-pgn 23…they will carry out the move in accordance with the attached checklist in appendix 1. they...

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust E-PGN-23 – Managing the Vacant Estate – V02 Oct 19 Part of CNTW (O)32 – Estates Operations and Maintenance Policy – V02

Estates Operations and Maintenance Practice Guidance Note

Managing Vacant Estate – V02

Date Issued

Issue 1 – Oct 19

Planned Review

Oct 22

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Part of CNTW(O)32 – Estates Operations and Maintenance Policy

Author / Designation Andrew Short – Operations Estates Manager

Responsible Officer / Designation

Paul McCabe – Director of Estates and Facilities (NTW Solutions Ltd)

Contents

Section Description Page No

1 Introduction 1

2 Scope 1

3 Statement 1

4 Responsibilities 2

5 Guidance 4

Appendices – attached to PGN

Document No: Description

Appendix 1 Checklist of Notifications

Appendices – listed separate to PGN

Document No: Description

Appendix 2 Notification of Closure of Section

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1 Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust E-PGN-23 – Managing the Vacant Estate – V02 Oct 19 Part of CNTW (O)32 – Estates Operations and Maintenance Policy

1 Introduction 1.1 As Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust and

its Subsidiaries including NTW Solutions Limited (CNTW) are owners and occupiers of various premises in various locations, there is a duty to manage the occupation of areas for a variety of purposes including:

Ensuring premises being occupied are fit for purpose

Ensuring the safety and security of vacant buildings

Providing mandatory information returns to the government on occupation

1.2 This duty is undertaken by Estates Department on behalf of CNTW. 1.3 When changes to service provision are being considered which may have

implications for the occupation of areas, then approval by the Estates Department is required.

1.4 There are ‘key personnel’ within the CNTW who must be informed as soon

as possible when a move is being considered, in order that the necessary action is taken to protect CNTW premises. The Associate Director should therefore liaise with the departments listed in Appendix 1 of this document.

2 Scope 2.1 This practice guidance note (PGN) together with any associated procedures

and guidance notes are intended to ensure properties are decommissioned correctly and that unnecessary financial costs are avoided. Any costs incurred in vacating accommodation must be met by the Service vacating the property, unless other arrangements are made in the Business Case

3 Statement 3.1 CNTW is committed to effectively managing its vacant properties to gain

best value for CNTW from its Estate. 3.2 CNTW has a duty to manage its vacant Estate in order to reduce the risk

to patients, staff, visitors and members of the public. 3.3 CNTW will put into place a managerial structure to manage the CNTW

assets in line with national guidance and good industry practice. 3.4 CNTW will ensure the Estates Department is supported by the resources

required to meet the objectives outlined in this document.

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4 Responsibilities 4.1 Associate Directors 4.1.1 Associate Directors/Departmental Team Leaders will be responsible for

the strategic decision to close or vacate a property. In many or most cases, this will also be associated with a capital investment business case involving a move to improved premises. In these cases the business case approval and strategic decision lies with the Corporate Decisions Team (or Board if over £6m investment) – as set out in the Trust’s Decision Making Framework.

4.1.2 Associate Directors should ensure effective “operational decommissioning”

of the accommodation and will be responsible for notifying the departments as listed in Appendix 1 in sufficient time to allow decommissioning to be planned and implemented. The nominated officer would continue to provide support, for example, in managing the transfer of furniture and equipment.

4.2 Operational Estates Manager (Support Services) 4.2.1 The Operational Estates Manager (Support Services) will regularly assess

the need for vacant property to be retained and advise of disposal where necessary. This will be in line with the Estates Strategy current at the time.

4.3 Capital Projects Team 4.3.1 The Capital Projects Team will appoint a nominated Project Manager to

oversee the removal of all staff, furniture and equipment from the affected area. The Project Manager will liaise with the Associate Director / Department Head for the duration of the move. They will carry out the move in accordance with the attached checklist in Appendix 1. They will be responsible for informing the Operational Estates Manager (Support Services) that the property is vacant.

4.4 Estates Department 4.4.1 The Operational Estates Manager (Support Services) will be the

‘Responsible Officer’ for the purposes of managing any property which becomes vacant. They will liaise with the relevant Estates Officer for the locality and ensure this guidance is adhered to.

