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Document Title Estates Operations and Maintenance Policy

Reference Number NTW(O)32

Lead Officer Malcolm Aiston

Director of Estates and Facilities

Author(s) (name and designation)

Paul McCabe – Head of Estates and Facilities

Ratified By Trust-wide Policy Group

Date ratified October 2015

Implementation date November 2015

Date of full implementation November 2015

Review Date October 2018

Version Number V01.2

Review and Amendment Log

Version Type of Change

Date Description of Change

V01 NEW Oct 15 New Policy

V01.1 Update Nov 16 Inclusion of PGNs – 01, 03, 04, 22, 23, 29, 30, 34 and 35

V01.2 Update Dec 16 Inclusion of PGNs 06 and 32

This Policy supersedes the following document which must now be destroyed

Reference Number Title

NTW(O)32 – V01.1 Estates Operations and Maintenance Policy

Estates Operations and Maintenance Policy

Section Contents Page No.

1 Introduction 1

2 Purpose 1

3 Scope 2

4 Definitions and Glossary 3

5 Roles and Responsibilities 5

6 Operational Framework 12

7 Delivering a Maintenance and Repair Service 19

8 Identification of Stakeholders 23

9 Equality Impact Assessment 24

10 Training 24

11 Implementation 24

12 Monitoring and Compliance 25

13 Standards/Key Performance Indicators 25

14 Fair Blame 26

15 Fraud Bribery and Corruption 26

16 Associated Documentation 27

Standard Appendices attached to Policy

Appendix A Equality and Diversity Impact Assessment 28

Appendix B Training Checklist and Training Needs Information 30

Appendix C Monitoring Tool 32

Appendix D Policy Notification Record Sheet - click here

http://nww1.ntw.nhs.uk/services/?id=5950&p=5539&sp=5545

Estates - Practice Guidance Notes (PGN) listed separate to Policy

(PGN) No: Title Issue No: Issue Date Review Date

E-PGN 01 Access to Estates – Helpdesk and Defect Reporting

1 Nov 2016 Nov 2019

E-PGN 02 Minor Works 1 Oct 2015 Oct 2018

Appendix 1 Minor Works – Flow Diagram 1 Oct 2015 Oct 2018

Appendix 2 Cost Estimate for Minor

Works – Form 1 1 Oct 2015 Oct 2018

Appendix 3 Minor Works Completion

Certificate – Form 2 1

Oct 2015 Oct 2018

E-PGN 03 Estates Log Books and Ward Property Service Guides

1 Nov 2016 Nov 2019

Appendix 1

Emergency Response when

Asbestos Containing

Materials are damaged

1 Nov 2016 Nov 2019

E-PGN 04 Management of Asbestos 1 Nov 2016 Nov 2019

Appendix 1

Emergency Procedure for

suspected damaged

Asbestos containing materials

1

Nov 2016 Nov 2019

Appendix 2 Accessing the Asbestos Register

1 Nov 2016 Nov 2019

E-PGN 05 Management of Electrical Systems

1 Oct 2015 Oct 2018

E-PGN 06 Portable Appliance Testing 1 Dec 2016 Dec 2019

Appendix 1 User checklist for electrical

equipment 1

Dec 2016 Dec 2019

E-PGN 07 Management of Fire Protection Systems

1 Oct 2015 Oct 2018

Appendix 1 Notification of Interruption of Fire Alarm Operation

1 Oct 2015 Oct 2018

Appendix 2 Modification Certificate 1 Oct 2015 Oct 2018

Appendix 3 Fire Hazard Rooms and Areas and Hazard Departments

1 Oct 2015 Oct 2018

(PGN) No: Title Issue No: Issue Date Review

Date

E-PGN 08 Management and Maintenance of Passenger and Goods Lifts

1 Oct 2015 Oct 2018

Appendix 1 Schedule of Lifts 1 Oct 2015 Oct 2018

Appendix 2 Schedule of Standards associated with Lifts

1 Oct 2015 Oct 2018

Appendix 3 Audit Form 1 Oct 2015 Oct 2018

E-PGN 09 Management of Heating Equipment Including Gas Safety

Dr

E-PGN 10 Management of Windows Dr

E-PGN 11 Management of Pressure Systems

1 Oct 2015 Oct 2018

Appendix 1 User / Owner Decision Tree 1 Oct 2015 Oct 2018

E-PGN 12 Permit to Work Procedures Dr

Appendix 1 Permit to Work Certificate Dr

Appendix 2 Guidance Notes on how to complete Permit to Work Certificate

Dr

Appendix 3 Notes to responsible / competent and authorised person

Dr

Appendix 4 Contractors Health and Safety Questionnaire

Dr

Appendix 5 Confined Spaces Guidance Dr

E-PGN 13 Management of Tools in the Patient Environment

Dr

E-PGN 14 Testing of Anti-Ligature Products

Dr

E-PGN 15 Application of Anti-Tamper Fixings

Dr

E-PGN 16 Management of Backlog Maintenance

1 Oct 2015 Oct 2018

E-PGN 17 Estates Contractor Management

1 Oct 2015 Oct 2018

Appendix 1 Determining the Competence of a Contractor

1 Oct 2015 Oct 2018

Appendix 2 Some Points to Consider when Contractors are Setting up Site

1 Oct 2015 Oct 2018

Appendix 3 Estates Contractor Management

2 Aug 2016 Oct 2018


Date

E-PGN 18 Management of Doors Including Automatic and Assisted Doors

Dr

E-PGN 19 Management of Staff Attack Systems

Dr

E-PGN 20 Management of White Goods

1 Oct 2015 Oct 2018

E-PGN 21 Management of Grounds And Gardens

Dr

E-PGN 22 Room Numbering and Name Management Procedure

1 Nov 2016 Nov 2019

Appendix 1 Building Floor Layout Examples

1 Nov 2016 Nov 2019

E-PGN 23 Managing Vacant Estate 1 Nov 2016 Nov 2019

Appendix 1 Checklist of Notifications 1 Nov 2016 Nov 2019

Appendix 2 Notification of Closure of Section

1 Nov 2016 Nov 2019

E-PGN 24 Management of Estates Waste

Dr Oct 2015 Oct 2018

Appendix 1 Flow Chart – Nature of Scrap Identified

1 Oct 2015 Oct 2018

E-PGN 25 Management of Building Inspections

Dr

E-PGN 26 Management of Drains and Sewerage Systems

Dr

E-PGN 27 Management of Keys and Associated Systems

1 Oct 2015 Oct 2018

Appendix 1 Estates Key Policy –

Contractors

1 Oct 2015 Oct 2018

Appendix 2 Key Register – Temporary

Loan Form

1 Oct 2015 Oct 2018

Appendix 3 Key Cabinet Register 1 Oct 2015 Oct 2018

Appendix 4 Keys – Long Term /

Permanent Issue Form 1 Oct 2015 Oct 2018

Appendix 5 Request for the Supply of

Keys 1 Oct 2015 Oct 2018


Date

E-PGN 28 Management of Signage Dr

E-PGN 29 Management of Ventilation Systems

1 Nov 2016 Nov 2019

Appendix 1 LEV Areas 1 Nov 2016 Nov 2019

E-PGN 30 Premises Assurance Model 1 Nov 2016 Nov 2019

E-PGN 31 Capital and Minor Works Standard Specification

Dr

E-PGN-32 PFI and Non NTW Sites Guidance

1 Dec 2016 Dec 1019

Appendix 1 Equipment List – St George’s

Park

1 Dec 2016 Dec 1019

Appendix 2 Equipment List – Walkergate

Park

1 Dec 2016 Dec 1019

Appendix 3 Sample Minor Works Form –

