GOVERNANCE AND COMPLIANCE


which says: ‘For many of these systems an equipment release or permit-to-work certificate will need to be completed to ensure that taking the ventilation system out of service does not compromise the activities of the user department. In any event, it will be necessary to liaise with the user department when switching the system off to carry out routine inspection and maintenance.’ The management of these ERC or PTW systems is directly linked to the size and complexity of the ventilation systems within an organisation, but is time-critical, and likely to involve a considerable amount of both time and close working with other stakeholders, e.g. clinical teams.


An AP(V)’s typical shelf and records.


easier if the people involved can work together without the need to seek blame or fault, and this approach is best established when issues are progressing well, and everyone is confident that they can trust and work with one another. It is far easier to meet informally over a coffee regularly to discuss what’s working well, rather than when something is wrong, and everyone is under pressure.


Review of verifications: Every ventilation system within a healthcare setting should have a sufficient initial validation to ensure that it is installed and functions correctly. Thereafter each year any critical ventilation system should have an annual verification to ensure that it continues to operate appropriately, and to provide a safe environment for the protection of both staff and patients. These verifications are similar to an annual ‘MOT’, to provide assurance to the organisation and clinical teams, and should be used to highlight any areas of historic issue (since the previous verification), and as a forward assurance of future performance. The results of these verifications are required to be communicated on the day of being undertaken to the AP(V), and are subject to an immediate review, and – if needed – escalation to other stakeholders such as clinicians or IPC colleagues to ensure that any identified issues are actioned as appropriate. In practical terms the detailed reports of the verification exercise can take up to a few weeks to be provided, and time is required to be given to the AP(V) to undertake a comprehensive review of these reports to ensure that all aspects are assessed and actioned as appropriate. It is usual that these actions are recorded in some form of live ‘tracker’ document to ensure confirmation of completion or action. The reports should form part of the assurance reporting to the Ventilation Safety Group (VSG) of issues, and provide evidence for both the Premises Assurance Model (PAM) returns and backlog investment and risk registers / strategies.


If – as in this instance – a glass trap keeps leaking, the author advises changing it for an isolation valve.


Management of Permit to Work (PTW) / Equipment Release Certificates (ERC): As a minimum, every critical ventilation system should be controlled by means of a suitable equipment release or Permit to Work system, as outlined under clause 5.5 of HTM 03-01 Part B,


PPM monitoring – SSoW & RAMS: One of the cornerstones of a safe and reliable ventilation system is the provision of regular and appropriate planned preventative maintenance, and this activity is required by law to be suitably controlled and managed by means of safe systems of work and task and system-specific risk assessments. These systems take time to set up, and require regular (at least bi-annual) review to ensure that they remain appropriate. New or refurbished systems also need to be added, and redundant systems removed. Developments in ways of working and plant and equipment technology should be reflected and updated as appropriate. Much of this information should be in place, and updates driven from the appropriate levels of information provided through the validation process for new projects or systems.


Review of sub-contracted services: Many organisations sub-contract out a number of key maintenance tasks. These typically can include fire damper drop testing, air-conditioning maintenance and servicing, and ductwork inspection and cleaning (especially kitchen extract cleaning). These tasks require specific competencies, and the AP is required to assess the companies and individuals undertaking this work. There is also an absolute requirement to review, assess, and action, the subsequent reports, which often entails remedial actions or follow-up work to ensure continued compliance or risk identification for assurance purposes.


VSG reports and attendance: The Authorised Person is required to be an active member of the Ventilation Safety Group (VSG), and – as such – provide, ideally via a written status report, regular updates and assurance to the group of appropriate maintenance and the condition of ventilation systems. The concept of this report is to produce an overview summary of ventilation management and control systems on an operational site basis to members of the VSG – to provide assurance that appropriate management controls are in place to maintain the ventilation systems, and minimise the risks to the organisation associated with the ventilation systems and compliance with legal obligations. This report should record, by exception, areas of concern and potential escalation through the organisation’s reporting structures, and also provide evidence for both the Premises Assurance Model (PAM) returns and backlog investment and risk registers / strategies.


Project design reviews: The AP(V) will typically be the first point of contact for any new or refurbishment project, and should always be involved and consulted on the practical aspects of any planned works at an early stage. This will involve attendance at planning and design meetings, often in conjunction with the AE(V) to ensure that new installations are compliant with the appropriate standards, and are operationally appropriate and maintainable.


28 Health Estate Journal March 2025


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