4.5 Facilities Department 4.5.1 The Facilities Department will, when instructed by the Operational Estates

Manager, ensure vacated premises are fully secure and arrangements in place for security patrols if necessary.

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4.6 Clinical and Corporate Teams 4.6.1 It is the responsibility of the Associate Director/Departmental Manager to

organise a departmental move. 4.6.2 When preparing for a move, the Associate Director/Departmental Manager

(or a nominated deputy) should identify:

All clinical and other service user records (all presumed to be sensitive and confidential);

All other records which include person identifiable data (e.g. staff records, payroll and employment records, recruitment files, notes associated with complaints - all presumed to be sensitive and confidential); and

All other administrative records (some of which might also be sensitive or confidential in nature) e.g. copy correspondence, budget reports, copy requisitions etc.

All computers and other storage devices (e.g. CDs and Memory sticks) that have data stored on them

Any notice boards/charts/leaflets with person identifiable information

A log should be produced scheduling all of the records that are sensitive or confidential and noting their location (e.g. Filing cabinet in room x), together with all of the computers and other data storage devices

Against each entry in the log, the intended destination of the items should be noted (including where the record is planned for disposal) along with the officer responsible for receiving them at the new site

4.6.3 Where contractors are assisting with the moves, they should be made

aware of the presence of sensitive records and their written procedures obtained identifying how they will safeguard them during transit. They must also sign a confidentiality agreement.

4.6.4 Cupboards and cabinets that are moved with records ‘in-situ’ should be

locked and clearly marked with the content, whether it is sensitive data, and its destination.

4.6.5 Other records should be packaged into boxes, which should be clearly

marked with the content, whether it is sensitive data, and its destination. If contractors are undertaking the packing, they should be supervised on-site by a member of staff at all times who is familiar with the records being

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packed, and who can ‘sign-off’ that the packing is complete and appropriate.

4.6.6 The IT Department should be informed of the date of the move and a

service request made so that they can safely unplug the equipment and ensure it is safely and securely packaged and also they will need to be present when the equipment is unloaded in the new premises.

4.6.7 Where premises are being vacated, it is important that, once the move has

taken place, the Associate Director, or nominated deputy, revisits the vacated premises to ensure that no residual records or other items are left on the premises.

4.6.8 When vacating a ward or department, the Clinical/Corporate Team will

ensure that the area is left safe and secure. All keys should be clearly labelled with the room number/name to which they relate. A comprehensive key schedule should be handed to the Estates Department along with all keys to the property. Alarm codes should also be supplied.

4.6.9 Clinical Teams should confirm that all clinical waste has been removed

from the property prior to vacating. All costs associated with the removal of any waste will be borne by the service/department moving out.

4.6.10 If the building is being sold/demolished or no longer the responsibility of

the Trust then a mini task force comprising of a representative(s) from the Estates Department and the Service should make a final check of the building before any keys are handed over to the new landlord (if appropriate).

4.6.11 For audit purposes the outcome of this visit should be recorded, signed/

dated and retained by the Estates Department. 5 Guidance – Vacant Property 5.1 On a property becoming vacant the keys should be handed over to

Estates Support Services Team, who will control access to the building. Dependant on the location and proposed future use of the building an assessment on the viability of appointing property guardians should be undertaken.

5.2 Once determined the following should be undertaken on all vacant

properties;

Removing or amending any internal or external signage

Determine which areas of statutory compliance are still required e.g. emergency lights, fire alarm testing, legionella precautions etc.

Review and update any risk assessments

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Ensure all compliance software is updated with the change

Ensure all internal records are updated with the change

Inform insurance company if the property has a value greater than £1million and has top up insurance

Assess if flushing is required and appoint Estates Operative/ Domestic/External Contractor as appropriate to carry out flushing as per revised risk assessments

Site Operations and log kept of any persons entering site

5.3 Where the property is to remain vacant the following actions also need to be undertaken:

Fire Officer to remove all firefighting equipment

Isolation and draining down of any live systems and recording in Building Log Book

Arranging for suspension of PPM Programmes with either in-house staff, or with external Contracted Maintenance Team

Turning down heating to frost protection level

Electrical systems to be switched off where possible – liaise with Informatics and Site Operations to ensure disconnection will not affect other users on site and security cameras

Where funds have been identified boarding up of empty buildings (including letterboxes) may be necessary to improve security

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Appendix 1

6 Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust Appendix 1 – Checklist of Notifications –V02 Oct 19 Part of E-PGN-23 – Managing Vacant Estate (CNTW(O)32 – Estates Operations and Maintenance Policy)

Checklist of Notifications for Associate Director / Project Lead to Action

Associate Director

Associate Director’s Actions Property Team to action:

Capital Projects and Planning SNH

Appoint a designated Project Lead or set up a de-commissioning group and produce an Action Plan with Timescales.

