HTM 00 Final

Policies and principles Health Technical Memorandum 00 Best practice guidance for healthcare engineering
Health Technical Memorandum

00: Policies and principles of
healthcare engineering
ISBN 0-11-322754-X
www.tso.co.uk
9 780113 227549
Health Technical Memorandum 00:
Policies and principles of healthcare
engineering
Health Technical Memorandum 00 Policies and principles of healthcare engineering
Crown copyright 2013

Terms of use for this guidance can be found at http://www.nationalarchives.gov.uk/doc/open-government-licence/
ii
Preface
About Health Technical Memoranda main source of specific healthcare-related guidance for
estates and facilities professionals.
Health Technical Memoranda (HTMs) give
comprehensive advice and guidance on the design, The core suite of nine subject areas provides access to
installation and operation of specialised building and guidance which:
engineering technology used in the delivery of healthcare. is more streamlined and accessible;
The focus of Health Technical Memorandum guidance encapsulates the latest standards and best practice in
remains on healthcare-specific elements of standards, healthcare engineering, technology and sustainability;
policies and up-to-date established best practice. They are
applicable to new and existing sites, and are for use at provides a structured reference for healthcare
various stages during the whole building lifecycle. engineering.
Figure 1 Healthcare building life-cycle
DISPOSAL CONCEPT
RE-USE
DESIGN & IDENTIFY
OPERATIONAL OPERATIONAL
MANAGEMENT REQUIREMENTS
Ongoing SPECIFICATIONS
MAINTENANCE TECHNICAL & OUTPUT
Review
PROCUREMENT
COMMISSIONING
CONSTRUCTION
INSTALLATION
Healthcare providers have a duty of care to ensure that Structure of the Health Technical
appropriate governance arrangements are in place and are Memorandum suite
managed effectively. The Health Technical Memorandum
series provides best practice engineering standards and The series contains a suite of nine core subjects:
policy to enable management of this duty of care. Health Technical Memorandum 00
It is not the intention within this suite of documents to Policies and principles (applicable to all Health
unnecessarily repeat international or European standards, Technical Memoranda in this series)
industry standards or UK Government legislation. Where Health Technical Memorandum 01
appropriate, these will be referenced. Decontamination
Healthcare-specific technical engineering guidance is a Health Technical Memorandum 02
vital tool in the safe and efficient operation of healthcare Medical gases
facilities. Health Technical Memorandum guidance is the
iii
Health Technical Memorandum 03 Electrical Services Electrical safety guidance for low
Heating and ventilation systems voltage systems
Health Technical Memorandum 04 In a similar way Health Technical Memorandum 07-02
Water systems represents:
Health Technical Memorandum 05 Environment and Sustainability EnCO2de.
Fire safety
All Health Technical Memoranda are supported by the
Health Technical Memorandum 06 initial document Health Technical Memorandum 00
Electrical services which embraces the management and operational policies
from previous documents and explores risk management
Health Technical Memorandum 07
issues.
Environment and sustainability
Some variation in style and structure is reflected by the
Health Technical Memorandum 08
topic and approach of the different review working
Specialist services
groups.
Some subject areas may be further developed into topics
DH Estates and Facilities Division wishes to acknowledge
shown as -01, -02 etc and further referenced into Parts A,
the contribution made by professional bodies,
B etc.
engineering consultants, healthcare specialists and
Example: Health Technical Memorandum 06-02 NHS staff who have contributed to the production of
represents: this guidance.
Figure 2 Engineering guidance

FIC DOC
H SPECI UM
L T EN
A TS
HE
HTM 08
HTM 01
Specialist
Services Decontamination
S T R Y S TA N D A
DU RD
IN S
& EUROPEAN
NAL ST
HTM 07
IO HTM 02
T
AN
NA
Environment & Medical

DA
H E A LT H S P E
INTER
CUMENTS
Sustainability Gases
RDS
HTM 00
RDS
INTER
Policies and
Principles
DA
NA
AN
IO
ST
T
NA
DO
HTM 06 L& N HTM 03

Electrical
IN EUROPEA S Heating &
DU D
C
Services STR AR Ventilation

IF I
IC
Y S TA N D Systems
IF
C
EC
D
HTM 05 HTM 04
O
Fire
SP
U Water
C
M Safety Systems H
EN T
TS AL
HE
iv
Executive summary
This Health Technical Memorandum (HTM) provides Designers should ensure that they read the HTM as a
general guidance on the engineering, technical and whole, since further engineering guidance may be
environmental aspects of healthcare building design. outlined and cross-referenced throughout.
Specific guidance for individual clinical settings is
available within appropriate Health Building Notes.
v
vi
Contents
Preface
Executive summary
1 Policy, context and requirements 1
Aims
Scope
Recommendations
Engineering governance
Engineering services
Management of access to engineering services
Development planning
Distribution requirements
Access
Working in confined spaces
Reviews
Exemplar emergency procedures
Sample procedure matrix
Resilience and emergency preparedness
Meeting risk requirements
Resilience of electrical supplies
Mobile units
Utilities
System capacity
Utility supplies
Life expectancy of engineering plant and equipment
Metering
Access to engineering service outlets and controls
Infection control
Space requirements for engineering plant and services
Mechanical services
Heating
Ventilation and cooling
Hot and cold water systems
Acoustics
Internal drainage
Building management systems
Fire safety
General fire safety standards
Fire detection and alarm systems
General electrical services
General electrical installations
Electromagnetic compatibility
Primary electrical infrastructure
Socket-outlets for cleaning equipment
Lighting systems
vii
General
Emergency lighting
External lighting
Patient/staff and staff emergency call systems
Security
CCTV installation
External services
Car park barriers
Door access control systems
Entertainment systems
IT and wiring systems
General
Telecommunication systems
IT systems
Pneumatic tube systems
Lifts
Lightning protection systems
Audio induction loop systems
Sustainability and energy efficiency
Validation and handover of engineering installations
2 Statutory and legislative requirements 22
Health and safety
Regulations, Approved Codes of Practice, Standards and guidance
Other commonly cited legislation
Electrical
Mechanical
Environment
Radiation
Fire
Food
Public health
Risk and/or priority assessment
3 Professional support 26
Management and responsibility
Management structure
Professional structure
Roles and responsibilities
Designated Person (DP)
Trust Senior Operational Manager (SOM)
Authorising Engineer (AE)
Authorised Person (AP)
Competent Person (CP)
Variation by service
4 Operational policy 29
Operational considerations
Records/drawings
Security
Monitoring of the operational policy
Contractors
Medical equipment purchase
5 Emergency preparedness and resilience 31
Overview
Creating an emergency plan
viii
Contents
System resilience, planning and design

Services and priorities
External impact
Security
Responsibility
Staff functions
Communications
Incident manager
Resource manager
Emergency procedure manual owner
Testing the plan
6 Training, information and communications 35
Overview
Building occupiers
Service and maintenance staff
The required workforce
Improving the workforce profile
Criteria for operation
7 Maintenance 37
Overview
Maintenance contractors
Maintenance policy
Tools
Instructions
Maintenance frequency
Maintenance planning
Original commissioning tests
Original and amended drawings
Functional tests
Inspections prior to recommissioning
Planned maintenance programme
Design of a planned maintenance programme
Review of the planned maintenance programme
8 References 40
ix
x
1 Policy, context and requirements
1.1 This Health Technical Memorandum provides (v) Fire safety (Health Technical Memorandum
general guidance on the engineering, technical and 05)
environmental aspects of healthcare building
(vi) Electrical services (Health Technical
design. Specific guidance for individual clinical
Memorandum 06)
settings is available within the clinical topic itself.
(viii) Environment and sustainability (Health
1.2 Consultation should take place at project and
Technical Memorandum 07)
design team level to ensure understanding of key
issues, healthcare delivery and the appropriate (ix) Specialist services (Health Technical
standards for healthcare engineering services. Memorandum 08)
1.3 Designers should ensure that they read this (x) Other existing HTM 2000 series guidance
publication as a whole, since further engineering documents.
guidance may be outlined in and cross-referenced 1.5 The design, construction and operation of health
within other sections. and community care bulidings should comply with
1.4 Health Technical Memorandum 00 Policies and all relevant aspects of engineering guidance,
principles of healthcare engineering covers the statutory requirements and best practice to ensure
following issues: high-quality engineering installations and services
suitable for their application.
a. overview of engineering services guidance;
1.6 The healthcare version of the National Engineering
b. statutory and legislative requirements;
Specifications (nes) replaces the old Model
c. professional support; Engineering Specifications and is designed to help
project teams with writing specifications.
d. operational policy;
e. training and workforce development; Aims
f. emergency procedures and contingency 1.7 Everyone concerned with the managing, design,
planning; procurement and use of a healthcare facility should
g. training, information and communications; understand the requirements of the specialist,
critical building and engineering technology
h. maintenance; involved.
j. engineering services. Guidance on specific types 1.8 Only by having a knowledge of these requirements
of engineering services can be found as follows: can the organisations board and senior managers
(i) Decontamination (Health Technical understand their duty of care to provide safe,
Memorandum 01) efficient, effective and reliable systems which are
critical in supporting direct patient care. When this
(ii) Medical gases (Health Technical understanding is achieved, it is expected that (in
Memorandum 02) line with integrated governance proposals)
(iii) Ventilation systems (Health Technical appropriate governance arrangements would be put
Memorandum 03) in place, supported by access to suitably qualified
staff to provide this informed client role, which
(iv) Water systems (Health Technical
reflect these responsibilities.
Memorandum 04)
1.9 By locally interpreting and following this guidance,
boards and individual senior managers should be
1
able to demonstrate compliance with their practical measures have been taken to minimise the
responsibilities and thereby support a culture of elements giving rise for concern.
professionalism which instils public confidence in
the capability of the NHS at local level. Recommendations
1.16 Boards and chief executives as accountable officers
Scope should use the guidance and references provided:
1.10 Healthcare premises are dependent on the safe and
w
hen planning and designing new healthcare
secure function of critical engineering services, the
facilities or undertaking refurbishments;
application of sound environmental measures, and
the support of key services. There are some w
hen developing governance systems which take
common principles that apply across the full range account of risk;
of engineering guidance and support the wider to establish principles and procedures which:
interface of all healthcarerelated equipment and
its environment. (i) recognise and address both corporate and the
individuals responsibilities;
1.11 The concept of providing and maintaining safe and
secure critical services carries a high priority and (ii) recognise the link between critical
applies across the widest range of applications. It engineering systems and emergency
must apply to patients, staff and the general public, preparedness capability;
that is, all users of the healthcare environment. (iii) reflect the important role that engineering
1.12 In a similar way, the duty of care in operational polices and principles, as implemented by
performance can contribute to the overall efficiency suitable qualified professional and technical
and safety of a healthcare organisation. Accessibility staff, can have in support of direct patient
to suitably qualified and competent staff is a key care.
factor when considering governance arrangements. 1.17 Once boards and chief executives have embraced
1.13 Evidence suggests that a comfortable healthcare the principles set out within this guidance and
environment can have a strong influence on the taken the necessary actions, their duty of care
healing cycle. This needs to be achieved in a responsibilities are more likely to be fulfilled, as will
sensitive way, with design having regard to the their ability to maintain public confidence in the
function and purpose of the specific and adjoining NHS at local level.
areas.
1.14 Staff and services must be resilient to ensure
Engineering governance
continuity of business and the safety of patients 1.18 Responsibility and, more specifically, the duty of
and staff, and be capable of providing a suitable care within a healthcare organisation are vested in
response to maintain a level of healthcare in all the management board and its supporting
circumstances. This guidance addresses the general structure.
principles, key policies and factors common to all
1.19 Engineering governance is concerned with how an
engineering services within a healthcare
organisation directs, manages and monitors its
organisation. Key issues include:
engineering activities to ensure compliance with
general health and safety; statutory and legislative requirements.
professional support; 1.20 Systems and processes need to be in place, backed
up with adequate resources and suitably qualified
operational and training requirements;
and trained staff.
emergency preparedness;
1.21 Healthcare organisations should ensure that sound
workforce planning and capability; internal controls, safe processes, working practices
maintenance. and risk management strategies are in place to
safeguard all their stakeholders and assets to prevent
1.15 To determine the right level of approach will often and reduce harm or loss.
require an assessment of the risk and an evaluation
of the factors that remain when reasonable and
2
Engineering services commissioning, maintenance, and future

