Item
m 10i
Ca
apittal proj
p jectts,
Es
stattes and
d Fa
aciliities
s
an
nnual repo
r ort
P
Produced by:
b
Chris Harding – D irector of Estates
E
& Facilities
F
b
P resented by:
Steve
S
Daviies – Finan
nce Director
Board
B
of Directorrs Meetin
ng
er 2015
10th Septembe
Action
A
for B
Board:

For info
ormation

For con
nsideratio
on

For dec
cision

Estates & Facilities biannual report
Executive Summary
2 Backlog Maintenance
4 Capital works at City Road
4 Satellite Sites
5 Estates & Facilities directorate report
6 Page 1
Estates & Facilities biannual report
Executive Summary
This report includes an update on the Estates and Facilities directorate, and includes progress
reports for major capital projects, for the year from October 2014 to September 2015. The
executive summary provides a précis of the important issues for the board; the following sections
include a further level of granularity if required.
The report includes developments which do not entail direct capital expenditure, but are estates
related in that they involve contractual issues relating to our occupancy at host hospitals.
This report also includes updates on the Estates & Facilities work streams and projects which fall
below the threshold for board approvals as these illustrate the scale of planned developments, and
demonstrate the delivery of the estates and facilities strategy as an enabler to Our Vision of
Excellence across City Road and satellite sites.
The major capital projects currently in progress are:
 City Road Theatre’s Upgrade programme;
 City Road backlog maintenance programme;
 City Road 3rd floor Injection Suite;
 St George's re provision and expansion; and
 Cayton Street PPU Expansion/Refurbishment.
The City Rd Theatres Upgrade programme was initially planned for commencement in autumn
2014, but the start date was delayed pending business approval to close the first two theatres. This
was given for 1st March 2015. Theatres 3 & 4 being the first pair to be implemented with 1&2, then
7&8, then 5&6 last, leading to a target completion date of 30th Nov 2015 which includes 3 weeks of
snagging. Proposed hand back of all theatres is Monday 9th November 2015. To date the first four
(Theatres 1-4) are complete and budget remains tight but on target despite the additional asbestos
and ventilation works uncovered during the programme.
The backlog maintenance programme for 2014/15 experienced difficulty in its completion due to
contractor based issues and change of staff in the capital role. This meant a carryover of the
programme into 2015/16. This work is now due for completion by the end of September 2015. The
new proposed works for external backlog maintenance is currently being specified ready for
tendering during August in order that it rolls on from the completion of the 14/15 works. Ingleton
Wood LLP has remained in place as Contract Administrators for continuity.
The building of a new intravitreal injection suite incorporating 4 injection treatment rooms and
associated ancillary rooms on the 3rd floor of City Road has been tendered and is currently under
review. With 3-4 months of construction works planned, a handover of January 2016 is the target.
St Georges University NHS FT’s plans for the relocation of the MEHFT service continue with
recent MEH Board approval given. St George’s are yet to approve the new modular building
(Wandle Annexe) proposed as our relocated outpatients department.
Following the acquisition of new leased space in Cayton Street, a feasibility study was produced to
support a business case and Board approval granted, ahead of occupation in September. The
Page 2
Estates & Facilities biannual report
study and case involves the options for occupying a number of floors both for private patients and
NHS patients.
Other capital projects successfully completed in this reporting period of note include:
 4th floor laser treatment rooms built within Private Patients;
 St Ann’s laser treatment room for the NHS Catalys trials;
 Northwick park medical gases enabling the provision of GA’s for theatres;
 Ocular prosthetics (RDCEC/Adults) refurbishment;
 Completion of patient/staff lift refurbishment program (2 remaining for budgeting within
2016/17); and
 First phase of CCTV replacement program (2nd phase to be completed by November 2015).
The estates & facilities directorate section includes reports from the following showing key issues
for the board to note:
 Estates& Facilities Directorate: 5 year strategy detailed report and implementation plan
submitted to FD and ManEx.
 Compliance: A compliance manager has been introduced to the directorate, whose role is to
review compliance relating to Estates and Facilities across all our sites in addition to supporting
the property management function.
 Estates services: All statutory maintenance up to date and approved persons appointed.
 Clinical technical services: Review of future structure underway.
 Domestic services: cleaning standards at Moorfields continues to be of a satisfactory
standard. The annual Patient-Led Assessment Care Environment took place on Monday 11th
April 2015.
 Portering: New portering software installed.