Clugstons

1 Dec 2016 Dec 1019

Appendix 4 Sample Minor Works Form -

Robertsons

1 Dec 2016 Dec 1019

Appendix 5 Brief Guide to Services 1 Dec 2016 Dec 1019

E-PGN 33 Redecoration Protocol Including Colour Standards

Dr

E-PGN 34 Pest Control 1 Nov 2016 Nov 2019

Appendix 1 Types of Pests 1 Nov 2016 Nov 2019

Appendix 2 Riddance Times for Pests 1 Nov 2016 Nov 2019

E-PGN 35 Emergency Planning 1 Nov 2016 Nov 2019

Appendix 1 Emergency Situation Assessment

1 Nov 2016 Nov 2019

Appendix 2 Emergency Response Log Sheets

1 Nov 2016 Nov 2019

Statement

It is the Policy of Northumberland, Tyne and Wear NHS Foundation Trust to provide, maintain and develop a high quality environment in a professional, efficient, cost effective and customer focused manner to enable the Trust to meet its aims today and in the future all for the benefit of clients, staff and visitors. In order to achieve this, the Trust shall put in place an operational structure with the necessary resources to comply with legislative requirements and current best practice. The Estate Department are tasked with the day to day provision of a range of professional services to the Trust, including capital development and project management, space management, grounds management, repairs and maintenance, engineering services and utilities. It must be recognised that all Trust staff have a part to play in ensuring that the Estate is used, operated and maintained in a way that allows us to achieve our Policy objective. In our roles as Chief Executive and Director of Estates and Facilities we accept our responsibility and ask you to do the same. Please help us to make our facilities a place where high standards are maintained at all times.

Northumberland, Tyne and Wear NHS Foundation Trust 1 NTW(O)32 – Estates Operations and Maintenance Policy – V01.2 – Issued Dec 16

1 Introduction 1.1 Northumberland, Tyne and Wear NHS Foundation Trust (the Trust / NTW)

provides a range of accommodation from around 80 locations, consisting of 8 principal sites and the remainder being made up of satellite properties across a large geographical area of 2,200 square miles. The estate is used to provide accommodation and facilities for service users, staff and visitors.

1.2 Various Acts, Regulations, ACOP’s etc., impose specific duties to safeguard

the health and safety of those who use our premises. These duties equally apply to a contractor or subcontractor on Trust premises, in respect of safeguarding our employees, patients and visitors from their activities.

1.3 NTW recognises its legal obligations to take necessary measures in the

provision of effective maintenance of buildings, fixed or portable equipment, engineering plant, systems and services. The key objectives of this Policy are to set out how the Trust intends to meet its estates related obligations.

1.4 The Trust is committed to fulfilling both its legal obligations and the

requirements outlined by the Care Quality Commission (October, 2010) that it shall meet the essential standards of quality and care.

1.5 NTW shall provide and maintain safe and healthy working conditions,

equipment and systems of work for all staff and visitors and to provide such resources, instruction, training, information and supervision as they need for this purpose. NTW aims to do all that is reasonably practicable to manage its Building and Engineering Services and to follow the steps laid out in this Policy.

2 Purpose 2.1 The purpose of the Policy is to set out details of the Trusts approach to

Estates operations and maintenance and ensure that all the properties occupied by the Trust are maintained and operated safely and kept in good condition in order to:

Comply with health and safety legislation requirements;

Ensure the standards are met as set out in Standards for Better Health and as modified over time by the Care Quality Commission;

Contribute to the overall control of infection agenda within the Trust;

Meet the requirements for Building and equipment maintenance as set out in legal and statutory requirements, specialist guidance (e.g. HTM’s);

To maintain the current value of the Trusts building stock, to minimise the breakdown or failure of components and to


extend the economic life of all the Trust’s assets as far as possible;

To maintain the health, comfort and environment for all Patients, staff and visitors to the Trust by ensuring weather tightness, adequate heating and ventilation and a high standard of maintenance to all supporting facilities;

To improve the energy efficiency and running costs of the buildings;

To ensure the Trust obtains cost effective and professional maintenance services, which make the best use of available resources;

To propose and review revenue and capital funding needs annually and advise on funding shortfalls or excesses in relation to risks, resources and required standards;

Minimise disruption and to ensure business continuity;

Ensure that robust monitoring and reporting mechanisms are in place. This Policy pursues and expects the good upkeep of buildings, engineering plant and equipment by regular inspection and maintenance in line with the Department of Health documents (Health Technical Memorandum series) and other recognised guidance, legislation and standards.

3 Scope 3.1 The Policy applies to all properties owned and maintained by the Trust.

Properties leased, rented or occupied under lease or other occupancy agreement where the Trust is responsible for maintenance will also be operated and maintained in accordance with this Policy.

3.2 The standards expected in our leased or PFI properties are no different from

those the Trust owns. The standards set out in this Policy and associated PGN’s will be the level of expectation required for premises operated under PFI contract, SLA or lease.

3.3 Estates Maintenance Services include electrical and mechanical services,

air conditioning and air handling, plumbing, joinery, building, painting and decorating, security systems, fire alarms, flooring, portable appliances, grounds and gardens, etc.