upgrading.
Management of access to engineering services 1.28 It should also be verified that there are adequate
1.22 Healthcare organisations have the responsibility to provisions made for additional services and
ensure that all service installations are specified, dismantling during the life of the system.
designed, installed, commissioned and maintained
(including future upgrade) with consideration for Development planning
services modifications and dismantling during the 1.29 It is essential to ensure that both engineering and
life of the building. architectural aspects are developed simultaneously
1.23 To satisfy these requirements, it is recommended from project inception. This should ensure that
that organisations: systems are safely integrated in terms of location,
distribution and future developments, and that
a. designate a person responsible to coordinate all service resilience is planned from the start.
the engineering services to ensure that the
services do not have any adverse effects on each 1.30 The architectural design should permit sufficient
other, the structure and personnel safety; space for services. Provision of extra space to allow
for future development is considered as best
b. ensure that a project file is available for all new practice.
projects, alterations or extensions, regardless of
the size of the project. The file should contain 1.31 Accurate and detailed drawings are essential for
specifications, drawings, and maintenance providing space requirements. However, these may
information including access and safe disposal not be available at the early design stage. An
at the end of its useful life; estimate of space requirements may have to be
made on preliminary drawings in order to avoid
c. ensure that adequate space is provided for costly revisions.
installation and maintenance staff and
appropriate access to services; Distribution requirements
d. adequately brief the designers on the current 1.32 An assessment of the distribution requirements
and future maintenance policies; should be considered, taking into account
e. ensure that any new work, alterations or communication, area, plant and distribution. This
modifications do not restrict existing access to must be related to the specific size and shape of the
plant and equipment. building etc.
1.24 Details of any asbestos survey must be made 1.33 Accommodation of vertical services will be decided
available to the design team and any contractors at an early design stage. The information may be in
prior to carrying out any work. the form of total area requirements to be divided
later as design progresses.
1.25 The Control of Asbestos Regulations 2006 includes
duties to protect those who come into contact with 1.34 Resilience and flexibility of services distribution
asbestos unknowingly or accidentally. The survey should be included at an early stage.
report should include details of any asbestos- 1.35 Departments that require heavily-loaded services
containing materials, their condition and location, should be grouped together and located near to the
and when they were last inspected. distribution centre if possible. This avoids large
1.26 A zoning policy allocating particular zones for runs and therefore distribution losses. Dependent
specific services should be agreed early in the design on the building design, it may be advantageous for
stage. The policy should also allocate crossover services to follow the main communication routes.
zones, minimum separation distances and shielding 1.36 Generally, the energy centre is the first plantroom
requirements in the event of it not being possible to to be installed on-site. This allows the main service
meet these requirements. routes to be determined. The next step would be to
1.27 Before putting any engineering systems into service, determine areas required for other plantrooms
the installation should be inspected, and it should including, for example, those at rooftop level.
be verified that access is available for 1.37 Consideration should be given to maximising the
flexibility of engineering services to allow the
3
maximum possible changes in the use of hospital a. most, if not all, services may require
departments. modification or renewal during the useful life of
the building. Accommodation should be
1.38 In multi-storey buildings:
planned for this to occur, taking into account
a. most flexibility is achieved by a small number of weight, size and configuration of the item.
large vertical ducts with adequate provision for During non-emergency renewals, it may be
horizontal space above ceiling level and below possible to remove door frames, windows,
structural members; partitions and other non-structural items. The
b. generally, less flexibility is achieved by a large renewal or modification of minor items does
number of smaller vertical ducts with ceiling not usually create problems except where piping
spaces for horizontal distribution as necessary; or cable lengths are restrictive;
c. the omission of space above ceilings produces b. the destruction of finishes to open up a trench
the least flexible arrangement. or vertical duct or existing access could be more
economic than the provision of expensive but
1.39 Convenient access should be provided to all service rarely-used permanent access. Costs versus
spaces. savings must be considered with regard to the
1.40 In single-storey buildings: cost of inconvenience/ disruption to functions
incurred at the time of replacement.
a. sufficient headroom should be allowed for
installation and maintenance purposes; Working in confined spaces
b. if a service trench is provided, where practicable, 1.46 A confined-space permit-to-work system should be
removable covers should be provided over the established, and personnel trained in the use of the
complete length of the trench. system.
Access 1.47 The system should address the following points:
1.41 Access to services should be considered at every assessment of the task to be undertaken;
stage of both the architectural and engineering identification of the potential risks/hazards;
design process.
ventilation;
1.42 The frequency of access required should be the
main factor considered. a ir quality testing, prior to entry and
continuously during access requirements;
1.43 Frequent access:
provision for special tools and lighting;
a. immediate access is required for plant, valves,
switches and other controls requiring frequent working methods;
attention for safe operation and maintenance; implementation of the working methods;
b. if enclosed, the access should be by door or monitoring of compliance of the system;
panel;
actions in case of emergency;
c. adequate clearance should be provided for ease
communication;
of working.
first-aid.
1.44 Intermittent access:
a. items that require access at intervals (for Reviews
example monthly) can be provided by means of
floor traps, removable panels in walls, false 1.48 Management should conduct regular reviews of the
ceilings and so on. It is recommended that effectiveness of the healthcare organisations
access panels be fitted by means of retained engineering structure and systems. The review
quick-release mechanisms rather than screws should cover all controls, including strategic,
and cups. operational, safety and engineering risk
management.
1.45 Renewal or modification of service:
4
Exemplar emergency procedures types of format which may be used, and the
different levels of technical content which may be
1.49 The following procedures have been prepared by appropriate on different sites.
trust estates and facilities management (EFM)
personnel to meet the needs of their own 1.51 Further procedures will be required within a
organisations during an emergency. healthcare organisation, and a regular review is
important to ensure that directives, staff and
1.50 They are not intended to be appropriate or equipment remain current.
definitive for all sites, but they give an idea of the
Procedure for electricity supply failure

Operational procedure reference no: ..
Hospital location: ..
Healthcare description (A&E, CCU, Ward 6 etc): ..
Key areas of equipment likely to be

Lighting, medical equipment, fixed and/or mobile computers and associated equipment, other non-medical
equipment (catering, waste disposal etc), communication systems (telephones, nurse call etc), heating and
ventilation.
Risk assessment
This procedure is linked to the overall hospital site procedure for failure of electricity supply and departmental
risk assessment register. This document should be reviewed on a regular basis and especially if any alterations to
equipment function, staff and responsibility take place.
Aims
This emergency procedure is intended to highlight the key issues that may arise at departmental level in the event
of electrical power failure. It is appreciated that this may be the result of a full site power failure, but it may also
be the result of a local failure for which notification will be necessary. The main aim is to provide a structured
approach to the safety of patients and staff and to minimise the risk associated with an electrical failure.
Identification of failure
This may be indicated by the failure of key observable elements, for example lighting and computer displays, but
may also be indicated by alarm signals from monitored supply panels on medical equipment, services and
systems.
5
Major supply failure

In the event of an obvious full electrical failure, do not wait for the restoration of supplies by generator, but
immediately take action.
Staff should safely complete or suspend any procedure being undertaken and prioritise their attention on the
most critical equipment and/or patients. Local standby supplies and equipment-based systems should be checked.
Where necessary, manual intervention should be started to ensure the safety of patients.
When supply is restored by generator, staff should ensure that all essential equipment is functioning correctly
and, where necessary, transfer equipment or patients onto essential supplies.
On restoration of the normal supply, staff should check that all systems and equipment have reset to normal.
Continued supply failure

If full supply loss should continue for several minutes, immediately contact the hospital duty manager via the
switchboard. The switchboard will also contact the duty engineer for attention.
Within the department, prioritise duties to ensure safety of patients and take preventative measures, where
possible, to minimise the workload.
In the event that it is identified as a local failure, contact the duty manager to gain further staff support from
other adjacent unaffected areas, or arrange to move the most critical patients to other departments.
Partial supply failure

If only part of the departments electrical systems fail, it is unlikely that standby systems will restore supplies
in the immediate term. First, minimise the risk to patients and identify the extent of the failure. Contact the
switchboard, who will alert the duty engineer and duty manager. Continue to monitor the situation and move
critical equipment and/or patients to fully supported areas where possible.
Awareness and training

Electrical supply failure is one of the most wide-ranging impacts on the normal running of a department. It is
likely that staff will be engaged in the regular testing of the standby systems, but further local awareness should
be engaged to ensure that all staff are aware of the departmental issues and the effects of a longer-term and full
failure. Where possible, this should be carried out at the workplace, but with minimum impact on patients.
Senior managers should liaise with the estates engineer to arrange simulation and practical support.
Emergency procedures should be an essential part of new staff induction to the department to ensure all local
issues are fully understood.
Review procedure
From incident experience and training evaluation, this procedure and any supporting information should be
reviewed and amended as necessary to ensure the document remains up-to-date and definitive for the
department.
This document was first issued on: .. (Date)
Amendments: ... (Brief details and date)
Plan approved and accepted by:
Senior manager
Head of department: .
6
Procedure for water contamination

Operational procedure reference no: .........................................................
Other relevant procedures: Engineering scheme to provide piped fresh water supplies
Scope
The following procedure is designed to instruct and advise on the operational requirements for dealing with
contamination of the water supply. It is not considered a definitive guide as the particular circumstances of the
incident will ultimately determine the course of action taken. It will attempt to highlight the responsibilities of
estates staff, clinical staff and on-call administrators.
Causes
Water may become contaminated in a number of ways, including:
contamination of the incoming water supply to the hospital site;
contamination due to substances inadvertently or maliciously added to the water storage systems;
contamination caused by the corrosion or decay of materials in contact with the water supply, for example
rusting metal and dead animals;
cross-contamination of water supply due to the effect of a process carried out on site by staff or contractors
where the safety devices are inadequate or non-existent, for example cross-contamination due to siphonage
from drains and stagnant water;
misoperation/failure of water treatment plant;
migration between domestic hot and cold water services.
Effects
The possible effects of contamination are varied, and will depend on the severity and degree of the
contamination. However, further investigation should be carried out if:
staff complain about the taste of the drinking water;
the water is discoloured;
the water has a distinctive smell (this could be the result of chemicals (for example chlorine), acid, sewage or
decaying matter);
the water appears normal but people using it have become sick.
Investigation and response

The size of the affected area must first be ascertained. This will give some indication of the extent of the problem
and may help to identify the source of the contamination.
The following actions may or may not require to be taken, depending on whether part of or the whole water
system has been contaminated:
inform the senior staff of affected departments to cease using the water;
contact the local water authority. The contamination may have originated from the main water incoming
supplies; there is likely to be an obligation not to contaminate the public water network;
take samples as necessary to determine the nature of the contamination;
once the extent has been determined, an assessment should be undertaken as to the nature of the
contamination. The use of microbiology staff is recommended;
7
isolate the affected area from the main supply to prevent further contamination;
take samples at various points within the affected area(s) for future analysis;
contact on-call or emergency administrative staff and advise them to arrange a supply of fresh water for areas
requiring it;
dependent on the nature of contamination, the cause may be obvious or easily located. If this is not possible,
carry out a systematic investigation of water supply systems;
if the cause of the contamination is located, isolate the contamination and carry out necessary works to resolve
the situation;
inform medical staff of the nature of the contamination and await advice on the clinical effect before restoring
the water supply to the area;
thoroughly flush all pipework (run taps, flush toilets, bidets etc) until further analysis shows no trace of
contamination;
when the water quality is restored and confirmed by medical or microbiology staff, allow normal use to
continue.
Further work
Study how the contamination has occurred and carry out preventative work if possible to avoid recurrence.
Review the operational procedure for the incident and modify as necessary.
Note the date and time of the incident, action taken and by whom, for future reference.
Relevant drawing nos: ..........................................................
Additional information
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
..............................................................................................................................................................................

Board member: .......................................................................................
Risk assessment
This document is linked to risk assessment no ..................... It should incorporate existing controls contained in
the risk assessment and should be modified if any changes to the risk assessment are made.
8
Procedure for piped medical gas failure

Operational procedure reference no: .........................................
Hospital location: ...........................................................
Plant or system description: .................................................
Systems in use:
Oxygen ref ................. Nitrous oxide ref .................
Nitrous oxide/oxygen ref ................. Medical air ref .................
Aims
The aim of this emergency procedure is to provide guidance and a structured approach to the management
response in the case of a major failure in supply of piped medical gases, and to safeguard patients at risk from any
such failure.
Identification of the source and nature of failure

This will normally be indicated by an alarm actuation at one of the following locations:
telephone exchange;
porters lodge;
boiler room;
main corridor;
ward 1;
ward 2;
ward 3.
On actuation of the alarm, the hospital switchboard must be contacted with a description of the alarm legend.
The switchboard operator will immediately contact the Duty Engineer or Duty Authorised Person (responsibility
allocated in the medical gas pipeline system (MGPS) operational policy) for the initial response and investigation
of the fault, and will follow switchboard procedures.
The situation will be assessed by the Duty Engineer and categorised accordingly as a minor or major failure of the
system.
Minor failure, not life-threatening

The Duty Engineer will contact the Authorised Person to have repairs carried out in accordance with Health
Technical Memorandum 02-01, and inform the Duty Senior Manager of the cause and outcome of the situation.
Permits-to-work will be issued in accordance with Health Technical Memorandum 02-01.
Major failure of supply

If a major failure of supply has occurred, the following procedure is to be followed by the Duty Engineer, who
will carry out the initial assessment and arrange for the following personnel to be contacted:
Authorised Person Senior Manager Senior Pharmacist Senior Nurse Senior Medical Officer/Surgeon
The situation will be re-assessed by the Senior Manager and a decision taken as to whether the major incident
plan is also implemented and brought into operation, together with the procedures outlined in this document.
9
Damage control
The cause and result of the damage to the system should be investigated by the Duty Engineer/Authorised
Person.
Drawings and schematics should be readily available.
Steps should be taken to limit the amount of disruption, and a temporary supply should be secured by either
valving or capping of damaged areas to enable emergency supply banks to cope during repairs. Failing this,
sufficient portable cylinders should be provided at the point of use.
Following damage limitation, valve-off the damaged section where possible and ensure back-up supply banks are
functioning.
Team members attendance should be confirmed. They should assemble at a predetermined location where
control will be handed from the Duty Engineer/Duty Estates Manager to the responsible Senior Manager.
The areas of responsibility for the various team members are outlined, but this list is by no means exhaustive and
should be further developed in the light of knowledge as the incident develops.
Areas of responsibility
Telephonist
First-line communications.
Initial coordination of response.
Assists with all communications and logs calls and responses.
Senior Manager
Coordination of all team members.
Recovery strategy and repair coordination.
Documentation.
Senior Pharmacist
Ordering and procurement of gases.
Purity checks on reinstatement of supply.
Senior Medical Officer, Surgeon/Senior Nurse

Clinical prioritisation of supply requirements.
Liaison with doctors and nursing staff.
Movement of patients where necessary.
Advice to other team members on clinical criteria.
Duty Engineer/Authorised Person

Initial response and coordination.
Damage limitation and securing supply.
Diagnosis and repair of failure.
10
Provision of temporary supplies (pipeline).

