2. Review methodology
2.1 Review process
2.1.1 The review process initially took place between 9th July and 30th August 2019. For this report no further information has been considered after 5th September 2019.
2.1.2 The approach taken was to gather information relating to the services detailed in section 1.2 in drawing, specification, report and oral form and to compare these to the specifications and guidance appropriate for the building type, drawing conclusions on whether what is provided matches the requirements. In addition to existing specifications and guidance, learning generated from recent experience and national and international guidance and expertise was also used to inform the review. This learning will also inform future guidance development in Scotland.
2.1.3 The review has included
- Establishing a brief.
- Establishing the baseline data to allow the brief to be met.
- Preparation of several question sets to get a greater understanding of the project.
- Preparation and management of detailed question sets and information requests.
- Commissioning UK topic experts to review certain aspects of the project.
- Several site visits.
- Several meetings.
- Analysis of data.
- Analysis of microbiology results related to the hot and cold water systems.
- A rapid review of the literature and international guidance on ventilation systems in relation to infection.
2.2 Specifications and Guidance
2.2.1 HFS currently provides a range of advisory and delivery services across a wide variety of topics from a portfolio which covers the built estate, engineering and environment and facilities management. With some exceptions these services are largely advisory in nature, identifying best practice and developing national guidance and standards.
2.2.2 HPS currently provides advice and guidance on all aspects of health protection nationally in Scotland, inclusive of expert advice and guidance on the topic of Healthcare Associated Infections (HAI) and antimicrobial resistance. It maintains and continues to develop a practice guide (National Infection Prevention and Control Manual – NIPCM) as well as a HAI Compendium of all extant guidance and policy appropriate for use in NHS Scotland. Like HFS, these services are largely advisory in nature, identifying best practice and developing national guidance and standards. The NHS Scotland NIPCM was first published on 13 January 2012 as mandatory guidance, by the Chief Nursing Officer (CNO (2012)1), and updated on 17 May 2012 (CNO(2012)01-update). The NIPCM provides guidance for all those involved in care provision and should be adopted for infection, prevention and control practices and procedures. The NIPCM is mandatory policy for NHS Scotland.
The authority of guidance produced by NSS and other national organisations e.g. Healthcare Improvement Scotland is best described by the definitions outlined below (SHTM 00 – Best practice guidelines for healthcare engineering):
2.2.3 Whilst guidance is deemed not compulsory by HSE (not legally enforceable), where compliance with guidance is specified in a contract, as is the case here, it becomes a contractual requirement. Therefore, any permitted deviation from it would be expected to follow a formal process with input from all relevant parties, with clarity around how the outcome was reached, including risk assessments where appropriate and sign off by all those authorised to approve it.
2.2.4 The terms specifications and guidance are used in the report to refer to the publications setting out the expectations about the level of service to be provided, including legislation, approved codes of practice and guidance. Compliance with guidance is reported on, regardless of whether this implies a contractual requirement or not, as contract compliance is outwith the scope of this report. For the avoidance of doubt we have not considered the project agreement and contractual compliance in accordance with its terms, as this is subject to a separate review commissioned by Scottish Government.
2.3 Reporting methodology
2.3.1 For clarity this report organises issues with each of the systems considered into a priority rating, identifying the importance of deviations from what would be expected based on the specifications and guidance. The distinction between the categories is based on NSS judgement of the degree of non-compliance and the implications of that non-compliance. The criteria used are described below.
|Significant – Concerns requiring immediate attention, no adherence with guidance
|Major – Absence of key controls, major deviations from guidance
|Moderate – Not all control procedures working effectively, elements of noncompliance with guidance
|Minor – Minor control procedures lacking or improvement identified based on emerging practice
|Observation and improvement activity
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