4 Definitions and Glossary 4.1 For the purposes of this document the following definitions apply:

Reactive maintenance is a repair service requested normally by the user department. When faults are reported they are allocated a priority from urgent to routine depending upon the nature of the fault. The priority will generally attract a pre-set response time;

Planned Preventative Maintenance (PPM) is the routine inspection and / or servicing of equipment, or the planned repair or replacement of components, elements or systems. On a time or hours run basis (e.g. lubrication, fire alarm testing, filter changes etc.);

Irregular or cyclical maintenance is work carried out in accordance with planned recurrent and often multi-year cycles (e.g. redecoration, flooring renewals);

Backlog maintenance is a term which covers situations where there is long standing outstanding maintenance which can only be tackled by larger investment projects. These types of maintenance issues are identified through risk assessments, service reports, backlog surveys and are incorporated into the Trusts Capital Programme where funding allows;

Minor works is a term which covers small items of Estates works involving adaptation, alteration and new installations which are often required to support changes in procedures and work practices. The typical value of Minor Works is below £5,000. Where alterations or improvements are required these require to be specifically funded, normally from an appropriate revenue budget. For this type of work a Minor New Works Form (available from the Intranet) will be completed by the requesting Directorate or Department and should be submitted to the Minor New Works Team (electronically);

Capital expenditure is defined as expenditure on a tangible productive resource with an expected life in excess of one year. The items will usually require repair and maintenance. The capitalisation threshold has been determined as expenditure of £5,000 (including VAT where this is not recoverable). All works and queries regarding capital works need to be approved prior to progression;

Service Contracts: Maintenance carried out by an external contractor at predetermined intervals and intended to reduce the probability of failure, breakdown or the performance degradation of an asset;

Out of Hours Emergency Maintenance Service


o This service provides a 365 day maintenance service that operates outside of normal working hours. It is accessed through the hospital switchboard. The objective of the Out of Hour’s Service is to make safe plant or equipment and to repair or rectify critical items to maintain a safe service. Calls are logged by the switch board and the on Call Estates Operations Manager / Officer is contacted to assist and they will determine the course of action.

Rechargeable Repairs

o These are repairs required following wilful damage to the Trust structure, fixtures and fittings.

4.2 For the purposes of this document the following glossary of terms is used:

AE Authorising Engineer;

AP Authorised Person;

BCP Business Continuity Plans;

DEL Directly Employed Labour;

DP Designated Person;

ERIC Estates Return Information Collection;

HBN Health Building Note;

HFN Health Facility Note;

HGN Health Guidance Note;

HTM Health Technical Memorandum;

IPCT Infection Prevention Control Team;

MNW Minor New Works;

NTW Northumberland, Tyne and Wear NHS Foundation Trust;

PAM Premises Assurance Model;

PPM Planned Preventative Maintenance;

PTW Permit to Work;


VFM Value for Money. 5 Roles and Responsibilities 5.1 Trust Board 5.1.1 The Trust Board has overall accountability for all the activities of the

organisation, which includes the management and maintenance of the Trusts estate. This includes the following: land and property matters;

Planning Strategic Investment in the Estate;

Land and Property Appraisal;

Asset Management;

Building Maintenance;

Engineering Maintenance;

Energy Management;

Grounds Maintenance;

Land and Property Disposal;

Space Management. 5.2 Chief Executive 5.2.1 The Chief Executive has overall statutory and operational responsibility for

the management and maintenance of the estate and will ensure the Trust:

Provide a safe and well maintained estate so far as is reasonably practicable, taking account of any statutory requirements;

Provide such resources, information, training, instruction and supervision to enable employees to maintain the estate safely and efficiently as far as is reasonably practicable;

Produces a regular quarterly / annual reports to inform the Trust that it is meeting its legislative standards and quality standards in accordance with the estate.

Monitoring of action against plans will be incorporated within the Trust Board performance review process;

Ensure the effective arrangements exist to allow collaboration between Estates, Departmental Managers and staff.


5.2.3 The Chief Executive delegates the operational day to day responsibility and

authority to the Director of Estate and Facilities, who will manage, maintain and control the estate as set out in this Policy and other related Policies.

5.3 Executive Director of Finance

5.3.1 The post holder has delegated responsibility from the Board for ensuring that appropriate maintenance strategies / systems, as well as properly trained staff, are in place.

5.3.2 The post holder has responsibility for ensuring regular reports are made to the Board giving details of information concerning estates risks and performance, noting emerging trends and recommending action as necessary.

5.4 Director of Estate and Facilities 5.4.1 The Director of Estates and Facilities will operate the management and

control systems outlined in this Policy along with the associated Practice Guidance Notes.

5.5 Head of Estates and Facilities 5.5.1 The Head of Estates and Facilities manages the Estates Management Team

which has overall responsibility for the delivery of the Operational Services and Budget. This Team comprises of the Head of Estates and Facilities and the Operational Estates Managers and a range of reporting staff.

5.6 Operational Estates Managers and Operational Estates Officers 5.6.1 The Operational Estates Managers / Officers have a responsibility to ensure

that their staff are instructed, trained, informed and supervised and are suitably competent to carry out their roles in a safe, effective and efficient manner.

5.6.2 The Operational Estates Managers / Officers are the designated officers for

Estates Maintenance Services. This position fulfils the role of Responsible / Authorised Person (AP) for Specialist Engineering and Building Services (these appointments are site specific).

5.6.3 Operational management of Estates Services includes building, engineering,

equipment, pest control, specialist maintenance and grounds and gardens with appropriate maintenance programmes and an annual review of maintenance activities.

5.6.4 All services have an appropriate maintenance programme and an annual

review of maintenance activities. 5.6.5 The Operational Estates Managers / Officers are responsible for the

implementation of the operational requirements of this Policy which include:

Staff management (i.e. sickness, appraisals etc.);


Promoting a safety culture amongst all staff;

Assessment and quantification of risk;

Reduction of risks to as low as reasonably practicable;

Identify and report higher level risks in the day to day business planning process;

Review all risks periodically or when there is a change in activity;

Instigating safe systems of work and working practices to minimise risks;

Maintaining appropriate records;

Compliance with all statutory legislation and Health Estates guidance as applicable to the healthcare environment;

Consulting with all stakeholders affected by building, engineering and maintenance activities;

Undertaking dilapidation and condition surveys.

5.7 Estates Supervisors 5.7.1 The Estates Supervisors provide day-to-day supervision and support to their

specific discipline to ensure that the section is able to provide give the highest level of safe, courteous and efficient service to the building’s users.

5.8 Estates Trade Staff 5.8.1 Estates Trade Staff are employed to work across both building and

engineering disciplines (mechanical and electrical). Their level of responsibility includes (but is not limited to) fabric maintenance, steam boilers and CHP plant, lifts, compressors, fire systems, emergency generators, electrical, heating, cooling and water systems, drains and security access systems.

5.8.2 Estates Trade Staff provide skilled installation and / or maintenance of

specialist services and will be directed, appointed, or authorised to work (if a contractor) by their Supervisor, dependant on the work involved.

5.8.3 Maintenance Assistants and Maintenance Assistants (Higher Level) will

undertake a range of duties as identified in their job description and under direction from Supervisors.