Testing and verification on reinstatement.
Recommissioning and documentation.
Designated Manager, Hotel Services

Provision of portering staff for moving and changing cylinders.
Liaison with other team members for manpower requirements.
Organisation of patient transport where needed.
Organisation of transport for support services.
Liaison with outside agencies and press.
Communications.
Debriefing
Following return to normality, a team debriefing should be held to review the emergency procedure and update
or correct any apparent weaknesses.
Review procedure
This procedure will be reviewed following any change in personnel, equipment, materials and environment or
following any change. It will be reviewed at regular intervals not exceeding 12 months.
Training and information

All staff involved will receive adequate training and instruction to enable them to carry out these procedures with
confidence during an emergency. This training will be recorded in the log attached, and updated on a regular
basis.
Amendments
Board member: .....................................................................
Risk assessment
This document is linked to risk assessment no ..................... It should incorporate existing controls contained in
the risk assessment and should be modified if any changes to the risk assessment are made.
11
Gas
Fire
Lifts
water
12
failure
Paging
Boilers
systems
Medical
Heating
Asbestos
checklist
Building
Kitchens
Flooding
Drainage
Infestation
Explosions
equipment
engineering
Incinerators
Operational
Refrigerators
management
Air pollution
Domestic hot
Clinical waste
(eg heatwaves,
Other extreme
Air-conditioning
Electricity supply
cold/frozen spells)
Operating theatres
Laboratory failures
weather conditions
Piped medical gases

Define ownership of the problem?
Will patient/Public/Staff safety/care be affected?
Will evacuation be required?
Sample procedure matrix
Risk of fire outbreak, or reduced fire-fighting ability?

Consider impact on electricity supply?
Consider impact on gas supply?
Consider impact on water supply?
Consider impact on drainage?
Consider impact on other services?
Increased risk of legionella?
Consider impact on site security?
Impact on fire alarms?
Will medical gases be affected?
Is there an impact on clinical waste?
Agree responsibility boundaries

Clinical department procedures?
Control of Infection Team involvement?
Do public relations need to be addressed?
Consider Service Level Agreements with purchasers?
Involve commercial services?
Record Trust personnel contact details?
Locate supply of specialist equipment?
Locate approved subcontractors?
Record specialist contractor contact details?
Keep records of actions taken?
Operational
Risk of fire outbreak, or reduced fire-fighting ability?
Consider Service Level Agreements with purchasers?

checklist
Will patient/Public/Staff safety/care be affected?
Record specialist contractor contact details?

Do public relations need to be addressed?
Control of Infection Team involvement?
Record Trust personnel contact details?

Consider impact on electricity supply?
Locate supply of specialist equipment?

Is there an impact on clinical waste?
Consider impact on other services?
Define ownership of the problem?
Consider impact on water supply?
Consider impact on site security?
Locate approved subcontractors?

Clinical department procedures?
Consider impact on gas supply?
Agree responsibility boundaries

Will medical gases be affected?
Keep records of actions taken?

Consider impact on drainage?
Involve commercial services?

Will evacuation be required?
Increased risk of legionella?
Impact on fire alarms?

Sewage plant
Sterilization
Telephones
Transport incidents
Water
contamination
Water supply
Water treatment
Resilience and emergency preparedness secondary power sources such as emergency

standby generators and uninterruptible power
Meeting risk requirements supplies (UPS) should be established following the
assessment of clinical and business continuity risks.
1.52 Clinical risk, business continuity risk and safety
factors are critical and with them the requirement 1.57 It may be appropriate to provide separate essential
for safe and resilient engineering services in support and non-essential small power distribution systems
of the environment and equipment used to fulfil or a dual unified system. This will enhance the
the functions of the premises. resilience of the electrical services as well as
facilitating the ability to test and repair faulty
1.53 The design and operation of health and community
system components whilst sustaining continuity of
care premises should therefore take full account of supply to operational areas. Electrical supply
planned and potential future increases in clinical resilience provisions should comply with the
and business continuity risks appertaining to the requirements of Health Technical Memorandum
functions of the premises and ensure that all key 06-01 Electrical services supply and distribution.
engineering services are sufficiently robust to
continue operating satisfactorily during emergency Mobile units
situations so as to minimise the risk of harm to
patients, staff and visitors. 1.58 Certain clinical services may be delivered from
mobile units, for example:
1.54 This should include consideration of engineering
service requirements during loss of normal mobile breast screening units;
incoming utility and local supplies and during mobile CT/MRI scanning units;
activation of emergency preparedness plans.
mobile theatres.
1.55 See also Chapter 5, Emergency preparedness and
resilience. 1.59 These units may be self-contained or may need to
be connected to mains services.
Resilience of electrical supplies 1.60 Where connection to mains services is required,
1.56 The resilience of the electrical supply and these should be provided in appropriate locations
distribution system and the capacity of any taking into account the following factors:
13
external access arrangements; Access to engineering service outlets

supplies capacities; and controls
t he need for isolation and protection of mains 1.66 The design and positioning of engineering service
services; outlets and controls should take account of safety
and access requirements. This includes
earthing arrangements;
consideration of the following:
t he need for weatherproofing of external
a. height of light switches, socket-outlets, taps and
equipment;
controls;
type of connection and security.
b. temperature of hot water and surfaces of
radiators, heat emitters and hot water pipes;
Utilities
c. provision of audio-visual indicators and signage
System capacity where appropriate (for example fire alarm
systems).
1.61 All engineering systems and equipment should be
fit for purpose and designed to have an initial
capacity to safely accommodate peak maximum Infection control
loads plus an additional allowance of 25% for 1.67 Informed by a clinical risk assessment, the design
future expansion. and installation of engineering services should
incorporate adequate measures to minimise
Utility supplies infection control risks so far as is practicable. In
1.62 Where new or changes to existing incoming utility particular, precautions should be incorporated to
services are required, discussions should take place ensure that within areas occupied by patients, staff
with each utility company concerned to establish and visitors:
incoming service routes, capacity requirements, a. Ventilation provisions are adequately filtered
tariffs, meter locations, access provisions and way with air changes and pressure differentials
leave requirements as soon as practical during the maintained in accordance with Health Technical
design process. Memorandum 03-01 Specialised ventilation
for healthcare premises and other guidance to
Life expectancy of engineering plant and reduce the risk of HCAI.
equipment
b. All exposed surface finishes of engineering
1.63 All principal items of plant and equipment should services and equipment are generally smooth,
have a minimum life expectancy as described in accessible and easy to wipe clean.
CIBSE Guide M.
c. Engineering services pipework, heat emitters,
1.64 Materials and components that will require electrical trunking, luminaries, accessories and
maintenance and replacement during the life of the specialist fixed control equipment are
facility, should be selected, located and fixed in appropriately encased to present a smooth
such a way as to minimise future inconvenience exposed surface with gaps sealed with a suitable
and disruption and to avoid temporary closure of substance to control the potential harboring and
all or part of the facility. propagation of bacterial growth.
Metering d. Sloped surfaces are provided instead of

horizontal surfaces to reduce the build-up of
1.65 Health and community care premises should be dust.
fitted with adequate provisions to monitor all
primary incoming and sub-distribution engineering e. All engineering components and equipment
services sufficient to comply with statutory that are regularly handled by patients, such as
legislation and to support energy efficiency. light switches, nurse call units, door entry
controls, TV sets etc are capable of being wiped
clean and disinfected or sterilised between
patient use.
14
Space requirements for engineering 1.76 The surface temperature of radiators should not
exceed 43C. Ceiling-mounted radiant panels can
plant and services
operate at higher surface temperatures as long as
1.68 The building design must incorporate adequate the surface is not easily accessible.
space to enable the full range of engineering plant
1.77 Exposed heating pipework, accessible to touch,
and services to be installed and kept operational.
should be encased and/or insulated. Further
1.69 Space for plant and services should provide: information is given in Health Guidance Note
an easy and safe means of access; Safe hot water and surface temperatures. Special
care should be taken when facilities are being
s ecure accommodation protected from provided for older, confused or mental health
unauthorised access; patients, and where children may be present.
a dequate space around the plant and services to 1.78 Care should be taken to ensure that heat emitters
permit inspection, maintenance and do not adversely affect the local temperature
replacement; and conditions of adjacent storage and preparation
f or the installation of further plant and services areas.
at a later date where this is anticipated to be 1.79 Heat emitters should be located under windows,
required. against exposed walls or in the ceiling above
1.70 Guidance on spatial requirements for engineering windows.
plant and services is contained in paragraphs 1.22 1.80 Where radiators are installed there should be space
1.47. between the top of the radiator and the windowsill
1.71 Further useful information on the provision of to prevent curtains reducing the output. There
space for plant is contained in BSRIA TN 9/92, should also be adequate space underneath to allow
and for building services distribution systems in cleaning equipment to be used.
BSRIA TN 10/92. 1.81 Ceiling-mounted radiant panels should preferably
1.72 With the exception of drainage and some heating run around the perimeter of the building. The
pipework, engineering services should not be panels should not be located over beds, patient
brought from the ceiling void of the floor below. trolley positions or in other locations where they
Service distribution to a particular area should be might radiate directly onto a patient or member of
contained within the service spaces on that floor. staff for a prolonged period.
1.73 Plant rooms, particularly for air-conditioning and 1.82 Ceiling-mounted radiant panels should be selected
ventilation, should be located as close as possible to to match the appearance of the adjacent ceiling and
the areas they serve, thus minimising the amount of should be sealed to the adjacent ceiling by means of
space necessary to accommodate large ducts. a gasket or similar device.
1.74 Care should be taken to ensure that noise and 1.83 Where appropriate, heating controls should be
structure-borne vibration cannot be transmitted provided to modulate heating circuit flow
beyond the plant room. Further guidance on temperatures to maintain the desired air
acoustics and vibration can be found in Acoustics. temperature.
1.84 Radiators or radiant panels may also be used to
Mechanical services offset building fabric heat losses in mechanically
ventilated spaces. The system should be designed to
Heating ensure that the heating and ventilation systems
1.75 General space heating requirements may be met by operate in a coordinated manner and do not cause
a variety of systems including under-floor the space to overheat.
pipework, radiators or ceiling-mounted radiant
Ventilation and cooling
panels, or by an air conditioning system. Designers
should ensure that the most appropriate method is 1.85 Ventilation systems should be designed in
employed with regard to the healthcare accordance with the requirements of Health
environment being provided. Technical Memorandum 03-01 Specialised
ventilation for healthcare premises.
15
1.86 Theoretical modeling of summer temperatures Internal drainage

should be undertaken to ensure that the ventilation
1.93 A system of soil and waste drainage including anti-
system is able to control air temperatures within an
siphon and ventilation pipework should be
acceptable range.
provided in accordance with BS EN 12056.
1.87 It is important to achieve a balance between
1.94 Where plastic pipework is used, suitable
economy in capital and energy costs and creating
intumescent collars should be fitted when
appropriate levels of comfort through mechanical
breaching fire compartments, and acoustic
ventilation/comfort cooling.
wrapping should be applied where drainage
1.88 Air movement induced by mechanical ventilation pipework runs above wards and other sensitive
should be from clean to dirty areas, where these areas.
areas can be defined. The design should allow for
1.95 The gradient of branch drains should be uniform
an adequate flow of air into any spaces having only
and adequate to convey the maximum discharge to
mechanical extract ventilation, via transfer grilles in
the stack without blockage. Practical considerations
doors or walls. However, such arrangements should
such as available angles of bends, junctions and
avoid the introduction of untempered air and
their assembly, as well as space constraints, will
should not prejudice fire safety (through the
normally limit the gradient to about 1:50
introduction of uncontrolled air) or privacy
(20mm/m).
(through the positioning of transfer grilles).
1.96 For larger pipes, for example 100 mm in diameter,
1.89 Local exhaust ventilation (LEV) will be required
the gradient may be less, but this will require high-
where exposure (by inhalation) to substances
quality workmanship if an adequate self-cleaning
hazardous to health cannot be controlled by other
flow is to be maintained.
means. The Health and Safety Executive (HSE)
publishes guidance notes, updated annually, on 1.97 Provision for inspection, rodding and maintenance
occupational exposure limits (Guidance Note EH should ensure full bore access and be located
40) for the control of exposure by inhalation of outside user accommodation. The location of
substances hazardous to health. The limits specified manholes within the building should be avoided.
form part of the requirements of the Control of
1.98 To prevent the ingress of bacteria, waste outlets
Substances Hazardous to Health (COSHH)
from distillation and refrigeration plant should
Regulations.
discharge via a trapped tundish or gully to the
drainage system at a point where infection risks are
Hot and cold water systems
minimal.
1.90 Water storage and distribution systems should be
1.99 Drainage/waste systems from air-conditioning units
designed in accordance with Health Technical
should be installed to prevent Legionnaires disease
Memorandum 04-01 The control of Legionella,
and back-feeding of bacteria into the unit.
hygiene, safe hot water, cold water and drinking
water systems. 1.100 Where diagnostic imaging is carried out and
providing that there is adequate dilution and the
1.91 Exposed hot water pipework, accessible to touch,
silver content has been effectively recovered,
should be encased and/or insulated. Special care
effluent can be discharged into the internal
should be taken when facilities are being provided
drainage system. Project teams should establish
for older, confused or mental health patients, and
acceptable levels for silver and other processing
where children may be present.
chemicals at the planning stage.
Acoustics 1.101 All drainage that may be used for the passage of
1.92 Consideration should be given at the earliest contaminated effluent should be clearly labelled.
opportunity to the requirements for privacy and 1.102 At an early stage in the design process, proposals
noise control. Guidance on sound attenuation for the collection and discharge of chemical and
requirements is given in Acoustics. Whenever radioactive contaminated effluent should be
background music or PA systems are installed, the discussed and verified with the sewerage
sound quality should be such that it is intelligible undertaker. Some water authorities may impose
and not subject to unwanted reverberations. restrictions on the quantity and rate of discharge of
such effluent into public sewers.
16
Building management systems General electrical services