Notify Capital Projects and Planning Team of service /accommodation moves.

Confirm details of new location (if appropriate) and/or full change of postal address, planned move date and final date of Occupation.

Provide an Inventory of any surplus/obsolete furniture to Capital Projects and Planning Team

All requests to reuse/reallocate the accommodation must be referred to the Capital Projects and Planning Team who will advise accordingly. This includes requests to view.

Re-allocate surplus furniture – advertise intranet.

Notify Night Co-ordinators/evening service as necessary

Arrange for any removal services and packing crates

Arrange a skip for removal of surplus rubbish/equipment.

Confirm occupation arrangements e.g. Trust property, leased, SLA or other.

Update Oakleaf, inform Estates Admin, Estates staff including on call team.

Update accommodation lists for Finance

Notify local authority rating department, where appropriate.

Commence marketing strategy if property surplus and requires disposal. if leased, negotiate dilapidation works prior to handover to landlord.

A member of the Team will, in conjunction with an Estates Manager, inspect the accommodation prior to its vacation.

Liaise with Estates and Facilities regarding security of building upon closure.

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Appendix 1


Estates Department

Notify Head of Estates of moves and closure date.

Complete ‘notification of closure sheet’ (App.1) and send to Estates.

Arrange for a Joiner to attend on day of move to remove any fixtures/fittings (e.g. Noticeboards, whiteboards)

Estates Department to action:

Liaise with Informatics and Site Operations to ensure any disconnections will not affect other users on site and security cameras.

Arrange to suspend if appropriate; PPM,

Statutory issues re emergency lights, fire alarm testing, legionella precautions etc.

Changes to Fire Alarm/Blick staff attack

Inform Utilities (gas, electric, water) of changes to service if applicable, and obtain final readings as necessary.

Inform Capital Accountant of any large asset moves.

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Appendix 1


Informatics Notify IT Department of moves and advise of closure date along with occupancy date for the new accommodation.

Book IT for day of move to cancel any network lines/ re-connect PC’s at new location.

Provide a list of IT equipment for removal/ transfer, and disposal of redundant equipment.

Order new PCs if required.

Complete appropriate documentation regarding user accounts, including removal of names from e-mail address lists, as appropriate.

Check for any meeting room changes on book-it.

IT to action:

Notify helpdesk of location changes.

Disconnect any network lines if necessary and re-connect PC’s on day of move.

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Appendix 1


Facilities (Security, Catering, Domestics, Site Operations, Portering and Transport, Switchboard)

Notify Head of Facilities of moves and advise of closure date along with occupancy date for the new accommodation.

Provide switchboard with a comprehensive list of all personnel names, titles, current telephone numbers, faxes, mobiles, and air call/pagers and other telephones associated with the move.

Update Tel numbers on Trust intranet site

Provide Site Ops with details of change of address and names of all staff connected to move.

Liaise with Facilities manager regarding payphones and/or vending machines

Arrange with Porters for any confidential and clinical waste to be collected prior to move.

Advise of any Local Authority Refuse collections which may need cancelling.

Inform domestic services, catering and laundry of move and closure date

Facilities to action:

Arrange transfer of telephone numbers/extensions

Arrange re-direction of internal post

Ensure that any payphones and/or vending machines are disconnected and emptied of cash.

Re-arrange necessary domestic, catering and laundry services.

Collection of any confidential and clinical waste.

Cancel or re-schedule any Local Authority Refuse collections as necessary.

Liaise with Estates Dept re security of building upon closure

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Appendix 1


Finance and Commissioning

Notify Finance Dept of move and advise of closure date along with occupancy date for the new accommodation.

Clarify with finance a revenue source Re Alarm system and on-call key holding cost for maintaining security of premises prior to moving out.

