Mr Kevin Ridge of NHS Wales Shared Services Partnership and the Authorised Person (AP) has been identified Steve Watkins, Estates Officer (Engineering) who has successfully completed his AP training. Weekly PPM procedures have been put in place and training provided to staff. Inspections carried out on all plant within PtHB. Report submitted with Estates Department currently working through all recommendations. To complete the management programme for the compliance of the ventilation systems within PtHB the AP will require formal appointment by the AE a specialist contractor will be appointed to to assist with the maintenance of all critical ventilation systems within the thb and the Planned Preventative Maintenance (PPM) programme for all ventilation systems be put fully in place. It is intended that these actions in place and thb fully complaint by the end of June Water Michael Cope, Estates Compliance and Works Manager is currently appointed as Responsible Person and Steve Watkins, Estates Officer (Engineering) is currently Statutory Compliance Progress Report Page 4 of 10 Board Meeting

5 appointed as Deputy Responsible Person for PtHB. Both of these individuals have received appropriate training to fulfil their duties. Two Works Maintenance Supervisors within the Estates Department have recently been trained to fulfil the Authorised Person role and the Department is currently considering the appointment of Competent Persons from within the works team. Risk assessments were undertaken by an external consultancy, Oakleaf, in early 2013 and are due for review in A recent audit was undertaken by Oakleaf to review the legionella policy, training needs and log book maintenance system undertaken by works staff, and put in place following the Legionella incidents in Legionella awareness training has been given to the Estates Department staff and Steve Watkins, Estates Officer (Engineering) has rolled this out across the estate, including a water flushing regime. 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. Contractors are currently being approached to provide fee quotes to undertake Thermostatic Mixing Valve (TMV), maintenance across the estate to further enhance compliance. In Brecon and Llandrindod Hospitals, PtHB have installed Chlorine Dioxide systems to continuously dose the water system with a chemical solution which inhibits legionella growth. The pipework in these hospitals is very old and the method of shot disinfection was not sufficient and a more permanent solution was sought following advice from Oakleaf and the HSE. Additional works is 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. Late March of this year, 2014, Oakleaf carried out their first annual audit on the management of legionella within PtHB and the Estates & Works Department are now currently waiting for the provision of the final report. Electrical Inspection & Testing A maintenance programme has been planned that will ensure that all buildings within the PtHB estate will be periodically inspected and tested. Electrical contractors John Bulpin Electrical were awarded the contract for carrying out the periodic inspection and testing for the entire PtHB estate. The duration of the Periodic Inspection & Testing will take approximately 29 weeks with an anticipated completion date of Friday the 4 of July, The programme of works includes the 9 main sites within the PtHB, and all other buildings owned by the PtHB. Due to the age of the estate, there will be remedial works identified from the inspection and testing. These remedial works will then be addressed on a risk basis. Statutory Compliance Progress Report Page 5 of 10 Board Meeting

6 To ensure that of the electrical periodic & inspection testing is continuously carried out within the entire estate thereafter, an annual Electrical Infrastructure PPM has been compiled to provide prompts for routine check, which is yearly and then 5 yearly. A copy of the current programme is contained in Appendix A Electrical: Portable Appliance Testing (PAT) Norwood Electrical (UK) Ltd has been engaged to carry put all the portable appliance testing within PtHB. All 9 major sites and associated clinics/health centres within the HB have been visited and testing completed. Norwood still have a minor presence to complete any tests missed in the first visit. To ensure that of the electrical portable appliance testing is continuously carried out within the entire estate thereafter, an annual portable appliance testing PPM has been compiled. A copy of the current programme is contained in Appendix A Asbestos PtHB has an Asbestos Policy which was formally adopted by the organisation in June 2012 following engagement with the Health and Safety Executive. The Asbestos Management Plan is currently being reviewed and revised. The implementation of the Asbestos Policy is through the contents of the Asbestos Management Plan. Nearly all of the Staff within the Estates Department have completed Asbestos awareness training and many are trained to Category B standard. Refresher training has been arranged for June 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. Over the current financial year, there will be further projects to remove asbestos from PtHB sites and this work will generally be incorporated with other works of refurbishment. The Compliance and Maintenance Manager will undertake full training so they are able to assist the responsibilities of Asbestos Manager. 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. A copy of the current programme is contained in Appendix A Gas Maintenance The Gas Safety Policy is currently with PtHB s Executive Board in draft form, pending approval. Gas service contractors, AMROC, were engaged to carry out the testing and servicing of all gas appliances across the estate. This exercise was completed in April This included all remedial works that were identified during Statutory Compliance Progress Report Page 6 of 10 Board Meeting

7 AMROCs visits. Powys teaching Health Board are currently 100% compliant in Gas Safety. Control of Contractors The Estates Department has written three documents for safe and efficient control of all contractors who work on or within the estates. These documents are, the Control of Contractors Policy, Control of Contractors General Code of safe Practice and Control of Contractors Supplier Pre-qualification Questionnaire. All three documents are currently with the Executive Board, pending approval. HSE is supportive of the new policy and at the date of this report has recommended some additional amendments to ensure that health and safety risk can be appropriately managed for large and small contractors. Fire Safety During 2013 Powys Teaching Health Board received numerous letters from Mid & West Wales (MWW) Fire & Rescue Service expressing concern that Health Board Fire Risk Assessments (FRA s) were not being actioned (there were a significant number of Red risks highlighted on FRA s in place). As a result of the concerns raised the Head of Estates employed the services of Fire Safety Consultant to assist PtHB. An overall initial appraisal of all of the main hospital sites has included: (i) Physical Fire Protection Measures in Place: (ii) Means of Escape Compartmentation Fire Alarms Emergency Lighting Fire Fighting Equipment Fire Safety Signage Procedural Fire Protection Measures in Place Site Procedures Departmental Procedures. A full report produced by the Fire Safety Consultant has been produced and outstanding actions from the report together with the actions needed to fully implement the Health Board s Fire Safety Policy were combined by the Quality & Safety Unit into a Fire Safety Action Tracker & Implementation Plan. This is progressed through the Fire Safety Group and the Estate Compliance Committee chaired by the Chief Executive. Conclusion This report has demonstrated that continuing good progress towards meeting our Statutory Compliance obligations is being made by the Estates Department across all key compliance disciplines/areas. The HSE are being communicated with on a regular basis to ensure that they are fully aware of progress and to ensure we meet our obligations to their satisfaction. Statutory Compliance Progress Report Page 7 of 10 Board Meeting

8 Going forward the Estates Department will be continuing to progress towards full Statutory Compliance whilst ensuring that procedures and processes are developed and implemented to ensure that these legacy compliance issues and associated risks are managed and reduced. Recommendation The Board is requested NOTE progress with Estates Compliance Report prepared by: Shelley Renwick Head of Estates and Property Presented By: Bruce Whitear Interim Director of Planning Background Papers Financial Consequences None The financial consequences of remedial works on the estate are included in the financial plan for The team continue to seek additional capital resource from Welsh Government to supplement currently available resource. Other Resource Implications Consultees Statutory Compliance Progress Report Page 8 of 10 Board Meeting

9 Appendix A Statutory Compliance Work streams Programmes Electrical Fixed Wire Testing issue 3.0 Electrical Portable Appliance Testing (PAT Testing) issue 2.0 Drawing Update & Asbestos Upload to Micad issue 2.0 Programmes Issue Under Separate Cover Statutory Compliance Progress Report Page 9 of 10 Board Meeting

10 Statutory Compliance Progress Report Page 10 of 10 Board Meeting