5.8.4 Estates Trade Staff will also be required to participate in the out of hours on

call system and to respond to emergency situations. 5.9 Grounds and Gardens


5.9.1 The Estates Grounds and Gardens Team comprises Senior Gardeners and

Gardeners. They will undertake a range of duties as identified in their job description and under direction from Supervisors.

5.10 Estates Administration Support Staff 5.10.1 The Administration staff play a vital support role in providing a support

service to the Estates Department and the wider Trust. Their key operational support duties are summarised as follows:

To provide an efficient help desk service dealing with customer calls and prioritising urgent requests;

To assist in the effective management of records and estates information.

5.11 Capital Projects Team 5.11.1 The Capital Projects Manager under the direction of the Director of Estates

and Facilities is responsible for the overall programme management of all Estate Capital Development Schemes. The Capital Projects Team shall ensure all new works are efficient in terms of value for money (VFM), energy usage, reducing future maintenance requirements and to comply with relevant HTM / HBN’s and other legislation.

5.11.2 The Capital Projects Manager under the direction of the Director of Estates

and Facilities will also monitor progress of agreed schemes and prepare and issue reports to inform and advise Trust Senior Management on a regular basis, all in accordance with Trust Policies and Procedures.

5.12 Trust Supplies Department 5.12.1 The Supplies Department will assist the Estates Department is responsible

for ensuring that Trust estates services are procured via a legally tendered procurement route and that the Trust’s Standing Financial Instructions are complied with. This includes national, regional and negotiated framework and contract agreements. A collaborative approach is adopted between Estates and the Procurement Department.


5.13 Clinical and Corporate Teams 5.13.1 Teams are responsible for ensuring that their staff are aware of their duty to

report building and engineering defects, breakdowns and repairs through the appropriate channels (Web Helpdesk for Non-Emergency and Switchboard for Emergencies) and also to operate the building and its equipment in a safe and appropriate way with appropriate training and competency.

5.14 Infection, Prevention and Control Team 5.14.1 It is the responsibility of the Infection Prevention and Control Team (IPC) to

provide specific input and support for all matters relating to the hospital environment, maintenance of hospital buildings and engineering systems and to work with Estates Operations. This will include the provision of:

Education for maintenance staff and management on infection prevention and control and the reduction in HCAI’s;

Guidance and support when advice on controlling the environment is required;

Advice on Risk Assessments for controlling the environment;

Identify priorities for action. 5.15 Employees 5.15.1 All Trust employees (including agency staff and contract staff) have a duty of

care to each other as set out within the Health and Safety at Work Act and to co-operate with their employer and not to tamper with safety devices and to reports defects and failures in accordance with Trust procedures.

5.15.2 Employees should report without undue delay all estates faults to the

appropriate help desk. 5.16 Contractors 5.16.1 All Contractors / Contract staff have a duty of care as set out within the

Health and Safety at Work Act and to co-operate with both the Trust and their employer to work safely and follow Trust Procedures.

5.16.2 Further information on the role of Contractors can be found in the ‘NTW

Control of Contractors Policy’. 5.17 Professional Structure 5.17.1 Whilst the Chief Executive and the Trust Board carry ultimate responsibility

for the safe and secure healthcare environment the structure below represents the professional adopted approach to the delivery of high risk impact Specialist Services within NTW.

These include the management of high voltage electricity, low voltage electricity, asbestos, water safety and quality, pressure systems etc. This relationship is shown below:


Figure 1 Professional Structure

5.17.2 The Designated Person (DP) provides the essential senior management

link between the organisation and professional support, which also provides independence of the audit reporting process. The DP will also provide an informed position at board level. The DP will work closely with the Senior Operational Manager to ensure that provision is made to adequately support Specialist Services.

5.17.3 The Trust Senior Operational Manager (SOM) may have operational and

professional responsibility for a wide range of Specialist Services. It is important that the SOM has access to robust, service specific professional support which can promote and maintain the role of the “informed client” within the healthcare organisation. This will embrace both maintenance and the development of service specific improvements; support the provision of the intelligent customer role and give assurance of service quality.

5.17.4 The Authorising Engineer (AE) acts as an independent professional

adviser to the healthcare organisation. The AE should be appointed by the organisation with a brief to provide services in accordance with Health Technical Memorandum guidance. This may vary in accordance with the specialist service being supported.

5.17.5 The AE will act as assessor and make recommendations for the

appointment of Authorised Persons, monitor the performance of the service, and provide an annual audit to the DP. To effectively carry out this role, particularly with regard to audit, it is preferable that the AE remains independent of the operational structure of the Trust.

5.17.6 The Authorised Person (AP) have the key operational responsibility for

high risk impact Specialist Engineering Services such as high voltage works. The appointed person will be qualified, sufficiently experienced and skilled to fully operate the specialist service. The AP will be nominated by the AE and appointed by the SOM (or Chief Executive) and be able to demonstrate:

Authorised Person

Appointed engineer

(specific to service)

Designated Person

(Board level or appointed

person)

Trust Senior Operational

Manager

Competent Person

(Trade staff or contractor with specific

skills)

Authorising Engineer

(Independent engineer, specific to

service)


Their application through familiarisation with the system;

Attendance at an appropriate professional course;

A level of experience and evidence of knowledge and skills. 5.17.7 The Estates Operational Managers / Officers fulfil these roles and the

appointments are site specific. An important element of this role is the maintenance of records, quality of service and maintenance of system safety (integrity). The AP is responsible for establishing and maintaining the roles and validation of Competent Persons, who may be employees of the organisation or appointed contractors. The Trust has more than one AP for a particular service. Administrative duties such as recordkeeping are assigned to specific APs and recorded in the related Operational Policies.

5.17.8 The Competent Person (CP’s) are skilled in the installation and / or

maintenance of the Specialist Service. The CP will be appointed, or authorised to work (if a contractor), by the AP and be able to demonstrate a sound trade background, qualifications and specific skill set in the Specialist Service.

5.17.9 They will work under the direction of the AP and in accordance with

Operating Procedures, Policies and Standards of the Service as determined by NTW. The Supervisors and Craftsmen fulfil these roles and the appointments are site specific.


6 Operational Framework 6.1 This document forms part of a framework, which comprises the following

elements:

Figure 2

6.2 Estates Related Practice Guidance Notes 6.2.1 A range of Estates related Practice Guidance Notes will form part of the

Appendices to this Policy. They will typically include those areas which directly impact on service users, staff and visitors.

6.2.2 The following specific Estates related Practice Guidance Notes will be put in

place (or will be developed), this list will be updated as required.