Security: The NHS Protect Self Review Tool (SRT) which is part of the NHS Contract was
completed and agreed with the Security Management Director (SMD) then forwarded to NHS
Protect. The NHS Protect Organisational Crime Profile 2015-16 has been completed and
forwarded to NHS Protect. The NHS Protect Reported Physical Assaults (RPA) statistics for
2014-15 were compiled and forwarded to NHS Protect.
Sustainability: The sustainable Development Strategy for the Health and Care system 2014 –
2020 has been fully reviewed and a strategy for Moorfields is currently being developed to
ensure our strategy is aligned.
Telecoms: Call centres created. All Estates SLAs maintained.
Transport services: The transport contract continues to be higher volumes that anticipated.
Successful Supplier Relationship Management (SRM) introduced.
Interpreting: Introducing trial telephone interpretation service as cost improvement.
Catering: 2015 Audit completed no issues identified.
The board is asked to note the progress made in the delivery of the backlog maintenance
programme and capital projects, and the overall performance of the Estates & Facilities directorate.
Page 3
Estates & Facilities biannual report
1.0 Backlog Maintenance
1.1 Fire Alarm Upgrade Works
2014/15 saw the completion of the fire alarm upgrade works with an L1 compliant system
throughout both RDCEC and City Road. 2015/16 sees the requirement for a graphics package to
allow an effective implementation of maintenance and alarm notifications, making visibility for our
staff and the Fire Brigade much easier in the event of activation. This is presently being specified
and will be seeking budget approval in Q3.
1.2 Fire door/compartmentation works
The backlog maintenance programme for 2014/15 experienced difficulty in its completion due to
contractor based issues and change of staff in the Capital role. This meant a carryover of the
programme into 2015/16. This work is now due for completion by the end of September 2015.
1.3 Lift Upgrade Works
Following a protracted delivery of Lift’s 1 & 3, Lift 6 was commenced in Oct 2014 via Jackson’s
Lifts. This was part of the tendered works (2014/15 Capital backlog programme) and we remained
with Jackson’s as there were liquidated ascertained damages (LAD’s) to recover and it was felt
keeping the new lift under the same supplier would make contract negotiations easier.
Lift 6 delivery was also protracted with further poor performance by Jackson’s incurring further
LAD’s. Lift 6 construction works are now complete awaiting final handover and insurance
inspection. Final LAD’s to be confirmed but MEH claim is approx. £31k inc VAT.
1.4 2015/16 Capital Programme
A sum of monies has been budgeted for asbestos removal, legionella control and external
maintenance including pest control, roof repairs and glazing replacements. These new proposed
works for external backlog maintenance is currently being specified ready for tendering during
August in order that it rolls on from the completion of the 14/15 works. These will be presented via
the Recruitment & Capital Schemes Panel.
The Estates department has also been addressing significant numbers of the smaller, discrete
backlog maintenance issues through its minor works programme.
2.0 Capital works at City Road
2.1 Theatre Upgrade Programme
The City Rd theatres upgrade programme was initially planned for commencement in autumn
2014, but the start date was delayed pending business approval to close the first two theatres. This
was finally given for 1st March 2015 with Theatres 3 & 4 being the first pair to be implemented on a
rolling schedule of approximately 8 weeks per pair, leading to a target completion date of 30th
November 2015 which includes 3 weeks of remedial activity and ‘catch ups’.
This programme represents a particularly challenging project given its location, criticality and
importance to the business in ensuring longevity of availability and compliance. The project has
now reached the half way stage with theatres 1-4 refurbished with new air handling systems,
digitised surgeons interfaces and HTM compliant systems throughout. Given the nature of the
works, the problematic issues (asbestos and ventilation works) uncovered during the programme
Page 4
Estates & Facilities biannual report
have been overcome with minimal impact to the overall programme. To date the budget remains
tight but on target even with the extra works uncovered.
Theatres are now capable of proving HTM 03-01 air flow compliance electronically and logging
history 24Hrs per day.
Completion of all theatres is due Monday 9th November 2015 followed by a three week period
where any items identified as a ‘better way’ or ‘collected along the way’ lessons learnt can be
retrospectively implemented in previous theatres.
2.2 CCTV Phase 2
This phase of the project has been split into two segments over 2015 with the initial stage including
an upgrade to all defective camera systems throughout City Road and new camera provisions
across A & E. The second stage will pick up on the medium priority areas including new provision
of coverage in lifts, stairwells and previously uncovered public spaces. All infrastructure has been
previously upgraded in Phase 1 so phases 2 and 3 (2016/17) will encompass the remaining
camera upgrades and new provision as identified as the lowest priority by LSMS.
3.0 Satellite Sites
3.1 St Georges
The host trust has a requirement to move MEH out of its current accomodation within the main site
and has to provide a new suitable location to allow us to continue our service. A proposal involving
a 4 storey modular construction with one and a half floors made available to MEH has been issued
by SGH. This will be known as the Wandle Annexe. MEH Capital has worked up an internal fit out
design, to be funded by MEH, and this has been approved by MEH Clinical teams and Board,
along with main hospital theatre reprovision. MEH is totally dependent upon SGH’s timescales for
the provision of this property with a possibility of March 2016 being mentioned for the shell building
completion. Fit out’s will follow this. We await confirmation of the SGH Board decision.
3.2 St Ann’s A scheme is being worked up to provide a separation of the hot water system within
the MEH leased property. At present MEH is entirely dependent upon the host Trust’s supply of
hot water and this represents the most agreeable solution to provide control of the safety of this
system to MEH. Expected delivery of this is September 2015.
Page 5
Estates & Facilities biannual report
4.0 Estates & Facilities directorate report
4.1
Development of 5 Year Estates and Facilities Strategy
Fully developed strategy with implementation plan forwarded to Financial Director for review.
ManEx considered this on the 1st of September.
4.2 Estates Compliance
Statutory and mandatory compliance: The Estates services that have been reviewed in terms of
meeting statutory compliance include:







Fire Safety Management – emergency lighting and fire alarm testing.
Portable Appliance Testing (PAT)
Fixed wire testing
LOLER (lifting operations and lifting equipment regulations)
COSHH (Control of substances hazardous to health) – Updated the Safety Data Sheets for
substances used and stored on site in line with new legislation. The availability of COSHH
risk assessments will form the next phase of this project.
Asbestos Control Management – The annual asbestos survey has been completed and
data is available on EMIS.
Review and development of staff competencies.
Lease management: The Director of Estates and Facilities and E&F Compliance Manager are
currently in negotiation with Croydon University Hospital regarding service charges, Barnet Enfield
and Haringey Mental Health NHS Trust (St Anns Hospital) in relation to lease renewal and North
West London Hospitals (Ealing Hospital) in relation to lease and license creation.
Theatre validation: Below shows the sites whereby the Trust occupies one or more surgical
facilities on a sole use or shared basis and the outcome of the validation. Remedial works have
been identified in the supporting reports and are directed to the host trust for completion and
rebalancing.
Satellite site
Bedford
City Road
Croydon
Darent Valley
Ealing
Mile End
Northwick Park
Potters Bar
Queen Mary’s
St Anns
St Georges
Page 6
Validation
2014/2015
14/08/2014
27/05/2014
25/02/2015
14/04/2014
Pass/Fail
19/09/2014
06/01/2015
22/04/2015
04-05/06/2014
Pass
Pass
Pass
Air flows
requested
Pass
Pass
04-05/10/2014
06/05/2014
Pass
Fail
Pass
Pass
Validation
Pass/Fail
2015/2016
Validation due
Refurbishment in progress
Validation in date
Validation due
Not received
Validation in date
Validation in date
08/04/2015
Pass
Validation due
Validation in date
Validation due
Estates & Facilities biannual report
Legionella Control: Water Quality Risk Assessments across all sites have been completed and
will be reviewed in two years, unless there is a major change to the water system.
For those sites that do not form part of the Trust’s water monitoring assurance program, including
Barking, Bedford, Croydon, Homerton, Loxford, Queen Mary’s, Stratford and Watford, a stringent
regime was implemented which reduced the positive results to an acceptable level which
demonstrated we had control of the water systems. Testing is now carried out on a quarterly basis
as per the instruction of L8 guidance.
Fire Safety Management: Following the recent reinstatement of the Fire Safety Working Group
fire safety management for all staff is being addressed. Extra training dates have been arranged to
cover the deficit. A comprehensive list of appointed Fire Warden’s across all Trust locations is now
available and training is underway resulting in higher compliance.
The annual fire risk assessments are in date and will be reviewed mid-2016.
4.3 Estates Services
The 2014/15 statutory insurance inspections are up to date and reviewed.
Staff management: The estates department workforce now comprises all permanent staff
members. Temporary staff has not been employed to support the function of the service for four
months.
The maintenance framework agreement in place at Northwick Park and St Anns Hospitals expired
at the end of July 2015. Maintenance will now be completed at these locations by the Trust’s inhouse estates team. A recruitment process is underway. The occupancy of Kemp House, Britannia
Walk (Nile Street) and Bath Street will also require additional posts to support service provision.
Approved persons: The Trust now has responsible persons in place, as outlined below:
Appointed person ventilation systems
Appointed persons for medical gases
Appointed person (limited authority) for
medical gases
Appointed persons for LV
Responsible person for water quality
Nominated fire manager
Garry Auger, Head of Estates and Maintenance
Paul Ashton, Senior Maintenance Manager
Andrew Taylor, Maintenance Supervisor
Sham Singh, Maintenance Engineer
Jay Schneider, Maintenance Engineer
Garry Auger, Head of Estates and Maintenance
Paul Ashton, Senior Maintenance Manager
Andrew Taylor, Maintenance Supervisor
Andrew Taylor, Maintenance Supervisor
Dean Carter, Electrical Craftsperson
Garry Auger, Head of Estates and Maintenance
Garry Auger, Head of Estates and Maintenance
Completed works at City Road and local sites:
 Converted the Health Records Office on the Lower Ground Floor to a ladies toilet.
 Refurbished the former Maintenance Manager’s Office into a new reception for the Estates
Helpdesk.
 Installed over one hundred new LED light panels on the Ground floor clinical areas.
 Chiller plant has been installed in the Boiler House.
 Voltage Optimisation system has been installed which has successfully reduced the energy
usage within the hospital building.
Page 7
Estates & Facilities biannual report