1.103 All engineering plant and equipment associated
General electrical installations
with the internal environment should, where
possible, be monitored and controlled by a 1.110 Electrical installations should comply with the
building management system (BMS) in accordance current edition of BS 7671 IEE Wiring
with Health Technical Memorandum 2005 Regulations together with Guidance Note 7
Building management systems. Requirements for Special Locations (Institute of Engineering and
the monitoring and control of specific types of Technology (IET)) and Health Technical
plant and systems are also covered in the relevant Memorandum 06-01 Electrical services supply
Health Technical Memorandum. and distribution.
1.111 Where applicable, electrical installations should
Fire safety also comply with Medical Electrical Installation
Guidance Notes (MEIGaN; Medicines and
General fire safety standards Healthcare products Regulatory Agency
1.104 Fire safety standards in healthcare premises need to (MHRA)).
be high owing to the vulnerability of occupants. 1.112 Prior to final design, a full assessment should be
1.105 In order to ensure appropriate fire safety standards, made of the clinical and business continuity risks,
the design and operation of health and community the range of room types (including equipment
care buildings should meet the objectives of requirements), occupation levels and resilience
Firecode (Health Technical Memorandum 05 requirements. This will influence the extent and
suite of documents) or provide a fire-engineered location of electrical services, the availability of
solution that achieves similar objectives. alternative sources of electrical supply and the need
for secondary power sources if appropriate.
1.106 It is important to establish during the design stage
those aspects of fire safety strategy that affect the Electromagnetic compatibility
design, configuration and structure of health and
community care buildings. The design team 1.113 Steps should be taken to prevent mains-borne and
should discuss and verify their proposals with the electrical radio frequencies from affecting
trust fire officer and the building control authority diagnostic and monitoring equipment, computers
or approved inspector, and ensure that the design or other sensitive electronic equipment. Guidance
team and all other design staff are fully acquainted on the avoidance and abatement of electrical
with the fire safety strategy for the design in terms interference is given in Health Technical
of operation (staff responsibilities, equipment Memorandum 06-01 Electrical services supply
provision, and building and engineering layouts). and distribution.
1.107 All staff should be familiar with the operational Primary electrical infrastructure
aspects of fire safety.
1.114 The primary electrical infrastructure (PEI),
Fire detection and alarm systems comprising the public electrical supply (PES) and
electrical distribution system equipment for the
1.108 The design of fire detection and alarm systems facilities, should be an integral part of the whole
should take account of the number of fire zones site/building network and provide adequate
(compartments) within the building, which in capacity for both normal and all assessed business
turn will be informed by an assessment of fire risk. critical needs.
It is important that the architect and design
engineer work together to ensure all fire risks are 1.115 The PES supply together with the facilities
properly understood and addressed in the design electrical distribution equipment should be sited in
solution. areas where access by the PES or healthcare
authorities to inspect and/or replace plant would
1.109 For specific guidance see Health Technical not disrupt normal communication routes. Careful
Memorandum 05-03 Part B Fire detection and consideration should also be given to the impact
alarm systems. from flooding, pipework leaks and mechanical
damage.
17
Socket-outlets for cleaning equipment 1.123 Fluorescent lighting in areas where clinical
procedures are carried out and/or medicines are
1.116 Sufficient socket-outlets (RCBO-protected) should
handled, including stores, must be derived from
be provided to enable the use of cleaning
lamps having suitable colour-rendering
equipment without the need to use extension
characteristics.
leads. Most floor scrubbers and polishers have 9
m-long power cables. 1.124 Light switches should be provided in easily
accessible positions and at appropriate locations in
Lighting systems corridors and general circulation areas. In areas
with multiple luminaires, switches should permit
General the selection of luminaires appropriate to the area
requiring illumination.
1.117 To achieve energy efficiency, lighting systems
should be designed to: 1.125 Ceiling-mounted fixed luminaires should not be
sited immediately above positions where people lie
maximise use of natural daylight; on a bed, couch or trolley to avoid glare. This
avoid unnecessarily high levels of illumination; applies to all spaces where people are consulted,
examined and treated.
i ncorporate efficient luminaires, control gear
and lamps; 1.126 Adjustable task lighting should be provided at the
bedhead for patients who wish to read.
incorporate effective controls.
1.127 Good lighting should be provided in all sanitary
1.118 Low energy or ultra-low energy lighting should be
spaces and there should be no reflective glare (see
considered as the primary lighting source.
BS 8300 and Approved Document M for details).
1.119 Where local circumstances permit, the use of time
1.128 Lighting services, including lighting controls,
switches or occupancy controls using infrared,
should comply with the following CIBSE
acoustic or ultrasonic detectors should be
guidance: Code for Lighting, Lighting Guide 2
encouraged. In corridors and general circulation
Hospitals and health care buildings and Guide
areas, lighting levels should be automatically
F Energy efficiency in buildings.
controlled to allow reduced levels of lighting (e.g.
with only up to 50% of luminaires switched on) 1.129 In areas where VDUs are in use, lighting should be
when the space is not occupied during normal designed to comply with CIBSE Lighting Guide 7
opening hours. Office lighting.
1.120 Lighting in sanitary spaces is generally assumed to 1.130 Lighting is important in enabling the effective
operate from passive infrared (PIR) sensors and cleaning of corners and edges that can harbour
therefore no light switches have been indicated on dust.
the example room layouts of sanitary spaces on
this website. Where light switches are required, Emergency lighting
reference should be made to Approved Document 1.131 Emergency lighting, incorporating escape lighting
M and BS 8300 for recommended location and standby lighting, should be provided in
heights. accordance with BS 5266 and building control
1.121 Lighting and the appearance of luminaires should and fire officer requirements.
be coordinated with architectural design. In 1.132 Escape lighting should also be provided in
particular, decorative finishes should be compatible accordance with Health Technical Memorandum
with the colourrendering properties of lamps and 06-01, Health Technical Memorandum 05-02
spectral distribution of the light source. See Fire safety in the NHS: Guidance in support of
Lighting and colour for hospital design. functional provision for healthcare services and
1.122 Where artificial lighting is provided in spaces CIBSE Lighting Guide 2.
where patients are examined or treated, it should
enable changes in skin tone and colour to be External lighting
clearly defined and easily identified. The quality of 1.133 The issue of light pollution should be taken into
lighting will need to be considered if video consideration when planning external lighting.
consultation is likely to take place.
18
Where possible, external lighting should not shine external entrances, car parking and pedestrian
excessively into adjacent properties. walkways may be at particular risk at night.
1.134 The following steps should be taken:
External services
Avoid excessive lighting.
1.144 Where premises do not operate over a 24-hour
Use sensor-activated luminaires. period, external engineering plant and equipment,
particularly security cameras and engineering
Ensure luminaires are correctly orientated.
service supplies, should be positioned and suitably
protected to minimise the risk of damage or
Patient/staff and staff emergency call interference when the premises are closed.
systems
1.135 Patient/staff and staff emergency call systems Car park barriers
should comply with Health Technical 1.145 To improve site security, and control unauthorised
Memorandum 08-03 Bedhead services. parking, it may be necessary to install car park
1.136 Patient/staff call points should be provided in all barriers. Where barriers are required, all electrical
spaces where a patient/attendee may be left alone services to them should be installed using external
temporarily, for example clinical rooms and WCs. cable runs routed below ground level as far as is
practical.
1.137 Staff emergency call points are for a member of
staff to call for assistance from another member of Door access control systems
staff. They should be provided in all spaces where
1.146 Health and community care buildings will
staff consult, examine and treat attendees/patients.
generally require controlled access to the building
1.138 Consideration should be given to the use of at the staff entrance and, internally, to staff areas.
modern technology and location of staff
1.147 Where door access control systems are required,
emergency call points to ensure that the risk of
these should consist of an electronic keypad, fob or
accidental operation is minimal and that, where
other approved door entry system installed in
necessary, they can act as a deterrent to potential
conjunction with a separate door entry intercom
aggressors in addition to enabling a response to an
system.
incident.
1.148 External door entry systems should be compatible
1.139 Patient/staff and staff emergency call systems may
with insurance requirements. They should be
be hard-wired or may form part of a multiplexed
weatherproof and vandal-resistant. Internal systems
data or radio system.
should be vandal-resistant.
1.140 Dedicated call points for summoning the crash
team may be provided. These are not standard Entertainment systems
installation and need to be specified for individual
rooms where patients are at a high risk of suffering 1.149 Entertainment facilities, such as television and
a cardiac arrest radio/music systems, may be provided in waiting
areas to mask sound transfer for confidentiality
1.141 A visual and audible indication of the operation of purposes or in staff rest areas to create a relaxing
each system should be provided at a suitable staff atmosphere.
base to identify the nature and origin of the call.
1.150 The entertainment services should comply with
1.142 Over-door indicator lamps and corridor indicator Health Technical Memorandum 08-03 Bedhead
lamps should be appropriately located to guide services.
staff quickly to the origin of the call.
IT and wiring systems
Security
General
CCTV installation
1.151 Where possible, a structured wiring system should
1.143 CCTV systems should be installed to monitor be provided. This will permit a unified approach
internal and external areas where there is a risk of to the provision of cabling for:
attack or vandalism. Areas such as receptions,
19
voice systems; tube systems, see Health Technical Memorandum