Accessing the Estates Helpdesk for Reporting Defects and Failures;

Minor Works Procedures;

Guidance Specific to PFI and non NTW sites;

Management and Control of Asbestos;

Management of Electrical Systems;

Portable Appliance Testing (PAT);

Management of Fire Protection Systems;

Management of Passenger Lifts and Lifting Equipment;

Management of Staff Attack Systems;

This Policy

Estates related Practice

Guidance Notes

DoH Documents

HTM's

Estatecode

Statutory Documents &

Industry Good

Practice

Related Trust Policies &

Estates Strategy

Estates Local Operational Procedures


Management of White Goods;

Management of Pressure Systems;

Management of Ventilation Systems;

Management of Heating Equipment including Gas Safety;

Management of Grounds and Gardens;

Management of Estates Waste;

Management and Control of Contractors;

Management of Building Inspections;

Management of Drains and Sewerage Systems;

Management of Windows;

Management of Doors including Automatic Doors;

Management of Keys and Associated Systems;

Management of Tools in the Patient Environment;

Pest Control;

Testing of Anti – Ligature Products;

Application of Anti-tamper Fixings;

Management of Signage;

Permit to Work Procedures;

Redecoration Protocol – Including Colour Standards;

Room Numbering and Name Management Procedure;

Managing Vacant Estate;

Capital and Minor Works Standard Specification;

Premises Assurance Model;

Estates Log Books and Information Left on Wards / Departments;

Emergency Planning.


6.3 Estates Local Operational Procedures – Including Permit to Work and

Risk Assessments 6.3.1 Estates LOP’s will detail the working arrangements and systems that are in

place to manage the day to day operational aspects of the estate in a compliant and safe manner.

6.3.2 Permit to Work systems covering, but not limited to, works involving or

affecting the following will be adhered to:

Confined or restricted spaces;

Hot Works including Drilling and Cutting;

Work on Electrical Systems;

Work on Pressure Systems;

Energy Systems;

Working at Heights;

Excavation. 6.4 Related Trust Policies 6.4.1 A range of Trust Policies and PGN’s are relevant to the operation of the

Estate, the key Policies are listed below, however, due consideration has to be given to other Policies / PGN’s need to be referenced as necessary.

NTW(O)01 - Development and Management of Procedural Documents;

NTW(O)05 - Incident Reporting Policy;

NTW(O)08 - Integrated Emergency Management Policy;

NTW(O)17 - Central Alerting System;

NTW(O)20 - Health and Safety Policy;

NTW(C)23 - Infection Prevention Control Policy;

NTW(O)33 - Risk Management Policy;

NTW(O)41 - Fire Policy. 6.5 Statutory Documents and Other Good Practice 6.5.1 Including all relevant Statutory Instruments, Approved Codes of Practice and

relevant British Standards, Building Regulations etc. The HSE in particular


produces Guidance, ACOP’s and Regulations, a description of the status each of these has is summarised as follows:

Guidance

The main purposes of guidance is to interpret helping people to understand what the law says including, for example, how requirements based on EC Directives fit with those under the Health and Safety at Work Act; Following guidance is not compulsory and employers are free to take other action. But if they do follow guidance they will normally be doing enough to comply with the law.

Approved Codes of Practice

Approved Codes of Practice offer practical examples of good practice. They give advice on how to comply with the law by, for example, providing a guide to what is ‘reasonably practicable’. For example, if regulations use words like ‘suitable and sufficient’, an Approved Code of Practice can illustrate what this requires in particular circumstances. Approved Codes of Practice have a special legal status. If employers are prosecuted for a breach of health and safety law, and it is proved that they have not followed the relevant provisions of the Approved Code of Practice, a court can find them at fault unless they can show that they have complied with the law in some other way.

Regulations

Regulations are law, approved by Parliament. These are usually made under the Health and Safety at Work Act, following proposals from HSC. This applies to regulations based on EC Directives as well as ‘homegrown’ ones. Regulations identify these risks and set out specific action that must be taken. Often these requirements are absolute to do something without qualification by whether it is reasonably practicable.


6.5.2 The legislation and key standards applicable to Estates are summarised below:

ACOP’s

o Legionella (ACOP L8); o Asbestos (ACOPs L127, L143); o Gas Safety (ACOP L56); o Hazardous Substances (ACOP L5); o Workplaces (ACOP L24); o Management of Health and Safety (ACOP L21); o Work Equipment (ACOPs L22, L114); o Lifting Equipment (ACOP L113); o Confined Spaces (ACOP L101); o Pressure Systems (ACOP L122); o Worker Involvement (ACOP L146).

Acts

o Environment Protection Act 1990; o Clean Neighbourhoods and Environment Act

2005; o Health and Safety at Work Act 1974; o Health Act 2006; o Occupiers Liability Act 1984; o Corporate Manslaughter and Corporate

Homicide Act 2007.

Regulations

o Control of Asbestos Regulations 2012; o Confined Spaces Regulations 1997; o Construction (Design and Management)

Regulations 2007; o Construction (Head Protection) Regulations;


o Control of Lead at Work Regulations 2002; o Control of Major Accident Hazards Regulations

1999 (amended 2005); o Control of Noise at Work Regulations 2005; o Control of Vibration at Work Regulations 2005; o Building Regulations; o Electricity at Work Regulations 1989; o Gas Safety (Installation and Use) Regulations

1998; o Gas Safety (Management) Regulations 1996; o Health and Safety (Signs and Signals)

Regulations 1996; o Management of Health and Safety at Work

Regulations 1999; o The Manual Handling Operations Regulations

1992 (as amended); o Personal Protective Equipment Regulations

2002; o Pressure Systems Safety Regulations 2000; o Provision and Use of Work Equipment

Regulations 1998; o Regulatory Reform (Fire Safety) Order 2005; o RIDDOR Regulations 2013; o Work at Height Regulations 2005 (amended

2007); o Workplace (Health, Safety and Welfare)

Regulations 1992; o Environmental Protection (Duty of Care)

Regulations 2005; o Hazardous Waste (England and Wales)

Regulations 2005; o Waste Electrical and Electronic Equipment

Regulations 2006;


o Waste Management Regulations 1996; o Control of Substances Hazardous to Health

(COSHH) Regulations (2004); o Provision and Use of Work Equipment

Regulations (PUWER) (1998); o Lifting Operations and Lifting Equipment

Regulations (LOLER) (1998). 6.6 Healthcare Standards 6.6.1 Department of Health Guidance specific to Estates has been issued for

many years and best practice will be followed. The documents include:

Health Facilities Notes;

Heath Building Notes;

Health Guidance Notes;

Health Technical Memorandums;

o HTM 00 – Policies and Principles; o HTM 01 – Decontamination; o HTM 02 – Medical Gases; o HTM 03 – Heating and Ventilation; o HTM 04 – Water Systems; o HTM 05 – Fire Safety; o HTM 06 – Electrical Services; o HTM 07 – Environment and Sustainability; o HTM 08 – Specialist Services.