Removed all the galvanised water manifolds in the main hospital and replaced these with
new copper manifolds and copper pipework, increasing the reduction of positive legionella
results.
Cycle storage has been installed in the car park facility of Ebenezer Street and staff car
parking bays have been made available that can be procured through the estates
department and payroll scheme which can include motorbikes.
Completed works at Kemp House:
 Installation and commissioning of new entrance doors at Kemp House and swipe card
access for Trust employees.
 Installed telecoms and data into Kemp House.
 Refurbishment of vacant rooms in Kemp House to allow staff groups to move in.
Current schemes at City Road and local sites:
 Learning and Disabilities assessment is underway which has included introducing pictorial
signage.
 Reviewing the feasibility of utilising the available space within the building formerly
occupied by Moorfields Pharmaceuticals.
 The Estates management team will shortly be undertaking ‘train the trainer’ schemes to
allow the training of Medical Gases for nursing and portering staff at all sites.
 In the process of scheduling a training session for steam utilisation training.
 Proposed the reinstallation of the original main entrance located on City Road for staff only
access.
 Asset tracking and management; physical assets, patient safety and throughput and staff
safety/work flow optimisation.
 Agility, a module of Estates Management and Information System (EMIS) is at the
commissioning stage and tests are being undertaken.
Current schemes at Kemp House:
 Planning and progression of refurbishment of vacant spaces in Kemp House as they
become available.
4.4 Clinical Technical Services (CTS)
The Head of Clinical Technical Services (CTS) at Moorfields Eye Hospital has resigned from post
to take up a new opportunity in the Medical Devices Industry. The Director of Estates & Facilities
in conjunction with the CTS team will now review and consider restructure of the department to
meet current and future requirements.
Below is the summary of key actions underway or completed.
 All mandatory training for staff completed
 Annual appraisals underway with completion before Head of CTS leaves organisation.
 Internal audit for the period October to December 2014 demonstrated compliance with
policy in relation to maintenance and repair procedures
 Internal audit for the period January to March 2015 demonstrated compliance with policy in
relation to maintenance and repair procedures
 Since March 2014, 457 medical devices were added to eQuip, the Trust Inventory
Management System. Total Inventory of Medical equipment is now 3568 and includes
equipment located in Theatres
 CTS continue to work closely with Finance to develop a robust medical equipment
replacement programme. Completion due October/November 2015
Page 8
Estates & Facilities biannual report