Check if there are any implications for Patient Monies/Bank Facilities.

Finance to action:

Identify funding to Estates for Trust Overheads e.g. continued maintenance, false alarms and vandalism of empty building.

Clinical Governance

Notify Head of Clinical Governance of move and advise of closure date along with occupancy date for the new accommodation.

Liaise with CG team re transfer, disposal, and secure storage of any patient records and identifiable data.

Ensure notice boards cleared and white boards wiped clean.

Human Resources

Notify Head of HR of moves and advise of closure date along with occupancy date for the new accommodation.

Complete relevant documentation for staff changes including transfer, redeployment, termination of temporary contracts etc.

Notify Payroll of staff base changes.

HR to action:

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Appendix 1


Pharmacy

Notify Head of Pharmacy of moves, advise of closure date along with occupancy date for the new accommodation.

Notify Night Co-ordinators/evening service as necessary.

Inform Infection Control Team.

Pharmacy to action:

Arrange transfer/disposal of drugs.

Arrange removal and re-location of drugs cabinets if surplus.

Supplies and Medical Devices

Notify Supplies Dept of moves and advise of closure date along with occupancy date for the new accommodation.

Provide Supplies with a list of all equipment which is under a maintenance service contract including Photocopiers, beds, baths, hoists, stand aids, weighing scales and wheelchairs which requires notification to suppliers of amended address details or termination of agreements.

Arrange delivery re-locations. Inform Supplies if “materials management” system is in operation.

Arrange for redirection of external post (Royal Mail)

Notify Medical Devices on [email protected] of any medical devices being moved, disposed of or no longer required. Include trolleys, mattresses, cushions, shower chairs, commodes, safety knives, as well as all physical health monitoring equipment.

Supplies to action:

Arrange termination/ transfer of maintenance contracts for any equipment (e.g. photocopiers) and/or Medical Devices (e.g. mechanical beds, baths).

Medical Devices to Action:

Update the medical device inventory, relocate any surplus medical devices still fit for purpose, ensure the safe disposal of medical devices no longer fit for purpose.

mailto:[email protected]

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Appendix 1


Consultation Issues

Internal Consultation

If the move impacts on staff moving bases, HR and Staff Side to be informed.

CQC Registration/ de-registration

Notify Director of Performance and Assurance of any service/premises closing down.

** For new inpatient facilities, inform Director of Commissioning and Quality Assurance 3 months in advance.

Referral agencies, Emergency Services, stakeholders, patients/relatives etc

Ensure all external agencies, relatives and carers are aware of service moves/closures and a general communication to be circulated.

Inform referral agencies, Emergency Services (Police, Fire, Ambulance), stakeholders, patients/relatives etc. of change of name, location, address, telephone numbers.

Communications Department

Prepare communication regarding move and re-location for Weekly Bulletin.

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Appendix 1


DAY OF MOVE Service Manager Actions:

Confirm that the accommodation has been cleared of all furniture and equipment, clinical and household waste, and personal identifiable information (e.g. patients’ records/IDs).

Ensure Area vacated is left secure – external doors and windows, alarms etc.

All keys and/or swipe cards together with alarm details, to be handed to Property and Planning/Estates/Site Operational Services depending on site – and must be clearly marked.

All keys should be clearly labelled with the room number/name to which they relate. A comprehensive key schedule should be handed to the Estates Department along with all keys to the property. Alarm codes should also be supplied.

Estates Department Actions:

Isolate systems, suspend PPM works as appropriate. Turn down heating to frost protection level.

Electrical systems to be switched off where possible – liaise with Informatics and Site Operations to ensure disconnection will not affect other users on site and security cameras.

NB statutory issues re emergency lights, fire alarm testing, legionella precautions etc.

Remove/amend site signage , Board up empty buildings (including letterboxes) to improve security

Access to vacant properties should be controlled by Estates (Property Team)/Site Operations and log kept of any persons entering site

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Appendix 1


Facilities Department Actions:

Ensure vacated premises are fully secure and arrangements in place for security patrols if necessary. NB Any incidents that occur within vacant accommodation must be reported to Risk Management in line with Trust Procedures for reporting of Accidents and Incidents.

-pgn 23…they will carry out the move in accordance with the attached checklist in appendix 1. they...

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