2009 Pneumatic air tube transport systems.
data systems;
imaging systems; Lifts
alarm systems. 1.159 Lifts may be required for general passenger
1.152 While such a universal cabling system is initially transportation, bed/stretcher transportation or
more expensive than separate voice and data service use. They may also be required in order to
systems, it may be more cost effective in the long comply with the requirements of the Disability
run. Discrimination Act 2005 and/or Approved
Document M of the Building Regulations.
1.153 In determining the nature of the IT system to be
provided, it is necessary to identify: 1.160 Consideration may be given to the installation of
lifts that do not require a separate machine room,
the areas to be served; particularly in buildings with less than three floors
whether structured cabling will be used; and/or where there is limited space available.
t he density of RJ45 data and telephone outlets 1.161 For further guidance on the design of lift
to be provided; installations, see Health Technical Memorandum
08-02 Lifts.
w
hether wiring will be on a flood or as
required basis.
Lightning protection systems
1.154 Where appropriate, specialists should be employed
1.162 Lightning protection systems should be evaluated
to assist in the design and installation of IT and
and, if necessary, installed in accordance with BS
telephone systems, including interfacing with
EN 62305.
service wiring and equipment suppliers to ensure a
fully operational and reliable system.
Audio induction loop systems
Telecommunication systems 1.163 Audio induction loop systems should be provided
1.155 The telecommunication system should comply in main receptions, seminar rooms and waiting
with the requirements of the public telephone areas in accordance with the Disability
operator (PTO), various Codes of Practice and Discrimination Act. They may be fixed or
British Standard specifications, in particular BS portable.
EN ISO 6506 and BS 6701 Part 1. 1.164 They should comply with the requirements of
1.156 Public telephones should be provided where BSEN 60118-4, IEC 60118-4, where applicable.
required, complete with coin box and acoustic 1.165 Audio loop systems should be able to provide an
hoods, as appropriate. Consideration should be interface with any PA or music system. In areas
given to disabled persons in relation to the height with televisions, they should be interfaced to
of payphones. provide TV sound into the local area loop system.
IT systems
Sustainability and energy efficiency
1.157 The IT system should include the installation,
1.166 Engineering services should use renewable and
termination, testing and commissioning of all
natural energy sources, wherever feasible. The
switches, routers, hubs, distribution cabling
energy consumption of engineering services should
complete with cable containment system, and
be further minimised through the use of low/zero
required RJ45 terminal outlets.
energy solutions and/or energy-saving devices.
Pneumatic tube systems 1.167 Account should be taken of the recommendations
in the following documents:
1.158 If a new pneumatic tube system is to be installed,
significant investigation needs to be undertaken to C
urrent editions of Building Regulations and
ensure that the system will meet required needs. Approved Codes of Practice.
For further guidance on the design of pneumatic
20
E
nergy Efficiency Office and Carbon Trust best consumption of incoming electrical supplies as
practice guidance. well as carbon emissions.
Sustainable development in the NHS U
se of thermostatic controls to limit
temperature increases and heat wastage.
Environmental strategy for the NHS
I ncreased pipe insulation to limit temperature
H
ealth Technical Memorandum 07-02
losses.
Encode making energy work in healthcare
1.168 Consideration should be given to using the
Sustainable health and social care buildings
thermal properties of the building when the
B
uilding Services Research and Information facility is not in use, for example at night or
Association (BSRIA) publications. weekends, where circumstances permit.
C
hartered Institution of Building Services 1.169 Engineering plant and equipment should be
Engineers (CIBSE) publications design recycled, wherever practical. Ideally any disposal of
guides, energy codes, technical memoranda, plant and equipment should not require a special
lighting guides, climate change levy. licence. Where a licence for disposal is necessary,
1.167 The following factors should be considered in these should be acquired as prescribed by statute.
order to minimise energy consumption: 1.170 Specific guidance can be found in Health
U
se of natural lighting and ventilation, Technical Memorandum 07-01 Safe
wherever feasible. management of healthcare waste, Health Technical
Memorandum 07-05 The treatment, recovery,
U
se of passive solar design, including the use of recycling and safe disposal of waste electrical and
solar heating panels, the use of reflective glass electronic equipment and Health Technical
and/or blinds to minimise solar gain, where Memorandum 07-06 Disposal of
appropriate, and locating heat-sensitive pharmaceutical waste in community pharmacies.
accommodation away from south facing fascias.
U
se of energy efficient equipment, including Validation and handover of engineering
high efficiency condensing boilers and motors, installations
and energy efficient luminaries.
1.171 It is important that, on completion of an
U
se of electronic inverter speed control devices installation and prior to hand-over, the
on air handling equipment instead of performance of the installation is fully tested and
alternatives such as belt pulleys or pole validated.
changing motors.
1.172 The final acceptable performance details should be
Power factor correction to major plant. recorded and, together with full manufacturers
U
se of presence detection, photocell and multi- operating and servicing details, test results,
circuit systems to control lighting. certificates, as-fitted drawings, manuals etc, made
available to users and the maintenance
U
se of a BMS system to provide automatic organisation before the installation is handed over.
time control switching (to shut down plant
1.173 Once the installation is fully operational, its
when not required) and performance
monitoring (to ensure plant is operating at performance should again be tested. This will
optimum levels) check that it is operating to the designed criteria.
1.174 Any risk management plans, operational
I mplementation of heat recovery, particularly
for ventilation systems. procedures and contingency plans should be fully
evaluated and tested with staff. Opportunities
Use of ground source heat pumps. should also be taken as soon as practical after
U
se of sensory taps, urinal controls, low volume physical completion of the facilities to familiarise
toilet cisterns and grey water (i.e. rain water and train staff in the use of all relevant equipment
harvesting or recycled water) to reduce water and services and to practice any procedures to
usage. ensure staff members understand what is required
of them.
U
se of combined heat and power plant
(including micro CHP plant) to reduce
21
2 Statutory and legislative requirements
2.1 There are numerous statutory and legal duties that Code of Practice, they will need to show that they
owners and occupiers of premises must adhere to. have complied with the law in some other way, or a
These are continually changing in the light of new court will find them at fault.
evidence and experience. Reference should be made
2.8 Standards (British or European), institutional
to these documents at the time of application.
guides and industry best practice play a large part
in how things should be done. They have no direct
Health and safety legal status (unless specified by regulations).
2.2 Current health and safety philosophy was However, should there be an accident, the applied
developed following the Report of the Robens safety practices at the place of work would be
Committee 1972, which resulted in the Health and examined against existing British or European
Safety at Work etc Act 1974. Standards. It would be difficult to argue in favour
of an organisation where safety was not to the
2.3 The standards of health and safety in the UK are described level.
delivered through a flexible enabling system
introduced in 1974 by the Health and Safety at 2.9 Guidance is issued in some cases to indicate the
Work etc Act 1974 and are typified by the best way to comply with regulations. But the
Management of Health and Safety at Work guidance has no legal enforcement status.
Regulations 1999.
2.4 The Health and Safety at Work etc Act 1974 leaves
Other commonly cited legislation
employers freedom to decide how to control the 2.10 There are numerous statutory and legal duties that
risks that they identify that is, to look at what the owners and occupiers of premises must adhere to.
risks are and to take sensible measures to tackle These are continually changing in the light of new
them. The Act is part of criminal law, and evidence and experience. Reference should be made
enforcement is by the Health & Safety Executive. to these documents at the time of application.
Successful prosecution can result in fines or
2.11 Some of the commonly cited legislation can be
imprisonment.
viewed in the list below. The list is not exhaustive,
but is intended to demonstrate the range of issues
Regulations, Approved Codes of Practice,
that should be considered. All references to
Standards and guidance
guidance/legislation/standards should be compared
2.5 Regulations are law, approved by Parliament. These to those current at the time of application. Latest
are usually made under the Health and Safety at published guidance always takes precedence.
Work etc Act following proposals from the Health
2.12 Only the primary Acts and main regulations are
& Safety Commission. Regulations identify certain
cited here. Most of these Acts and regulations have
risks and set out specific actions that must be taken.
been subjected to amendment subsequent to the
2.6 Approved Codes of Practice give advice on how to date of first becoming law. These amending Acts or
comply with the law by offering practical examples regulations are not included in this list.
of best practice. If employers follow the advice,
Health and Safety at Work etc Act 1974
they will be doing enough to comply with the law.
Factories Act 1961 (as amended)
2.7 Approved Codes of Practice have a special legal
status. If employers are prosecuted for a breach of The NHS and Community Care Act 1990
health and safety law, and it is proved that they did
Consumer Protection Act 1987
not follow the relevant provisions of an Approved
22
Disability Discrimination Act 1995 (DDA) T

he Plugs and Sockets etc (Safety) Regulations
1994
T
he Management of Health and Safety at Work
Regulations 1999 T
he Radio Equipment and Telecommunications
Terminal Equipment Regulations 2000
W
orkplace (Health, Safety and Welfare)
Regulations 1992 E
lectromagnetic Compatibility Regulations
1992
P
rovision and Use of Work Equipment
Regulations 1998
Mechanical
Manual Handling Operations Regulations 1992
S upply of Machinery (Safety) Regulations 1992
P
ersonal Protective Equipment at Work and Supply of Machinery (Safety)
Regulations 1992 (Amendment) Regulations 1994
H
ealth and Safety (Display Screen Equipment) L
ifting Operations and Lifting Equipment
Regulations 1992 Regulations 1998 (LOLER)
Confined Spaces Regulations 1997 Gas Appliances (Safety) Regulations 1995
T
he Reporting of Injuries, Diseases and G
as Safety (Installation and Use) Regulations
Dangerous Occurrences Regulations 1995 1998
(RIDDOR 95)
The Lifts Regulations 1997
The Working Time Regulations 1998
Noise at Work Regulations 1989
C
ontrol of Substances Hazardous to Health
The Pressure Systems Safety Regulations 2000
Regulations (COSHH) 2002
The Pressure Equipment Regulations 1999
Health and Safety (First-Aid) Regulations 1981
S imple Pressure Vessels (Safety) Regulations
H
ealth and Safety (Consultation with
1991
Employees) Regulations 1996
T
he Construction (Design and Management)
H
ealth and Safety Information for Employees
Regulations 1994
Regulations 1989
T
he Construction (Health, Safety and Welfare)
H
ealth and Safety (Safety Signs and Signals)
Regulations 1996
Regulations 1996
The Building Regulations 2000
E
mployers Liability (Compulsory Insurance)
Regulations 1998 Environment
T
he Health and Safety (Training For The Environmental Protection Act 1990
Employment) Regulations 1990
T
he Control of Pollution (Amendment) Act
S afety Representatives and Safety Committees 1989
Regulations 1977
T
he Waste Management Licensing Regulations
Control of Asbestos at Work Regulations 2002 1994 (as amended)
Electrical E
nvironmental Protection (Duty of Care)
Regulations 1991
Electricity Act 1989
T
he Controlled Waste (Registration of Carriers
E
lectricity Safety, Quality and Continuity
and Seizure of Vehicles) Regulations 1991
Regulations 2002
H
azardous Waste (England and Wales)
Electricity at Work Regulations 1989
Regulations 2005
B
S 7671:2001 (IEE Wiring Regulations, 16th
List of Wastes (England) Regulations 2005
Edition)
P
ollution Prevention and Control (England and
T
he Electrical Equipment (Safety) Regulations
Wales) Regulations 2000
1994
23
Clean Air Act 1993 Fire

E
nvironmental Protection (Prescribed Processes) T
he Regulatory Reform (Fire Safety) Order
Regulations 1991 2005
T
rade Effluent (Prescribed Processes and T
he Furniture and Furnishings (Fire) (Safety)
Substances) Regulation 1989 Regulations 1988
Controlled Waste Regulations 1992 D
angerous Substances and Explosive
Atmospheres Regulations (DSEAR) 2002
Environment Act 1995
P
ackaging (Essential Requirements) Regulations Food
2003
The Food Safety Act 1990
C
ontrol of Pollution (Oil Storage) (England)
T
he Food Safety (General Food Hygiene)
Regulations 2001
Regulations 1995
T
he Landfill Tax Regulations 1996 and Landfill
T
he Food Safety (Temperature Control)
Tax (Qualifying Material) Order 1996
Regulations 1995
C
hemicals (Hazard Information and Packaging
for Supply) Regulations 2002 Public health
Town and Country Planning Act 1990 P
ublic Health (Infectious Diseases) Regulations
1998
The Control of Pollution Act 1974
Medicines Act 1961
P
roducer Responsibility Obligations (Packaging
Waste) Regulations 2005 2.13 This list demonstrates the complex services that
exist within a healthcare organisation. A further
W
aste Electrical and Electronic Equipment
brief description of each piece of legislation is given
Directive 2002
in Appendix 1 of this document.
Water Industry Act 1991
Water Supply (Water Quality) Regulations 2000 Risk and/or priority assessment
Water Resources Act 1991 2.14 In carrying out design, operational and
management evaluation, a consistent method of
Water Supply (Water Fittings) Regulations 1999 assessment should be engaged to ensure that
Control of Lead at Work Regulations 2002 adequate information, consultation and appraisal is
undertaken across the whole range of influences.
Control of Pesticides Regulations 1986
2.15 Although some elements of a particular assessment
Noise & Statutory Nuisance Act 1993 may be complex (for example whole-life costing,
The Climate Change Act 2008 net present value, patient criticality, resilience etc),
it is important to keep the collective assessment as
Radiation simple as possible.
Ionising Radiations Regulations 1999 (IRR99) 2.16 One method is to establish an evaluation matrix
which allows information across two scales to be
The Radioactive Substances Act 1993 (RSA93)
represented in an easily understood way that helps
I onising Radiation (Medical Exposure) users come to a particular decision.
Regulations 2000
2.17 Both scales are graded from lowest to highest such
R
adioactive Materials (Road Transport) that a combination of the assessments can be
Regulations 2002 represented. For example, an event analysis may
appear as below: mapping the likelihood of an
M
edicines (Administration of Radioactive
event happening and the consequences of the
Substances) Regulations 1978
effect.
24
2.18 In a similar way, a cost/benefit matrix may be

constructed or a risk/design measure assessment
made (see page 25).
2.19 A more detailed example of applied risk assessment
may be found in the Department of Healths
(2005) A risk-based methodology for establishing
and managing backlog.
Probability Rating
Certain 5 5 10 15 20 25
Likely 4 4 8 12 16 20
Possible 3 3 6 9 12 15
Unlikely 2 2 4 6 8 10
Rare 1 1 2 3 4 5
Rating 1 2 3 4 5
Effect Insignificant Minor Moderate Major Catastrophic
25
3 Professional support
3.1 Managers of healthcare property and services need appointed person should have access to a robust
technical and professional support across a range of structure that delivers governance, assurance and
specialist services. This support should be embraced compliance through a formal reporting mechanism.
into the structure and responsibility framework of
the organisation to ensure an adequate approach Management structure
for each of the areas covered by the healthcare-
specific technical engineering guidance. 3.5 To engage and deliver the duties required, a
healthcare organisation may consider the structure
3.2 Within this building engineering guidance, a range shown below. In following this structure, healthcare
of measures are discussed to meet the needs of each organisations may consider that the necessary
service. This section considers the principles, professional and technical resilience is available to
standards and common features that will be provide a robust service.
applicable as a core approach.
Professional structure
Management and responsibility
3.6 While a chief executive and the board carry
3.3 Healthcare organisations have a duty of care to ultimate responsibility for a safe and secure
patients, their workforce and the general public. healthcare environment, it can be assigned or
This is to ensure a safe and appropriate delegated to other senior executives.
environment for healthcare. This requirement is
identified in a wide range of legislation. 3.7 However, it may not be generally possible to
maintain a senior executive with specialist
3.4 At the most senior level within an organisation, this knowledge for all professional services; external
responsibility does not need to include technical, support may therefore be required.
professional or operational duties, but the
Healthcare organisation management board:

Accountable officer
Executive and non-executive members
External independent Senior estates &

professional support facilities officer
Appointed qualified
technical staff
Competent Assessed (safety)

technical staff support staff
26
3 Professional support
3.8 An independent adviser for audit purposes, 3.14 The DP will work closely with the Senior
assessment and operational advice may also be Operational Manager to ensure that provision is
required. made to adequately support the specialist service.
3.9 The structure shown below represents a
Trust Senior Operational Manager (SOM)
professional approach to delivery of a specialist
service. 3.15 The SOM may have operational and professional
responsibility for a wide range of specialist services.
3.10 Within a specific service, other support staff for
It is important that the SOM has access to robust,
safety, quality and process purposes may be
service-specific professional support which can
required.
promote and maintain the role of the informed
3.11 Within certain healthcare organisations, some client within the healthcare organisation. This will
elements of specialist services are not present (high embrace both the maintenance and development of
voltage electrical, decontamination, medical gas service-specific improvements, support the
pipelines etc). In this case, an appropriate level of provision of the intelligent customer role and give
professional support should be considered. assurance of service quality.
3.12 It is possible for several organisations to share the
Authorising Engineer (AE)
same professional staff either individually or
collectively; however, it is usual for the Authorising 3.16 The AE will act as an independent professional
Engineer role to remain independent of the adviser to the healthcare organisation. The AE
organisation, with particular regard to the critical should be appointed by the organisation with a
audit process. brief to provide services in accordance with this
guidance. This may vary in accordance with the
Roles and responsibilities specialist service being supported.
3.17 The AE will act as assessor and make
Designated Person (DP) recommendations for the appointment of
3.13 This person provides the essential senior Authorised Persons, monitor the performance of
management link between the organisation and the service, and provide an annual audit to the DP.
professional support, which also provides To effectively carry out this role, particularly with
independence of the audit-reporting process. The regard to audit, it is preferable that the AE remains
DP will also provide an informed position at board independent of the operational structure of the
level. trust.
Designated Person
Appointed senior executive
(board level) with assigned
responsibility for service
Authorising Engineer Trust Senior Operational

Appointed independent Manager
professional engineer Informed client/intelligent
(specific to service) customer
Authorised Person
Appointed qualified
technical engineer (specific to
service)
Competent Person
Assessed and qualified
craftsperson
(specific to service)
27
Authorised Person (AP) record-keeping should be assigned to specific APs

and recorded in the operational policies.
3.18 The Authorised Person has the key operational
responsibility for the specialist service. The person
Competent Person (CP)
will be qualified and sufficiently experienced and
skilled to fully operate the specialist service. He/she 3.22 This person provides skilled installation and/or
will be nominated by the AE and be able to maintenance of the specialist service. The CP will
demonstrate: be appointed, or authorised to work (if a
contractor), by the AP. He/she will demonstrate a
h
is/her application through familiarisation with
sound trade background and specific skill in the
the system and attendance at an appropriate
specialist service. He/she will work under the
professional course;
direction of the AP and in accordance with
a level of experience; and operating procedures, policies and standards of the
service.
evidence of knowledge and skills.
3.19 An important element of this role is the Variation by service
maintenance of records, quality of service and
maintenance of system safety (integrity). 3.23 The particular detailed roles and responsibilities
will vary between specialist services, and the
3.20 The AP will also be responsible for establishing and guidance given in the appropriate building services
maintaining the roles and validation of Competent engineering categories should be followed to ensure
Persons, who may be employees of the organisation that the necessary safe systems of working are
or appointed contractors. established and maintained.
3.21 Larger sites may need more than one AP for a
particular service. Administrative duties such as
28
4 Operational policy
4.1 The healthcare organisations management board is 4.10 The Authorised Person responsible for engineering
responsible for setting overall operational policy, services should take a lead in explaining to users the
and it is the Designated Person as the senior function of the system, and organise adequate
executive who has responsibility for information and training about the system.
implementation.
4.11 Maintenance and safety are two closely related
4.2 The building services engineering guidance on this subjects. General safety is largely dependent on
site should enable an organisation to be aware of good standards of maintenance being attained and
the issues relative to a particular service and support staff safety disciplines being mutually exercised.
any operational policy that has to be prepared.
4.3 It is acknowledged that some organisations have Records/drawings
separate procedures that are referenced within the 4.12 The organisation should have accurate and up-to-
operational policy under the control of other date records and/or drawings. These should be
specific departments. readily available on site, in an appropriate format,
4.4 Where the operation of engineering services is vital for use by any Authorised Person responsible for
to the continued functioning of the healthcare engineering services.
premises, operation and maintenance may require 4.13 A unique reference number should identify the
special consideration; therefore, improving equipment. This should correspond to that shown
resilience within the critical engineering systems on the records/drawings.
should be considered.
4.14 The records/drawings should indicate the type and
make of the equipment.
Operational considerations
4.15 Database systems could be used to link plant
4.5 The operational policy should ensure that users are
reference numbers to locations on drawings and
aware of the capacity of the specific system and any
detailed records of the plant and its maintenance.
particular limitations.
4.16 A schematic diagram of the installation should also
4.6 A maintenance policy that pursues and expects the
be available and displayed in each plantroom or
good upkeep of plant and equipment by regular
service area, scheduling key components.
inspection and maintenance is evidence of best
practice. 4.17 When additions or alterations are to be made to
existing installations, the Authorised Person
4.7 All safety aspects of operation associated with
responsible for engineering services should ensure
particular plant or equipment should be clearly
that the current as-fitted information is available in
understood by operational staff.
an acceptable format. On completion of the work,
4.8 Nursing, medical and other staff should be aware of the records/drawings should be updated and the
the purpose of any alarm systems and of the course service alterations noted and dated.
of action to be taken in the event of an emergency
occurring. Security
4.9 Staff responsible for engineering plant operation 4.18 All means of service isolation, regulation and
should be aware of the activities necessary to ensure control (except those in plantrooms) should be
the continued safe operation of the system and secured in such a way that they can be fixed in the
what action should be taken in an emergency. normal position.
29
4.19 In the case of those components that may have to 4.26 Work should only be carried out by suitably
be operated in an emergency, the fixing method qualified contractors within the range of design,
should be capable of being overridden. installation, commissioning or maintenance of
services as appropriate. Evidence of current
4.20 All plantrooms should be kept locked, suitably
registration should be by sight of the correct
signed and under access control.
certificate of registration.
4.21 A procedure in the operational policy for
4.27 The operational policy should set out the
controlling access, including in the event of an
responsibilities for monitoring the work of
emergency, should be established.
contractors. The Authorised Person responsible for
4.22 Adequate means of engineering plant isolation and the specific engineering services would normally
safe working areas should be provided for all coordinate this. The call-out procedures for a
operational and maintenance contingencies to contractor, particularly in the event of a fault or an
allow temporary plant where required and safe emergency, should be set out in the operational
working around equipment. policy.
Monitoring of the operational policy Medical equipment purchase

4.23 The Designated Person is responsible for 4.28 The Authorised Person responsible for engineering
monitoring the operational policy to ensure that it services should be consulted during initial
is being properly implemented. This should be discussions on the purchase of any medical
carried out on a regular basis, and the procedure for equipment that will be connected to the
such monitoring should be set out in the engineering services. This is to ensure that the
operational policy. system has sufficient capacity and can continue to
deliver the required service.
4.24 The responsibility for monitoring specific aspects
may be delegated to appropriate key personnel. For 4.29 The policy should state the procedures to be
example, the responsibility for monitoring the followed and the personnel who need to be
implementation of the permit-to-work procedure consulted before a new item of medical equipment
would normally be delegated to the Authorised is connected to an engineering service.
Person. The details of such delegation shall be set
out in the operational policy.
Contractors
4.25 All contractors should comply with the
organisations safety procedures. This should be
clearly stated in the operational policy.
30
5 Emergency preparedness and resilience
Overview including patient care, staff comfort, and health

and safety.
5.1 This chapter contains advice on developing NHS
facilities that are resilient to a range of threats, 5.6 Failures in essential support systems may lead to
emergencies and hazards. See also Health Building patient evacuation and the temporary closure of
Note 11-01 Supplement A Resilience and wards, which could have a major impact on the
emergency planning in primary and community publics confidence in a healthcare organisation.
care. 5.7 Additionally, dependent on the scale or nature of
5.2 A healthcare organisation should sustain plans for the incident, the ability of the organisation to
the purpose of minimising the impact from continue an acceptable level of healthcare services
emergencies, maintaining services and protecting may itself be compromised.
patients and staff. 5.8 It is the responsibility of the healthcare
5.3 Healthcare organisations should contribute and organisations management to ensure that their
receive information through their local resilience premises comply with all legislation. Additionally,
forum (LRF), which exchanges views and when considering the implications of, for example,
knowledge across a wide range of services within a an incident associated with terrorism, reference
local community. should also be made to the NHS Emergency
Planning Guidance 2005.
Note 5.9 Planning for such emergencies can help to reduce
In all aspects of emergency and operational planning, the impact. By developing an emergency plan,
trusts should ensure engagement with the emergency healthcare organisations should be able to restore
planning officer and local security management lead. systems to normal as quickly as possible after an
emergency, using safe working methods and
Wider specific NHS guidance on the management of making the best use of available resources.
non-clinical business continuity in healthcare facilities
can be found in the NHS Emergency Planning 5.10 Plans need to be regularly tested and updated to
Guidance 2005. meet changing circumstances.
5.11 Emergency and contingency planning cannot be
5.4 Healthcare organisations may encounter such carried out in isolation.
scenarios as:
5.12 All arrangements should be agreed through
u
nplanned interruption to a utility supply (gas, consultation and dialogue.
water, electricity etc);
5.13 Individual services or departments should be
u
nexpected equipment and service distribution encouraged to accept responsibility for contingency
failures (telephones, water pipework, medical arrangements. This is particularly important for
gases etc); services provided through associated contracts (via
a civil incident (act of terrorism, civil PFI partners, commercial business, service level
disturbance etc); agreements etc).
a n environmental incident (floods, transport 5.14 Essential-service contingency plans should not be
incident, storm damage, overheating, or other confused with major incident plans (although the
extreme weather event). two should be consistent):
5.5 Such failures or incidents, when they occur, can m

ajor incident plans generally are outward-
have an impact on all aspects of healthcare services, looking and deal with the healthcare
31
organisations response to a public incident for 5.18 From an understanding of the area and the
which an immediate high level of healthcare is healthcare activity that takes place, all the estates
required; services and facilities that exist in the range of
buildings on-site should be considered.
c ontingency planning is generally inward-
looking and deals with actions needed to 5.20 The table below gives a broad list of suggested
maintain a healthcare facility in a safe and topics for consideration. It is not a comprehensive
operational status under adverse conditions. list and may not be applicable to all sites, but it
should act as a prompt to establish the services
5.15 It is possible that some features from both plans
list.
may be needed for a complex incident, but lines of
responsibility should be clearly defined and
understood at all times. System resilience, planning and design
5.21 Resilience of the various systems and services (for
Creating an emergency plan example water and fuel) is ideally provided at the
design stage of a healthcare facility. This could
5.16 All plans should be documented and supported by
include:
as much information as possible. This should be
kept up-to-date and under constant review. p
riority allocation of the site by local utility
suppliers which provide alternative routes for
5.17 It is important to define the area to which the plan
site supply, should parts of the external
will apply. This will usually be by site rather than
infrastructure be damaged or contaminated;
individual buildings to avoid repetition of
procedures and to embrace the wider service issues.
Table 1 Suggested systems and services for consideration when creating an emergency plan
System Services External influence

