The draft HTM 03-01 revision, however, states clearly that the guidance contained in Part B applies to all ventilation systems installed in healthcare premises, irrespective of the age of the installation. Backroom systems, and tucked-away basement plant rooms in older buildings in the estate, will all be covered.

What is meant by ‘specialised’ or ‘critical’? We can find no really clear definition of what is meant by ‘specialised’ or ‘critical’. HTM 03 has always listed the departments that will usually have specialised ventilation requirements (operating and laser surgery suites, intensive treatment and isolation units, imaging, X-ray, and scanning units, and ‘path’ labs etc.), without expressly omitting other areas. The temptation may well have been to focus limited resources on these named critical areas and ‘front of house’, when surely all ventilation systems in premises delivering healthcare services have always presented the need to provide a good standard of ventilation for patients and staff? The new wording seems to leave no room for doubt that everything is to be included in the ventilation maintenance and management strategy. It calls for an inventory of all ventilation systems installed and in use, or capable of being used, including those at community and mental health facilities. The new guidance provides a powerful argument for increased maintenance budgets.

Get the measure of the job The foundation of planning is of course the system information – the up-to-date asset register and inspection records. The Ventilation Safety Group simply cannot operate effectively without a recent asset register, inspection report, and risk assessment, not least because it is required to produce a ventilation policy document on behalf of the healthcare provider. While in its simplest form this document can be a straightforward statement that the provider or Trust will follow the guidance provided in HTM 03-01: Part B, it may, according to the HTM, ‘also specify any departures from that guidance in terms of local additional requirements or derogations’. That calls for a detailed understanding of the assets.

The systems the guidance expects you to have covered are: n local exhaust ventilation systems (LEVs).

n critical healthcare ventilation systems (CHVs).

n general ventilation systems (GVS). n general extract systems (GES). n smoke and heat exhaust ventilation systems (SHEVs).

That looks like a ‘full house’ to us, and indeed there are many provider Trusts

54 Health Estate Journal February 2021

Only regular inspection will tell if a clean is necessary to meet HTM-03 requirements. Build-up of lint or fluff deposits like this is probably unavoidable, but as long as it is monitored, and action taken when necessary, should not be a major concern. This amount of fouling, after about 10 years in use, would not, on its own, trigger a clean.

with ventilation policies that do already apply HTM 03 principles to all parts of buildings within or attached to areas that can be accessed by patients. Doing so is not a big leap in compliance on inspection; ventilation ducts house fire dampers, which should be inspected and tested anyway. As indicated earlier, air-handling units have drip trays, pumps, and drains, that present risks of waterborne pathogens, and are (or should be) already subject to Legionella prevention measures (HTM 04 and ACOP L8 best practice).

Not all is well ‘within the real world’ Lest we fall into the trap of just describing ways to write policies and tick compliance boxes, we should be mindful that all is not necessarily well in the real world – this is not a desk exercise. In the course of our inspection work, we have seen simply unacceptable levels of corrosion, rooftop systems sitting in puddles of stagnant water, the bio-risk of fungal growth and fire risk of dust accumulation in ducts, water collected in corroded air-handling unit drip trays, and fire dampers that are simply not fit for purpose. It may be worth noting here that, among all the other regulations and standards it mentions, HTM 03 expects the principles of ACOP L8 to be adhered to, and, in our experience, the mention of that usually gets the attention of the budget controllers.

Our point, however, is not to create tension between estates and finance managers, but to stress that the risks that the revised guidance addresses are often real and present dangers. The solutions, however, are rarely easy, or the procedures would already be in place. Ideas like fitting sinks and drainage in plant rooms so that drip trays can be cleaned easily could mean big capital expenditure – not least because these rooms often have solid concrete ground-floor or basement floors. Having the means for visible inspection in all plant and ducts is a laudable goal, but they should have been designed in when the plant was installed. Adding them now carries a price ticket. Even where such portholes do already exist, we often find that internal lamps have failed, and that neither the budget nor the clinical downtime needed to replace them are readily available. Lack of easy access for inspection may mean more clinical downtime has to be factored in at inspection time. The recommendation to have clinicians serving on the VSG will certainly help with planning, and to make a case for prioritising changes that can minimise clinical downtime. Having a current asset register, inspection report, and risk assessment, is the foundation of good, efficient, and economical management. With the new guidance imminent, this may mean revisiting what might be a comprehensive register of perceived high- risk areas, but is not a complete register of all systems.

Management approach

It is Ventilation Safety Groups (VSGs) that will oversee, ensure, and enable, day-to- day delivery on the recommendations of Part B. While they do also oversee the design and modification of systems, the main thrust of their work will be in maintaining the standards of existing systems.

The revised standard refers specifically, and at length, to VSGs and their composition. We anticipate that Trusts will be looking at who else can add value to the management of ventilation plant at their next scheduled policy review, if not sooner, and will agree that the broader church from which members are drawn will be an advantage.

Composition of Ventilation Safety Groups

Ventilation Safety Groups (VSGs) will ‘typically’ comprise: n A Duty Holder – typically the Trust CEO. n A Designated Person – the person who will make Trust senior management at board level aware of any major risks presented by the hospital ventilation systems.

Surface corrosion behind rigid bag filters like this will only be spotted by visual inspection. It can build up quickly, damaging the fabric of the system.

n An Authorising Engineer – an independent person who provides advice, audits the system, and reviews documentation.

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