Estate Code;

Premises Assurance Model (PAM). 6.6.2 Estates staff will be required to follow the requirements of the HTM and

other healthcare related documents. 7 Delivering a Maintenance, Repair and Minor Works Service


7.1 Maintenance and repairs will be delivered by the use of Directly Employed Labour (DEL), general or specialist contractors. The specific work of these groups are supervised by the Operational Estates Managers, Estates Officers and Supervisors who are accountable for obtaining quotations, placing orders, supervising and certifying completion in accordance with the Trust’s Standing Financial Instructions and Standing Orders for Contractors. For DEL labour they must ensure an effective and efficient service that demonstrates best value. The Standards of Business Conduct / Register of Interests must be completed if placing orders with firm where there is a family / friend link. Audit trails exist for these methods of delivery as records may be requested to demonstrate work undertaken for assurance purposes. This work is undertaken to ensure compliance against a range of legislation and standards as detailed in Section 6.

7.2 Planned Preventative Maintenance (PPM) 7.2.1 Planned preventive maintenance is regular, scheduled work carried out to

keep equipment in good working order and to optimise its efficiency, cost effectiveness and availability. This activity involves regular, routine cleaning, lubricating, testing, calibrating and adjusting, checking for wear and tear and eventually replacing components to avoid breakdown.

7.2.2 Most of the work that the Estates Teams carry out is unseen by Directorates

and Departments and this is the planned maintenance. Planned maintenance is carried out in accordance with schedules arranged by the Operational Estates Managers based on legal requirements, manufacturer's recommendations and warranty criteria.

7.2.3 If a Head of Department is concerned about any item in their area which is

on the planned maintenance schedule they should discuss the matter directly with the Operational Estates Managers.

7.2.4 PPM works are normally carried out during working hours to the agreed

schedule. There are two types of PPM's:

Statutory Maintenance is undertaken to comply with statutes and underpinning regulations relating to the building / engineering elements within a building and operations undertaken from the premises such as 5 yearly fixed wiring tests, portable appliance testing, asbestos management, management of water systems, lift inspections, pressure systems;


Mandatory / Business Critical Maintenance is carried out under the recommendation made by organisations that are not enshrined in statute but will be referred to as best practice in a coroners court, a criminal or civil action for damages against the Trust or individual officers of the Trust. These include Approved Codes of Practice, British Standards, ISO Standards, Hospital Technical Memorandum(s) and manufacturers recommended instructions.

7.3 Reactive Maintenance 7.3.1 Reactive maintenance is a repair service requested normally by the user

department. When faults are reported they are allocated a priority from urgent to routine (Priority A-D) dependent upon the nature of the fault. The priority will generally attract a pre-set response time this varies on PFI sites but is the following for Non PFI sites.

Emergency Repairs - Priority A: Emergencies (Immediate Response)

o This is for major emergencies where personal

injury or severe property damage may occur if it is not dealt with immediately;

o During normal working hours the Estates

Department will seek to either make safe or complete the works within 1 hour;

o All out of normal hours call outs will make safe as

soon as possible

Very Urgent Repairs - Priority B: within 1 working day

o This is for repairs where further property damage may occur or use of facility may be compromised if it is not dealt with promptly;

o The Estates Department has 1 working day to

action and effect a repair.

Urgent Repairs - Priority C: within 2-5 working days

o For routine repairs not likely to cause injury to persons or further property damage if not considered as priority A or B;

o The Estates Department has up to 5 working

days to action and effect a repair.


Routine Repairs - Priority D: More than 5 Working Days

o The Estates Department will have up to 28

working days to action and complete the repair.

7.3.2 All responsive maintenance requests must be made to the Trust Estates

Helpdesk Systems without exception. This can be either by phone or via the intranet. The link on the Intranet gives 24 hour access for the logging of non-emergency reactive maintenance works.

7.3.3 Estates staff are responsible for the quality of the responsive maintenance

service provided and shall carry out random quality inspections to determine satisfactory completion and acceptable workmanship.

7.4 Rechargeable Repairs 7.4.1 These are repairs required following wilful damage to the NTW structure,

fixtures and fittings by staff, patients and visitors. This could include the loss of equipment e.g. staff attack handsets, vandalism, arson, loss of keys, etc.

7.5 Out of Hours Emergency Maintenance Service 7.5.1 There are a range of situations and activities within Trust premises that

require some form of emergency on-call arrangement to ensure health and safety and business continuity for 24 hours a day, 7 days a week.

7.5.2 The service provided by the Estates Operations Department for out of hours

emergency maintenance is to isolate and make safe. Individuals are not expected to remain on Hospital premises whilst on call. However, they will be expected and required to respond to calls during their “on call” period and to deal with them appropriately and within a reasonable timeframe, including attendance at the workplace if necessary. The individual will not refer the call on to others, unless it has been directed to them inappropriately. Individuals are expected to fulfil responsibilities arising as a result of being on call to acceptable standards.

7.6 Redecoration Program 7.6.1 The Estates Department will maintain the decoration of the buildings. All

internal and external painting will be carried out on a cyclical basis or as needs determined by the Estates Department. Where damage or excessive marking has occurred in between the cycle then this may be addressed by redecorating s single wall or area.

7.6.2 The paint product and colour schemes can only be selected from the Trusts

approved colour guide (see relevant E-PGN).


7.7 White Goods 7.7.1 The Estates Department shall be responsible for the maintenance and

replacement of white goods such as washing machines, tumble dryers, food fridges, freezers, cookers and microwaves. These will be replaced when they can no longer be economically repaired, this will be the decision of the Estates Department.

7.8 Grounds and Gardens 7.8.1 The Trust has extensive and diverse grounds and gardens which are

managed by the Grounds and Gardens Team, the work they do is summarised as:

Grass Cutting;

Hedge Cutting and Pruning;

Shrub Bed Maintenance;

Herbaceous Border Maintenance;

Bedding Plants;

Leaf Clearance;

Litter Clearance;

Weed Control;

Hard and Soft Landscaping Projects;

Minor Arboricultural Work – Felling / Clearance. 7.9 Helpdesk 7.9.1 The Trust deploys specialist software to assist with the delivery, monitoring,

and control of work associated with reactive maintenance and planned preventative maintenance. It is via this software that the requests for assistance is recorded and managed.

7.9.2 Reactive maintenance requests can be logged quickly, and the requestors

have access to interrogate the database without the need to navigate around the software. The requestor can check the current status of any maintenance request, and review history enabling queries to be answered immediately, this is done via the link on the Intranet.