Mains electricity supply Catering patients and staff Mains water contamination
Standby generators Key clinical departments (A&E, theatres, Air pollution
UPS + other batteries critical care etc) Flooding
Mains water Estates & facilities management Mains sewage treatment failure
Hot water (including engineering, APs, CPs etc) Transport routes and infrastructure
Treated water (renal etc) Transport Infestation
Heating and ventilation Portering Civil disturbance
Steam Administration support Explosion
Pneumatics Patient information Excavation
Building Management System Cleaning Terrorism incidents
Drainage Waste disposal Communications
Surface/foul/waste Laundry Other severe/extreme weather conditions
Fuel supplies Medical supplies and wildfires
Gas/oil/other Fuel supplies
Communications Water drainage
Telephones (fixed) Security
Mobile
Paging
Electronic
IT and patient information system
Lifts
Sterilization and decontamination
Medical gases
Fire alarms
Refrigeration (food, mortuary, blood
supplies, pharmacy equipment etc)
Medical equipment
Building structure
Suggested systems and services for consideration when creating an emergency plan
32
5 Emergency preparedness
r esilient internal infrastructure systems which laundry, waste disposal, transport etc need to be
provide flexibility in services supplies to confirmed, and all lines of communication and
buildings; supply chains regularly tested.
p
rovision of alternative fuel sources, with 5.29 It is also necessary to discuss and establish the
appropriate storage capacity on-site (for priorities of clinical services within the plan. These
example, fuel oil as back-up to natural gas for will move from life-critical functions (operating
boiler plant); theatres, critical care areas, neonatal intensive care
units, emergency care) through diagnostic services
e nhanced levels of on-site standby capacity for
(imaging, laboratories) and on to clinical support
electricity supplies by the use of CHP systems,
(blood, sterile services, pharmaceutical supplies,
the sizing of standby generator plant, and
medical gases etc).
flexible electrical distribution systems;
5.30 Prioritised but flexible, estate and facilities services
a ppropriate monitoring and storage capacity for,
which underpin clinical priorities will provide a
for example, water supplies.
good platform for the organisation to cope with the
5.22 Planning and designing for resilience whenever the impact of emergencies and speed up recovery to
opportunity arises that is, when new sites/ provide normal business continuity.
buildings or departments are being considered and
when major refurbishments are taking place is a External impact
key responsibility of the management board.
5.31 External influences are perhaps the most difficult
5.23 This will require a clear understanding of the element of contingency planning due to the wide
critical operational service requirements and the range of scenarios that could be presented.
type and level of ongoing service needs in the event Consequently, scenario planning for every
of an emergency/incident. eventuality is very unlikely.
5.24 Prerequisite information should be provided at the 5.32 However, some of the most likely scenarios and the
planning and design stage to enable an appropriate key issues arising should be examined, evaluated
level of resilience to be built in. For this purpose, and, where possible, tested to ensure that some
close liaison should take place between the form of response is in place for that eventuality (for
organisations emergency planning officer and the example loss of major utility, external
estates and facilities professionals at the earliest communication links etc).
possible stages.
5.25 Of particular importance in times of emergency are Security
all forms of communication systems. Email, mobile 5.33 Areas of clinical concern (for example radiology,
phones, advanced telephone/telemedicine and pathology) may require enhanced access control,
patient data systems may all require a detailed and staff and contractor screening, in accordance
analysis of the effect of failure loss. with the NHS Security Management Manual.
5.26 Proposed changes to any communication system 5.34 Adverse incidents may present exceptional
should ensure that consideration is given to the requirements to control security, access, patient and
requirements of emergency plans and staff safety etc. Planning should ensure that
communication-service resilience before decisions measures are available and understood which may
are taken. include additional staff resources (drawn from non-
5.27 These considerations should also include home/ critical roles) for entry/exit control, increased
mobile communication systems for key staff who awareness and communications, defined
will be required in the event of an emergency or management responsibility etc.
adverse incident.
Responsibility
Services and priorities 5.35 If the issue or incident remains predominantly an
5.28 Maintaining services is an essential function of estates or facilities issue, action should be
business continuity and must be a priority within a coordinated through the estates and facilities
contingency plan. Alternative sources of catering, management (EFM) structure. However, if the
33
cause and/or effect escalates into a more major Communications

event, and a major incident is declared, the lines of
5.41 This is a vital responsibility which should be
responsibility should revert to the major incident
assigned to someone who has a wide range of
plan structure.
knowledge about the site and the infrastructure. It
5.36 Accountability must be maintained within the may also be necessary to coordinate between
healthcare organisations structure. The chief departments, media, public, emergency services,
executive and board members must be aware of the and other healthcare managers and providers.
proposed contingency plans, although it is likely
that operational managers will implement the Incident manager
actions. 5.42 This will probably be the most senior Operational
5.37 The structure of different organisations will mean Manager available.
that staff with varying levels of experience and
expertise could be called on to deal with estates and Resource manager
facilities emergencies. 5.43 This role is necessary for emergency procurement,
5.38 Written emergency operational procedures should contact with external support, and maintaining a
therefore be easily understood by those people record of staff on site. It is important to ensure that
expected to use them. For example, if the staff welfare requirements are also considered and
management structure is such that emergencies included in the plans.
associated with engineering services will always be
handled by a qualified and experienced engineer, Emergency procedure manual owner
the emergency operational procedure may be highly 5.44 For each key role identified, there should be a
technical. specific copy of the manual, and individual
5.39 In many cases, however, standby staff who may be departments should have a copy assigned to a
the first to attend an emergency will not have the named individual whose role it is to maintain and
technical knowledge to make appropriate decisions. review the details to ensure they remain valid.
If this is the case, emergency operational procedures
should be detailed and specific, and should include Testing the plan
instruction on where and how to seek assistance 5.45 Small elements of the plan should be exercised in
from a more experienced colleague at any stage. order to familiarise staff and to test procedures.
This instruction should normally include more
than one route and more than one level of 5.46 Larger and more wide-ranging exercises should be
management (that is, it should have some carefully planned to ensure that control is
communication resilience). maintained and that reversion to status quo is easily
achieved. An alternative is to carry out a table-top
Staff functions exercise where a scenario approach is tested and
staff are challenged to deal with the issues that
5.40 Individuals who are responsible for different parts arise.
of the emergency process should be identified,
notified and trained accordingly. Key functions will 5.47 These approaches should engage all staff involved
include: in contingency and emergency planning for the
healthcare organisation so that all lessons learned
communications; can be shared across all services and used to update
incident manager; the plans.
resource manager;
emergency procedure manual owner.
34
6 Training, information and communications
Overview Building occupiers

6.1 All staff involved, irrespective of employer, need to 6.4 The engineering services and their functions and
be adequately trained and competent to undertake operation should be explained to the building
the work expected of them. This is especially occupiers. This will assist in understanding the safe
pertinent to work on critical engineering systems operation and capability of the particular system
and services where errors may have significant when changes are being considered.
implications.
Service and maintenance staff
6.2 All personnel employed in the operation and
maintenance of critical engineering services, 6.5 Training of all staff involved with the operation or
including maintenance personnel and operators, maintenance of the engineering services is essential
should receive adequate, documented training. to realise the optimum use of facilities and the
Personnel should not commence their duties until safety of staff, patients and the public.
this training has been completed and detailed
operating instructions have been provided. The required workforce
6.3 As a minimum, training should include: 6.6 All staff involved, irrespective of employer, need to
be adequately trained and competent to undertake
a. the prime function for the operation and
the work expected of them. This is especially
maintenance of the critical engineering service;
pertinent to work on critical engineering systems
b. operational policies; and services where errors may have significant
implications.
c. safety provisions;
6.7 Consequently, a process needs to be developed
d. first-aid (as appropriate);
which regularly checks that the workforce is
e. emergency procedures; competent and suitably trained to cover all aspects
f. use of respiratory equipment (as appropriate); of the work required. The following issues may
require consideration:
g. duties to be performed;
a nalysis of maintenance profile (review of
h. actions in the event of a fire; existing practice);
j. problems and hazards that can arise from failing a ssessment of emergency repair experience (to
to follow the agreed operating, monitoring and inform staff profile);
maintenance procedures;
p
lanned and first-line maintenance of
k. the permit-to-work system and safety equipment (to determine essential skills);
procedures in use (when appropriate);
r ecruitment and retention experience (to
m. the danger of making unauthorised understand the likely labour pool available);
modifications, alterations or additions to the
critical engineering service, as well as the skills gap (determined by an analysis);
possible legal consequences; p
otential/ideal staff profile (as if setting up a
n. the procedure to be followed if it is suspected new structure);
that the system is no longer operating correctly. p
ossible training (to meet the above if not
available from in-house arrangements).
35
6.8 From this type of assessment, it should be possible 6.14 The cost of training and the cost of apprenticeships
to determine the service shortfalls relative to loss of can be difficult to secure. When presented as part
staff for whom a natural replacement is not readily of an overall assessment with, at least, a medium-
available, and the skill shortages of existing staff term plan, it can deliver cost-efficient provision of
and the skill shortage for equipment or systems services meeting the future need of the
installed etc. organisation.
6.9 The resulting analysis may give rise to either a 6.15 Training and the quality of service are inter-linked.
training need for existing staff or a need for a staff/ Taking full advantage of multiskilling and flexible
structure review with possible training implications. working practices will begin to deliver the cost and
It may also identify a service which may be more performance efficiencies required from the services.
cost-effectively provided by an outsourced contract.
6.10 While it is important to address the staff profile by Criteria for operation
trade or service, it may be useful for an organisation 6.16 Maintenance staff should be trained in all
to link the outcome with other service profiles. maintenance procedures.
This may indicate some common issues, economies
6.17 The depth of training will depend on the level of
of scale for training needs, useful feeder groups and
required maintenance, but it should at least draw
a better general overview of the service, which can
attention to any risks and safety hazards arising due
be used to inform a priority assessment.
to maintenance activities.
Improving the workforce profile 6.18 Other personnel who monitor plant or who carry
out routine plant maintenance should be trained
6.11 Many of the traditional training routes no longer
in:
provide the level of opportunity relevant to the
healthcare sector; at the same time, skills and a. understanding the visual displays;
competences needed are becoming more and more b. acknowledging and cancelling alarms;
specific to the healthcare sector.
c. taking required actions following alarm
6.12 One challenge is to encourage more young people messages;
to enter the services sector of healthcare
organisations under specific programmes such as d. obtaining the best use of the system.
the modern apprenticeship scheme where skills can 6.19 Training (including refresher training) will need to
be delivered to meet a specific need. Another is to be repeated periodically in order to cater for
develop a multi-skilled approach to service delivery. changes in staff or the systems.
In each case, training and development will be an
important factor in the solution. 6.20 Records of the training provided should be kept
up-to-date.
6.13 With an understanding of the existing workforce
profile, a training plan may be established to meet 6.21 On completion of training, employees should be
the short-, medium- and long-term requirements assessed by an Authorised Person to ensure that the
that are needed to satisfy the organisations training programme has been understood and that
requirements. they are competent to undertake the work required.
36
7 Maintenance
Overview 7.9 Initial maintenance of equipment is particularly

important to establish validation of warranties.
7.1 The frequency of any particular maintenance Responsibility for this can be focused effectively by
activity and the need for planned preventive including the first 12 months maintenance in the
maintenance of the critical engineering services supply contract. If maintenance is to be provided
should be determined and continually assessed by the supplier/installer, it will be advantageous to
throughout its operation. This is to avoid detail the costs in the initial tender invitations.
unnecessary routine maintenance while ensuring
the services remain safe and available. 7.10 The maintenance contractor may not be the
equipment provider, services manufacturer or the
7.2 Healthcare organisations should make available to installation contractor. Clear understanding needs
maintenance personnel originals of commissioning to be established as to who is responsible for what,
data, as-fitted drawings, manuals etc, and records of and what maintenance service will be provided.
any changes implemented since commissioning.
7.11 Management should be satisfied that the contractor
7.3 Schedules of routine maintenance activities, responsible for the regular maintenance of the
suggested spares lists, and operational information engineering services employs staff who:
should be readily available. This could be achieved
by the use of computer-based systems to maintain a. understand the extent and nature of the
plant databases, maintenance requirements and healthcare to which the service relates;
records. b. are competent to do the work and have had the
7.4 Monitoring of data from the critical engineering necessary training;
services enables faults to be rectified at an early c. have a knowledge of the installed system;
date.
d. maintain a current awareness of the
7.5 The actual frequency of any particular maintenance manufacturers equipment, including computer
activity and the need for planned preventive hardware and software;
maintenance of the critical engineering services
should be determined and continually assessed e. have access to modern diagnostic equipment;
throughout its operation. This is to avoid f. have good technical support;
unnecessary routine maintenance while ensuring
the services remain safe and available. g. are supported by an adequate supply of spares.
7.6 The initial frequency of maintenance will depend 7.12 Records of service reports and attendance dates
on the manufacturers recommendations and the (both scheduled and achieved) should always be
circumstances of application. available.
7.7 Record sheets should be completed for all Maintenance policy

maintenance actions.
7.13 A maintenance policy that pursues and expects the
Maintenance contractors good upkeep of equipment by regular inspection
and overhaul is a sign of good management. An
7.8 Organisations may arrange for the appointment of appreciation of safety, at all times, by operational
a contractor to provide a maintenance service and staff should be encouraged.
emergency breakdown support should directly-
employed staff not be suitably qualified or
available.
37
Tools shutdown to be slotted into the overall planned

