Management and Assurance
NSS Review: Omissions identified in key roles within the management structure, ease of access to information.
NHS Lothian response: Management roles and responsibilities and will be identified and the responsibility matrix will be reviewed on a regular basis. Archiving of information will be revised in line with guidance and contract requirements
through NHS Lothian’s Corporate Management Team.
|Issue||NSS Review||NSS Action Assessment||NHS Lothian action|
|Structures and processes||Structures and processes are not fully in place to assure the Board that the facility is being operated in compliance with contract requirements. These should be in place from the point where the building services referred to in this report are put into use.||NHS Lothian and IHSL should adopt the management and reporting processes as described in SHTM 00 – Best Practice Guidance for Healthcare Engineering and the SHTMs for each critical engineering service.||AGREED
Contract management arrangements will follow SHTM 00.
|Contract requirements||Some of the records and documents necessary for the effective and safe operation of the hospital could not be found. The document management system appears to lack a logical structure which will impact on the ability to readily find necessary information. Some of the sections contain none, or only part, of the documentation they should have as required by the Construction (Design and Management) Regulations 2015.||The Board should require IHSL to rectify the filing structure of the documentation and verify that the information contained is both complete and accurate as required by the Construction (Design and Management) Regulations 2015.||AGREED
A review and demonstration of completeness has been requested from IHSL and additional information has been provided by them.
|Alarms||The alarms for the building are reportedly un-prioritised, resulting in a very large number of alarms potentially masking critical alarms.||Prioritise alarms to make most critical failures visible and manageable. Until alarms are prioritised, have procedures and staff in place to ensure critical alarms are not missed as per SHTM 08-05 - Specialist services building management systems.||AGREED
NHS Lothian has requested a programme to confirm this in place by the end of September.
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