7.9.3 The specialist software enables the Management Team to maintain a plan /

service history by recording work done, breakdowns etc., which assists in prioritising plant and equipment replacement programmes.

7.10 Minor Works – Costing Under £5,000


7.10.1 Where alterations or improvements are required these require to be specifically funded, normally from an appropriate revenue budget. For this type of work a Minor New Works Form (available from the Intranet) will be completed by the requesting Directorate or Department and should be submitted to the Minor New Works Team (electronically).

7.10.2 For example, the work might comprise of reconfiguring and redecorating a

small office, providing adjustable shelving, suspended ceilings or a change of floor coverings. For work of this nature a site visit is organised, the Estates person will confirm the requirements and provide a specification complete with an estimate of cost for the required works.

7.10.3 All minor new works are priced and managed by the Operational Estates

Teams. 7.10.4 On-going revenue costs associated with maintenance requirements and

future replacement will also need to be met by the budget holder. 8 Identification of Stakeholders 8.1 This Policy follows the criteria set out in NTW(O)01 – Development and

Management of Procedural Documents, this Policy was circulated Trust-

wide for a four week consultation to the standard distribution listed below:

Corporate Decisions Team;

Local Negotiating Committee;

Consultant Psychiatrists;

Community Services Group;

Specialist Care Group;

Inpatient Care Group;

Psychological Services;

Clinical Governance and Medical Directorate;

Safeguarding;

Trust Allied Health Profession Service Steering Group;

Finance, IM&T, Estates and Performance;

Staff-Side;

Trust Pharmacy;


Workforce;

Communications. 9 Equality Impact Assessment – Appendix A 9.1 In conjunction with the Trust’s Equality and Diversity Officer this Policy has

undergone an Equality and Diversity Impact Assessment which has taken into account all human rights in relation to disability, ethnicity, age and gender. The Trust undertakes to improve the working experience of staff and to ensure everyone is treated in a fair and consistent manner. (See Appendix A – Impact Assessment Form).

10 Training – Appendix B 10.1 Providing a well maintained estate requires Estates staff to have specialist

skills. These training requirements will be covered in an Estates LOP. 10.2 It is the Trust’s objective to provide effective training that will:

Contribute towards making staff competent in their duties;

Help to avoid accidents and incidents;

Help avoid the financial costs of breakdowns. 10.3 It is not envisaged that non estates staff will require any specific training,

however, where any specific requirements are identified they will be addressed in the relevant Estates Practice Guidance Notes E-PGNS.

11 Implementation 11.1 As this Policy reflects current Estates Practice, it is considered that a target

date of November 2015 is achievable for the contents to be implemented within the organisation. E-PGN’s will be implemented as they are ratified by the Trust-wide Policy Group.

11.2 This will be monitored by the Estates and Facilities Management Group

during the review process. If at any stage there is an indication that the target date cannot be met, then the Group will consider the implementation of an action plan.

12 Monitoring and Compliance 12.1 There are a number of ways in which the compliance to this Policy and

Practice Guidance Notes will be monitored, these are set out below. 12.1.1 Premises Assurance Model


The NHS Premises Assurance Model (PAM) has been developed to promote the sharing of best practice and lessons learnt across providers with a common aim of improving the performance of premises utilised in the delivery of clinical services and delivering on premises aspects of the quality and productivity challenge. The focus of the model is on five key domains;

o Finance / Value for Money; o Safety; o Effectiveness; o Patient Experience; and o Board Governance.

12.1.2 The Estates Department shall undertake a PAM review on an annual basis

and report the findings to the Board and the Finance, Infrastructure and Business Development Committee.

12.2 On a periodic basis a statutory compliance audit will be undertaken by

external consultants appointed by the Director of Estates and Facilities. The methodology of the audit will be to review with the Estates Management Team through interviews and inspections of records how they are complying with statutes and how they are satisfactorily discharged.

12.3 A random selection of buildings are inspected by the Estates Operations

Manager to verify that statutory maintenance has been carried out, that all documentation is available and has been correctly certified. A report will be issued detailing the findings and will also highlight where corrective action is required. This will be reported to the Audit Committee on an annual basis.

13 Standards / Key Performance Indicators 13.1 A monthly report will be provided to the Operational Management Team on

the performance of the Operational Service and progress on corrective action sheets issued following audits. The Report will identify activity measures including:

Number of emergency Out of Hours calls;

Number of reactive maintenance requests received;

% of reactive maintenance requests completed within response times;

Number of statutory planned preventative maintenance jobs issued;


% of statutory planned preventative maintenance jobs completed within response timeframes;

Identify critical incidents;

Stock rotation and holding (annual reporting);

Complaints and comments;

Training undertaken;

Payments of invoices within 30 days;

Appraisals undertaken;

Sickness rate;

Legislative changes and implications. 14 Fair Blame 14.1 The Trust is committed to developing an open learning culture. It has

endorsed the view that, wherever possible, disciplinary action will not be taken against members of staff who report near misses and adverse incidents, although there may be clearly defined occasions where disciplinary action will be taken.

15 Fraud, Bribery and Corruption 15.1 The Trust takes fraud and corruption very seriously. All cases of actual or

suspected fraud and corruption will be vigorously and promptly investigated

and appropriate actions will be taken. Any cases of fraud and corruption will

ordinarily be investigated by the Trust’s Local Counter Fraud Specialist in

accordance with the Trust’s Fraud, Bribery and Corruption Policy and

Response Plan - NTW(O)23. The Trust fully appreciates that the employee

may be concerned about issues of confidentiality. In every case the Trust

will take reasonable steps to respect individual confidentiality as far as

reasonably practicable.

15.2 Where you have an honest and reasonable suspicion that fraud or

corruption has occurred, is occurring or is likely to occur, any concerns can

be raised directly with the Trust’s Local Counter Fraud Specialist, whose

contact details are available in Appendix 1 of the Trust’s Fraud Bribery and

Corruption Policy and Response Plan - NTW(O)23.

15.3 All staff and Contractors must comply with Trust Standing Orders, Standing

Financial Instructions and the Bribery Act 2010. Failure to do so may result


in disciplinary action and you may also be liable for prosecution and civil recovery proceedings.

16 Associated Documentation 16.1 A range of associated documents are linked to this Policy, these are set out

in more detail in Section 6 of this Policy.


Appendix A

Equality Analysis Screening Toolkit

Names of Individuals

involved in Review

Date of Initial

Screening

Review Date Service Area / Directorate

Paul McCabe May, 2014 May, 2018 Trust-wide

Policy to be analysed Is this policy new or existing?

