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

2. Ventilation Risks – Breaking the Law!
Health Acts – Patient Safety - Infections
Health and Safety at Work Act
CoSHH – Local Exhaust Ventilation (LEV)
Advisory Committee on Dangerous Pathogens.
Building Regs. – Fresh air; HTM’s & HBN’s
Medicine Acts – Quality assurance
NP's 5/14

3. HTM 03-01, Part B, Nominated Persons
Designated Person
Authorising Engineer (Ventilation) – AE(V)
Authorised Person (Ventilation – AP(V)
Competent Person (Ventilation – CP(V)
Infection Control Officer
Plant operator
NP's 5/14

4. HTM 0301; B. Hierarchy of Authority
Designated Person
Appointed senior executive
(NHS Board level)
responsibility of service
Authorised person AP(V)
Appointed qualified technical engineer
(Specific to service)
Authorising engineer AE(V)
Appointed independent professional engineer
Board senior operational manager
Informed client
Competent person CP(V)
Assessed and qualified craftsperson
(Specific for service)
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5. Duties and Responsibilities Designated Person
Board level manager
Direct link to Operational management
Will communicate Board policy to Organisation
Will require the service be provided
Will require evidence that it has been (Annual audit report)
Will present strategic operational plan to board
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6. Duties and Responsibilities Authorising Engineer (Ventilation) – AE(V)
Expert in Healthcare Ventilation
Independent of Board and its organisation
Conducts an audit of ventilation provision
Provides independent advice
Recommends candidates for AP(V) and CP(V)
Reviews reports and documentation
May provide training for AP(V) and CP(V)
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7. Duties and Responsibilities Authorised Person (Ventilation) – AP(V)
Manager with knowledge of Healthcare Vent.
Trained in the duties of an AP
Appointed in writing by Designated person
Implements policy procedures to ensure the safe provision of ventilation in Healthcare
Recommends candidates for CP(V)
Overseas outside contractors standards
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8. Duties and Responsibilities Competent Person (Ventilation) – CP(V)
Craftsman / Technician grade
Knowledgeable in Healthcare Ventilation
Trained in the duties of an CP
Appointed in writing by Designated person
Carries out service and maintenance of ventilation systems in a Healthcare setting
May oversee internal and external work
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9. Duties and Responsibilities Infection Control Officer
Consultant Microbiologist or Designated Infection Control Officer
Advises Board on infection control issues
Chairs Infection Control committee
Provides support to AP(V) (who should be a member of the Infection Control committee)
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10. Annual Audit of Ventilation
Element
Compliance 1
Management issues 2
Authorised Person 3
Competent Person 4
Infection Control 5
LEV systems 6
Critical Healthcare systems 7
Fire issues 8
Plant locations 9
Energy efficiency 10
Support issues
NP's 5/14

11. Typical initial Audit report
Element 1) - Management Issues
Comment
Designated person
Mr. C. Y. Arse – Director of Estates
Authorising Engineer (Ventilation) appointed?
Yes – Malcolm Thomas
Authorised Person (Ventilation) appointed?
Nominated only
Competent Person(s) (Ventilation) appointed?
Infection Control Person appointed? No
Inventory of LEV systems available?
Inventory of specialised healthcare systems?
Are all systems uniquely identified?
Not always
Is there an up to date condition survey?
Is there a system replacement programme?
NP's 5/14

12. Typical initial Audit report
Element 2) - Authorised Person (Ventilation)
Comment
Name
Mr. I.M. Trying – Possible
Mr. N. Bothered - Possible
Position
IT – Estate Manager
NB – Assistant Estate Manger
Work location
Nonsuch Hospital
Training records
IT - None
NB – 2 weeks Ventilation at Eastwood Park c1992
No training but local knowledge
Area / site of responsibility
Element 3) - Competent Person(s) (Ventilation)
Comment
Name(s)
Mr. E. Skives (Mech) – Possible
Mr. R. Keen (Elec) - Possible
Position
ES – Mechanical craftsperson
RK – Electrical craftsperson
Work location
Nonsuch Hospital
Training records
ES – None
RK - None
Area / site of responsibility
NP's 5/14

13. Typical initial Audit report
Element 5) - LEV Systems
Comment
Location of inventory
None (See Appendix 1)
Are all LEV systems listed? No
Is each system clearly labelled and its area served identified?
Does each system have a log book or Information file?
General file of LEV system annual inspection reports
Does the file contain design, commissioning, and verification information?
See above
Does the file contain records of repair, maintenance and routine inspections?
On maintenance system computer
Is each system subject to a statutory inspection every 14 months?
Yes (Hazards Ltd.)
Is there a designated “user” contact for each system?
Department head
Is there a “Hand over / Hand back” and/or PtW system in operation when work is being undertaken on the system
Yes
NP's 5/14

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

15. Typical initial Audit report
Element 6) – Specialised Healthcare Systems
Comment
Location of inventory
None (See Appendix 2)
Are all specialised healthcare systems listed? No
Is each system clearly identified/labelled
Yes
Does each system have a log book or Information file?
Does the file contain design, commissioning, validation and verification information?
Is each system subject to an annual verification?
Is each system subject to routine maintenance?
On maintenance system computer
Is there a designated “user” contact for each system
Department head
Is there a “Hand over / Hand back” and/or PtW system in operation when work is being undertaken on the system
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16. AHU with Plate Heat Exchanger
NP's 5/14

17. UCV Theatre ventilation
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18. Typical initial Audit report
Element
Compliance
Management Issues
25%
Authorised Person(s) (Ventilation)
10%
Competent Person(s) (Ventilation)
Infection Control Person
90%
LEV Systems
60%
Specialised Healthcare Systems
Fire Issues
35%
Plant Locations
50%
Energy efficiency
Support aspects
30%
NP's 5/14

19. How did they do?
How would you do?
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