maintenance programme to minimise disruption.
7.14 Special tools to carry out the necessary basic level of
breakdown, maintenance or overhaul should be
Original commissioning tests
held in stock.
7.22 It is recommended that the original tests are
7.15 Instrumentation and tools that are classified as
checked and/or witnessed by suitably qualified staff
safety tools should always be available on site, and
on behalf of the client and signed off by both client
their position known to those who may need to use
and contractor.
them.
7.23 These tests generate the contractually agreed
Instructions records of the original commissioning procedures
related to particular items of equipment or plant.
7.16 It is essential that practical training is given to all
They must be accurate, retained and kept in a safe
operational and maintenance staff to ensure that
place. Reference to these documents should be
work routines, operational procedures, and correct
made from copies, as they represent the history of
application of the safety procedures and rules are
the equipment or plant. The originals should not
implemented.
be handled for reference purposes in confirming
7.17 Initial and, where appropriate, ongoing training tests or in discussion, the exception being as legal
should be given by the manufacturer to all documents.
technical staff as part of the contract requirement,
and should be based on the operating and Original and amended drawings
maintenance manuals, which themselves should be
7.24 As with test records, these drawings have
supplied as part of the contract.
contractual significance, being the original as-built
form.
Maintenance frequency
7.25 They are legal documents showing the assembly
7.18 The frequency of maintenance will be influenced
and construction of a system, and healthcare
by several operating factors, such as information
organisations should ensure that complete and
supplied by manufacturers. This information
accurate drawings are handed over to them on
should be used to maintain the operational
completion of the work.
integrity of an item of plant or equipment.
7.26 These drawings, with dated amendments made
7.19 Planned preventive maintenance (or maintenance
during the construction phase up to final
at fixed intervals irrespective of a service need)
acceptance, should not be amended. Where
should be balanced against the application of
subsequent changes are made, these should be
breakdown maintenance. The best approach may
entered on separate amended drawings and noted
be a mix of both, depending upon local factors and
to indicate the date and reference as appropriate.
circumstances.
Functional tests
Maintenance planning
7.27 Functional tests are a practical demonstration of
7.20 Irrespective of the scale of operation, maintenance the operation of an item of equipment or plant.
programmes are essential to ensure that all the The commissioning functional test record sheet
critical engineering service equipment is checked, should be preserved for future reference. It will be
inspected, tested, repaired or replaced at the the comparative reference for all future
appropriate time. This makes sound economic maintenance tests throughout the life of the item of
sense, as it enhances the operational life span of the equipment or plant.
equipment and maximises the potential for its
availability for use. 7.28 The frequency of such routine tests can depend on
the use of the equipment as represented by the
7.21 To ensure that an organised maintenance running hours or operations. Experience may well
programme is carried out economically, it should dictate this requirement on the basis of routine and
be supported by a reporting system of defect and specific time-checks.
failure. Classifications of urgency would allow for
those defects requiring extensive plant isolation and
38
7 Maintenance
Inspections prior to recommissioning be obtained, a programme should be drawn up in

consultation with the Authorised Person and the
7.29 Before any engineering service equipment or plant
maintenance person.
is put back into service following a period of
maintenance, a thorough inspection of all 7.32 Although the manufacturer may carry out certain
operational controls, protection settings, alarms inspection and maintenance procedures under the
and indications should be carried out. This would terms of his guarantee, these may not constitute a
normally be the responsibility of the person full PM programme. The user or their
undertaking the work, the Competent Person, or representative should therefore ensure that the
the Authorised Person. complete PM programme is carried out by the
maintenance person during the guarantee period.
Planned maintenance programme 7.33 The user or their representative should also
7.30 The planned maintenance programme should be implement any reasonable instructions given by the
designed according to the following principles: manufacturer during this period. Failure to carry
out maintenance tasks and periodic tests could
where the correct functioning of important affect safety.
components is not necessarily verified by the
periodic tests prescribed for the critical 7.34 A set of procedures should be developed for each
engineering service, those components should critical engineering service, containing full
be regularly tested, and reference to testing instructions for each maintenance task.
them should be included in the schedules of 7.35 It is important that maintenance is planned so that
maintenance tasks. This applies, for example, to any plant or equipment is out of service for as little
door interlocks that may only be required to time as possible.
perform their safety function when presented
with an abnormal condition; 7.36 Where practicable, maintenance should be
scheduled to immediately precede any periodic
the maintenance programme should include, at tests.
appropriate intervals, those tasks such as
lubrication and occasional dismantling of Review of the planned maintenance programme
particular components (such as pumps), the
need for which is indicated by normal industry 7.37 The PM programme, procedures and records
best practice, manufacturers advice and should be reviewed at least once a year by the user
experience. Apart from those tasks, the and the maintenance person in association with the
maintenance programme should concentrate on Authorised Person. To do this, it is necessary to
verifying the condition of the critical keep systematic records of all work done, so that
engineering service and its components by judgement can be made in consultation with the
means of testing and examination without manufacturer on what changes, if any, to the PM
dismantling. Parts that are working correctly programme would be best.
should not be disturbed unnecessarily. 7.38 The review should aim to identify:
maintenance should be carried out under a a. any emerging defects;
quality system such as BS EN ISO 9000. Spares
fitted to critical engineering services constructed b. any changes required to the maintenance
under a quality system should be sourced from programme;
the manufacturer or a similarly approved quality c. any changes to any maintenance procedure;
system.
d. any additional training required by personnel
Design of a planned maintenance programme concerned with maintenance;
7.31 The planned maintenance (PM) programme

e. whether records have been completed
supplied by the manufacturer should be used where satisfactorily, signed and dated.
it is available. If no manufacturers programme can
39
8 References
Health Technical Memorandum 02-01 Medical gas CIBSE Code for Lighting, Guide F Energy efficiency
pipeline systems. in buildings.
nes for healthcare projects. CIBSE Lighting Guide 7 Office lighting.
Control of Asbestos Regulations 2006. Lighting and colour for hospital design. DH, 2004.
Health Building Note 00-07 Resilience planning for Health Technical Memorandum 05-02 Fire safety in
the healthcare estate. the NHS: Guidance in support of functional provision
for healthcare services.
Health Technical Memorandum 06-01 Electrical
services supply and distribution. Health Technical Memorandum 08-03 Bedhead
services.
Health Technical Memorandum 03-01 Specialised
ventilation for healthcare premises. Health Technical Memorandum 2009 Pneumatic air
tube transport systems.
Health Technical Memorandum 08-01 Acoustics.
Health Technical Memorandum 08-02 Lifts.
TN 9/92 Space and weight allowances for building
services plant inception stage design. Health Technical Memorandum 07-06 Sustainable
health and social care buildings: Planning, design,
TN 10-92 Space allowances for building services
construction and refurbishment.
distribution systems.
Building Regulations.
Health Guidance Note Safe hot water and surface
temperatures. Carbon Trust.
Health and Safety Executive Guidance Note EH 40. Sustainable development in the NHS. DH, 2001.
Control of Substances Hazardous to Health (COSHH) Sustainable development: Environmental strategy for the
Regulations. National Health Service. DH, 2005.
Health Technical Memorandum 04-01 The control of NHS Sustainable Development Unit.
Legionella, hygiene, safe hot water, cold water and
Building Services Research and Information Association.
drinking water systems.
Chartered Institution of Building Services Engineers.
Health Technical Memorandum 2005 Building
management systems. Health Technical Memorandum 07-01 Safe
management of healthcare waste.
Firecode.
Health Technical Memorandum 07-05 The treatment,
Health Technical Memorandum 05-03 Part B Fire
recovery, recycling and safe disposal of waste electrical
detection and alarm systems.
and electronic equipment.
Institute of Engineering and Technology Guidance Note
Health Technical Memorandum 07-06 Disposal of
7 Special Locations.
pharmaceutical waste in community pharmacies.
MEIGaN Medical Electrical Installation Guidance.
Management of Health and Safety at Work Regulations
Medicines and Healthcare products Regulatory Agency.
1999.
CIBSE Code for Lighting.
NHS and Community Care Act 1990.
CIBSE Code for Lighting, Lighting Guide 2 Hospitals
Disability Discrimination Act 1995 (DDA).
and health care buildings.
40
8 References
Management of Health and Safety at Work Regulations Pressure Systems Safety Regulations 2000.
1999.
Pressure Equipment Regulations 1999.
Workplace (Health, Safety and Welfare) Regulations
Simple Pressure Vessels (Safety) Regulations 1991.
1992.
Construction (Design and Management) Regulations
Provision and Use of Work Equipment Regulations 1998.
1994.
Manual Handling Operations Regulations 1992.
Construction (Health, Safety and Welfare) Regulations
Personal Protective Equipment at Work Regulations 1996.
1992.
Building Regulations 2000.
Confined Spaces Regulations 1997.
Environmental Protection Act 1990.
Reporting of Injuries, Diseases and Dangerous
Control of Pollution (Amendment) Act 1989.
Occurrences Regulations 1995 (RIDDOR 95).
Waste Management Licensing Regulations 1994.
Working Time Regulations 1998.
Environmental Protection (Duty of Care) Regulations
Control of Substances Hazardous to Health Regulations
1991.
(COSHH) 2002.
Controlled Waste (Registration of Carriers and Seizure of
Health and Safety (Consultation with Employees)
Vehicles) Regulations 1991.
Regulations 1996.
Hazardous Waste (England and Wales) Regulations 2005.
Health and Safety Information for Employees
Regulations 1989. List of Wastes (England) Regulations 2005.
Health and Safety (Safety Signs and Signals) Regulations Pollution Prevention and Control (England and Wales)
1996. Regulations 2000.
Employers Liability (Compulsory Insurance) Regulations Clean Air Act 1993.
1998. Environmental Protection (Prescribed Processes)
Health and Safety (Training For Employment) Regulations 1991.
Regulations 1990. Trade Effluent (Prescribed Processes and Substances)
Control of Asbestos at Work Regulations 2002. Regulations 1989.
Electricity Act 1989. Controlled Waste Regulations 1992.
Electricity Safety, Quality and Continuity Regulations Environment Act 1995.
2002. Packaging (Essential Requirements) Regulations 2003.
Electricity at Work Regulations 1989. Control of Pollution (Oil Storage) (England) Regulations
Electrical Equipment (Safety) Regulations 1994. 2001.
Plugs and Sockets etc (Safety) Regulations 1994. Landfill Tax Regulations 1996.
Radio Equipment and Telecommunications Terminal Chemicals (Hazard Information and Packaging for
Equipment Regulations 2000. Supply) Regulations 2002.
Electromagnetic Compatibility Regulations 1992. Town and Country Planning Act 1990.
Supply of Machinery (Safety) Regulations 1992. Producer Responsibility Obligations (Packaging Waste)
Regulations 2005.
Lifting Operations and Lifting Equipment Regulations
1998. Waste Electrical and Electronic Equipment Directive
2002.
Gas Appliances (Safety) Regulations 1995.
Water Industry Act 1991.
Gas Safety (Installation and Use) Regulations 1998.
Water Supply (Water Quality) Regulations 2000.
Lifts Regulations 1997.
Water Resources Act 1991.
Noise at Work Regulations 1989.
41
Water Supply (Water Fittings) Regulations 1999. Food Safety Act 1990.
Control of Lead at Work Regulations 2002. Food Safety (General Food Hygiene) Regulations 1995.
Noise & Statutory Nuisance Act 1993. Food Safety (Temperature Control) Regulations 1995.
Ionising Radiations Regulations 1999. Public Health (Infectious Diseases) Regulations 1988.
Radioactive Substances Act 1993. A risk-based methodology for establishing and managing
backlog. DH, 2005.
Ionising Radiation (Medical Exposure) Regulations 2000.
Health Building Note 11-01 Supplement A Resilience
Radioactive Materials (Road Transport) Regulations
and emergency planning in primary and community
2002.
care.
(The) Regulatory Reform (Fire Safety) Order 2005.
NHS Emergency Planning Guidance 2005.
Furniture and Furnishings (Fire) (Safety) Regulations
1988.
Dangerous Substances and Explosive Atmospheres
Regulations (DSEAR) 2002.
42

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Policies and principles Health Technical Memorandum 00 Best practice guidance for healthcare engineering

Health Technical Memorandum

Crown copyright 2013

Figure 1 Healthcare building life-cycle

Figure 2 Engineering guidance

Environment & Medical

HTM 06 L& N HTM 03

Services STR AR Ventilation

System resilience, planning and design

Engineering services commissioning, maintenance, and future

Access 1.47 The system should address the following points:

Procedure for electricity supply failure

Key areas of equipment likely to be

Major supply failure

Continued supply failure

Partial supply failure

Awareness and training

Procedure for water contamination

Investigation and response

Plan approved and accepted by:

Procedure for piped medical gas failure

Identification of the source and nature of failure

Minor failure, not life-threatening

Major failure of supply

Senior Medical Officer, Surgeon/Senior Nurse

Duty Engineer/Authorised Person

Provision of temporary supplies (pipeline).

Designated Manager, Hotel Services

Training and information

Piped medical gases

Risk of fire outbreak, or reduced fire-fighting ability?

Agree responsibility boundaries

Risk of fire outbreak, or reduced fire-fighting ability?

Consider Service Level Agreements with purchasers?

Will patient/Public/Staff safety/care be affected?

Record specialist contractor contact details?

Record Trust personnel contact details?

Locate supply of specialist equipment?

Consider impact on water supply?

Consider impact on site security?

Locate approved subcontractors?

Agree responsibility boundaries

Keep records of actions taken?

Involve commercial services?

Increased risk of legionella?

Impact on fire alarms?

Resilience and emergency preparedness secondary power sources such as emergency

external access arrangements; Access to engineering service outlets

Metering d. Sloped surfaces are provided instead of

1.86 Theoretical modeling of summer temperatures Internal drainage

Building management systems General electrical services

voice systems; tube systems, see Health Technical Memorandum

2 Statutory and legislative requirements

Disability Discrimination Act 1995 (DDA) T

Clean Air Act 1993 Fire

2.18 In a similar way, a cost/benefit matrix may be

Healthcare organisation management board:

External independent Senior estates &

Competent Assessed (safety)

Authorising Engineer Trust Senior Operational

Authorised Person (AP) record-keeping should be assigned to specific APs

Monitoring of the operational policy Medical equipment purchase

Overview including patient care, staff comfort, and health

5.5 Such failures or incidents, when they occur, can m