NTW(O)32 Estates Operations and Maintenance

Policy

New

What are the intended outcomes of this work? Include outline of objectives and function aims

The purpose of the Policy is to set out details of the Trusts approach to Estates operations and maintenance and ensure that all the properties occupied by the Trust are maintained and operated safely and kept in good condition. This Policy pursues and expects the good upkeep of buildings, engineering plant and equipment by regular inspection and maintenance in line with the Department of Health documents (Health Technical Memorandum series) and other recognised guidance, legislation and standards. The Policy applies to all properties owned and maintained by the Trust. Properties leased, rented or occupied under lease or other occupancy agreement where the Trust is responsible for maintenance will also be operated and maintained in accordance with this Policy.

Who will be affected? e.g. staff, service users, carers, wider public etc.

All Staff

Protected Characteristics under the Equality Act 2010. The following characteristics have protection under the

Act and therefore require further analysis of the potential impact that the policy may have upon them

Disability No Impact

Sex No Impact

Race No Impact

Age No Impact

Gender reassignment

(including transgender)

No Impact

Sexual orientation. No Impact

Religion or belief No Impact

Marriage and Civil

Partnership

No Impact

Pregnancy and Maternity No Impact


Carers No Impact

Other identified groups No Impact

How have you engaged stakeholders in gathering evidence or testing the evidence available?

Through standard Policy consultation mechanisms

How have you engaged stakeholders in testing the policy or programme proposals?


For each engagement activity, please state who was involved, how and when they were

engaged, and the key outputs:


Summary of Analysis Considering the evidence and engagement activity you listed above,

please summarise the impact of your work. Consider whether the evidence shows potential for

differential impact, if so state whether adverse or positive and for which groups. How you will mitigate

any negative impacts. How you will include certain protected groups in services or expand their

participation in public life.

Not Applicable

Now consider and detail below how the proposals impact on elimination of discrimination,

harassment and victimisation, advance the equality of opportunity and promote good relations

between groups. Where there is evidence, address each protected characteristic

Eliminate discrimination, harassment and victimisation

Not Applicable

Advance equality of opportunity Not Applicable

Promote good relations between groups Not Applicable

What is the overall impact? Not Applicable

Addressing the impact on equalities Not Applicable

From the outcome of this Screening, have negative impacts been identified for any protected

characteristics as defined by the Equality Act 2010? NO

If yes, has a Full Impact Assessment been recommended? If not, why not?

Manager’s signature: Paul McCabe Date: 25th June, 2014


Appendix B

Communication and Training Check List for Policies

Key Questions for the accountable committees designing, reviewing or agreeing a new

Trust Policy

Is this a new policy with new training requirements or a change to an existing policy?

New Policy

If it is a change to an existing policy are there changes to the existing model of training delivery? If yes specify below.

No

Are the awareness/training needs required to deliver the changes by law, national or local standards or best practice?

Please give specific evidence that identifies the training need, e.g. National Guidance, CQC, NHSLA etc.

Please identify the risks if training does not occur.

Best Practice

Please specify which staff groups need to undertake this awareness/training. Please be specific. It may well be the case that certain groups will require different levels e.g. staff group A requires awareness and staff group B requires training.

All staff – awareness of their responsibilities

Is there a staff group that should be prioritised for this training / awareness?

Estates Staff

Please outline how the training will be delivered. Include who will deliver it and by what method. The following may be useful to consider: Team brief/e bulletin of summary Management cascade Newsletter/leaflets/payslip attachment Focus groups for those concerned Local Induction Training Awareness sessions for those affected by the new policy Local demonstrations of techniques/equipment with reference documentation Staff Handbook Summary for easy reference Taught Session E Learning

Estates Staff training requirements will be covered in Estates LOP. It is not envisaged that non estates staff will require any specific training, however, where any specific requirements are identified they will be addressed in the relevant Estates Practice Guidance Notes E-PGNS.

Please identify a link person who will liaise with the training department to arrange details for the Trust Training Prospectus, Administration needs etc.

Paul McCabe


Appendix B – continued

Training Needs Analysis

Staff / Professional Group Type of

Training

Duration

of

Training

Frequency of Training

Estates Staff

Copy of completed form to be sent to:

Training and Development Department,

St. Nicholas Hospital

Should any advice be required, please contact:- 0191 245 6770 (internal 56770)


Appendix C Monitoring Tool

Statement The Trust is working towards effective clinical governance and governance systems. To demonstrate effective care delivery and compliance, policy authors are required to include how monitoring of this policy is linked to auditable standards / key performance indicators will be undertaken using this framework.

NTW(O)32 – Estates Operations Policy Name Monitoring Framework

Auditable Standard / Key Performance Indicators

Frequency / Method / Person Responsible

Where results and any associated action plan will be reported to, implemented and monitored; (this will usually be via the relevant governance group).

1. In order that the Trust has assurance that this Policy is being complied with the Estates Department will compile evidence and complete the NHS Premises Assurance Model (PAM). PAM has been developed to promote the sharing of best practice and lessons learnt across providers with a common aim of improving the performance of premises utilised in the delivery of clinical services and delivering on premises aspects of the quality and productivity challenge.

How often – Annual basis

How will this be done -

Premises Assurance Model Review

Who will do this – Estates Department and periodically independently verified by Internal Audit

PAM review paper to the Trust Board (Presented by Director of Estates and Facilities)

2. Statutory Compliance Audit monitoring the following:

Fire maintenance

Asbestos

Water safety

Pressure systems

Gas

Lifting equipment

Electrical

The KPI is to maintain greater than 95% compliance.

How will this be done – the compliance data is recorded on an on-going basis on the C365 Compliance Software Package, this data is reported on a monthly basis to the Estates Officers Meeting and on a Quarterly basis to the Estates Governance, Quality and Performance and Risk Management Group.

Who will do this – Operational Estates Managers

Estates Officers Meeting and on a Quarterly basis to the Estates Governance, Quality and Performance and Risk Management Group.


NTW(O)32 – Estates Operations Policy Name Monitoring Framework

Auditable Standard / Key Performance Indicators

Frequency / Method / Person Responsible

Where results and any associated action plan will be reported to, implemented and monitored; (this will usually be via the relevant governance group).

3. Monitor the work activity of the Estates Department, specifically:

Defect requests – no KPI but monitor volume of activity.

Defects completed in timescale KPI 90%

PPM completion KPI 95%

How will this be done – the data is recorded on an on-going basis on the CAFM system, this data is reported on a monthly basis to the Estates Officers Meeting and on a Quarterly basis to the Estates Managers Group in the Estates and Facilities Quarterly Monitoring Report.

Who will do this – Operational Estates Managers

Estates Officers Meeting and on a Quarterly basis to the Estates Managers Group.

The Author(s) of each Policy is required to complete this monitoring template and ensure that these results are taken to the appropriate Quality and Performance Governance Group in line with the frequency set out.