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How to Assess the Risk with your Ventilation System Malcolm Thomas 01179221768 - 07814077474.

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Presentation on theme: "How to Assess the Risk with your Ventilation System Malcolm Thomas 01179221768 - 07814077474."— Presentation transcript:

1 How to Assess the Risk with your Ventilation System Malcolm Thomas

2 NP's 5/142 Ventilation Risks – Breaking the Law! Health Acts – Patient Safety - Infections Health and Safety at Work Act CoSHH – Local Exhaust Ventilation (LEV) Advisory Committee on Dangerous Pathogens. Building Regs. – Fresh air; HTM’s & HBN’s Medicine Acts – Quality assurance

3 NP's 5/143 HTM 03-01, Part B, Nominated Persons Designated Person Authorising Engineer (Ventilation) – AE(V) Authorised Person (Ventilation – AP(V) Competent Person (Ventilation – CP(V) Infection Control Officer Plant operator

4 HTM 0301; B. Hierarchy of Authority NP's 5/144 Designated Person Appointed senior executive (NHS Board level) responsibility of service Authorised person AP(V) Appointed qualified technical engineer (Specific to service) Authorising engineer AE(V) Appointed independent professional engineer (Specific to service) Board senior operational manager Informed client Competent person CP(V) Assessed and qualified craftsperson (Specific for service)

5 NP's 5/145 Duties and Responsibilities Designated Person Board level manager Direct link to Operational management Will communicate Board policy to Organisation Will require the service be provided Will require evidence that it has been (Annual audit report) Will present strategic operational plan to board

6 NP's 5/146 Duties and Responsibilities Authorising Engineer (Ventilation) – AE(V) Expert in Healthcare Ventilation Independent of Board and its organisation Conducts an audit of ventilation provision Provides independent advice Recommends candidates for AP(V) and CP(V) Reviews reports and documentation May provide training for AP(V) and CP(V)

7 NP's 5/147 Duties and Responsibilities Authorised Person (Ventilation) – AP(V) Manager with knowledge of Healthcare Vent. Trained in the duties of an AP Appointed in writing by Designated person Implements policy procedures to ensure the safe provision of ventilation in Healthcare Recommends candidates for CP(V) Overseas outside contractors standards

8 NP's 5/148 Duties and Responsibilities Competent Person (Ventilation) – CP(V) Craftsman / Technician grade Knowledgeable in Healthcare Ventilation Trained in the duties of an CP Appointed in writing by Designated person Carries out service and maintenance of ventilation systems in a Healthcare setting May oversee internal and external work

9 NP's 5/149 Duties and Responsibilities Infection Control Officer Consultant Microbiologist or Designated Infection Control Officer Advises Board on infection control issues Chairs Infection Control committee Provides support to AP(V) (who should be a member of the Infection Control committee)

10 NP's 5/1410 Annual Audit of Ventilation ElementCompliance 1Management issues 2Authorised Person 3Competent Person 4Infection Control 5LEV systems 6Critical Healthcare systems 7Fire issues 8Plant locations 9Energy efficiency 10Support issues

11 NP's 5/1411 Typical initial Audit report Element 1) - Management IssuesComment Designated personMr. C. Y. Arse – Director of Estates Authorising Engineer (Ventilation) appointed?Yes – Malcolm Thomas Authorised Person (Ventilation) appointed?Nominated only Competent Person(s) (Ventilation) appointed?Nominated only Infection Control Person appointed?No Inventory of LEV systems available?No Inventory of specialised healthcare systems?No Are all systems uniquely identified?Not always Is there an up to date condition survey?No Is there a system replacement programme?No

12 NP's 5/1412 Typical initial Audit report Element 2) - Authorised Person (Ventilation)Comment NameMr. I.M. Trying – Possible Mr. N. Bothered - Possible PositionIT – Estate Manager NB – Assistant Estate Manger Work locationNonsuch Hospital Training recordsIT - None NB – 2 weeks Ventilation at Eastwood Park c1992 No training but local knowledge Area / site of responsibilityNonsuch Hospital Element 3) - Competent Person(s) (Ventilation)Comment Name(s)Mr. E. Skives (Mech) – Possible Mr. R. Keen (Elec) - Possible PositionES – Mechanical craftsperson RK – Electrical craftsperson Work locationNonsuch Hospital Training recordsES – None RK - None Area / site of responsibilityNonsuch Hospital

13 NP's 5/1413 Typical initial Audit report Element 5) - LEV SystemsComment Location of inventoryNone (See Appendix 1) Are all LEV systems listed?No Is each system clearly labelled and its area served identified? No Does each system have a log book or Information file? General file of LEV system annual inspection reports Does the file contain design, commissioning, and verification information? See above Does the file contain records of repair, maintenance and routine inspections? On maintenance system computer Is each system subject to a statutory inspection every 14 months? Yes (Hazards Ltd.) Is there a designated “user” contact for each system? Department head Is there a “Hand over / Hand back” and/or PtW system in operation when work is being undertaken on the system Yes

14 NP's 5/1414 Preliminary Inventory of LEV systems LEV ID Department LEV location LEV DescriptionComment None Estates Welding shop Welding fume extract system Crap None Carpenters workshop Multi point wood working machinery ducted extract system No access – door locked None Fracture clinic ? Mobile plaster saw and extract (DeSouter) 3 systems identified in annual reports NoneEndoscopy?Decontamination room This is not an LEV system NoneBiochemistry? Fume cupboard None Histology inc Mortuary ? Safety cabinets, cut up benches and fume cupboards 8 systems identified in annual reports NoneDental? 11 systems identified in annual reports NonePharmacy Aseptic suite I would expect to find a fume cupboard or Class2 safety cabinet in Pharmacy?

15 NP's 5/1415 Typical initial Audit report Element 6) – Specialised Healthcare SystemsComment Location of inventoryNone (See Appendix 2) Are all specialised healthcare systems listed?No Is each system clearly identified/labelledYes Does each system have a log book or Information file? No Does the file contain design, commissioning, validation and verification information? No Is each system subject to an annual verification? Yes Is each system subject to routine maintenance? On maintenance system computer Is there a designated “user” contact for each system Department head Is there a “Hand over / Hand back” and/or PtW system in operation when work is being undertaken on the system Yes

16 NP's 5/1416 AHU with Plate Heat Exchanger

17 NP's 5/14 17 UCV Theatre ventilation

18 NP's 5/1418 Typical initial Audit report ElementCompliance Management Issues25% Authorised Person(s) (Ventilation)10% Competent Person(s) (Ventilation)10% Infection Control Person90% LEV Systems60% Specialised Healthcare Systems60% Fire Issues35% Plant Locations50% Energy efficiency35% Support aspects30%

19 How did they do? How would you do? NP's 5/1419


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