CTS – IT Projects. We now have a programme of work with the IT project manager. Works
completed are Haag Streit software upgrade, Pentacam upgrades from XP to Windows 7
and Topcon OCT software at City Road and Satellite Units.
We procured, commissioned and installed new equipment for the Nelson Health Centre in a
timely manner to ensure service delivery.
Planned preventative maintenance (PPM) for medical equipment is on target
Capital Medical Equipment bids have been reviewed and agreed.
Head of CTS is now the Trust authorised signatory for IRAS R&D projects
Specific to Moorfields and in response to the Bedford SI, the Head of CTS and Clinical
Engineers are the designated and authorised personnel to complete the set up process, for
uploading the Trust standardised lens and surgeon IOL calculation constants for preoperative ophthalmic biometry, from a USB stick or CD into the biometry machine.
Currently conducting laser trials at both St Georges Hospital and City Road to replace the
existing devices as the equipment is no longer supported by the supplier.
Moorfields Dubai Medical Devices Management has been reviewed and recommendations
made. Awaiting response from Operation Director as to how to proceed.
Ghana Korle bu Hospital further delayed due to area floods. New date for commissioning
12th to 26th September.
Clinical Engineers have received first line training from Heidelberg (Spectralis, HRT and
HRA) and Carleton (Haag Streit Tonometers)
Clinical Engineers have completed Electrical Safety Testing Training to Medical Devices
standard BS EN 60601 & IEC62353. Certified with distinction. Certificates displayed
outside CTS office.
Clinical Engineers are now registered with full membership with the Institute of Physics &
Engineering in Medicine (IPEM) and now qualify as registered Clinical Scientist. Staff have
applied for registration as IEng and will complete this process by the end of August. This
further demonstrates CTS commitment to providing a qualified and quality service.
CTS are preparing for the CQC Inspection. Outstanding work is in updating the Medical
Devices Policy to reflect current practices as introduced by the Head of CTS.
4.5 Hostel
In order to accommodate patient’s pre and post-surgical procedures for non-clinical reasons, there
are hostel beds available on 1st floor Mackellar Ward. The hours of service are 8.30pm – 8am
Mon-Fri, and 7.30pm to 8am, weekends. The hostel is a night service and staffed by a warden
who has no nursing or medical training. Users of the Hostel are called Lodgers.
Approximately 1210 lodgers including escorts stay in the hostel per annum. Up to 50-75%, are
escorts. This equates to 3-4 people a night.
This is a goodwill service, however lodgers have to meet general criteria to stay and be
accompanied by an escort.



Patients who have had a general anesthetic or deep sedation who are fit for discharge but
have no home support
Patients who have had surgery and require review the following day are unable to go home
and return for the early review because they live too far away or are too frail
Post-operative patients who do not require nursing care but live alone and are too frail to
travel on the day of surgery
Page 9
Estates & Facilities biannual report


Pre-operative patients who need to stay in the hostel the night before their surgery because
they are required to book in for surgery at 7.30am, but live too far away to travel to the
hospital on the same day
Carers who will be required to look after the patients staying in the hostel.
Lodgers do not pay to stay in the hostel, so costs relate to workforce, of which there are 2 wardens
to cover 2 shifts.
4.6 Domestic Services
Patient-Led Assessment Care Environment (PLACE)
The annual Patient-Led Assessment Care Environment took place on Monday 11th April 2015. The
audit details have been submitted in the Health and Social Care Information Centre (hscic). The
result of our performance has not been published as yet. As soon as this information becomes
available this will be communicated out to key stakeholders.
Domestic cleaning
The cleaning provider at City Road continues to deliver a high cleaning standard. Below is the
overall performance for 2014 – 2015.
Quarter 1
Risk category
Very High Risk Category ‐ Pre‐
rectification
Very High Risk Category ‐ Post‐
rectification
High Risk Category ‐ Pre‐
rectification
High Risk Category ‐ Post‐
rectification
Significant Risk Category ‐ Pre‐
rectification
National Significant Risk Category ‐ Post‐
Standards of rectification
Clenliness in Low Risk Category ‐ Pre‐
the NHS
rectification
Low Risk Category ‐ Post‐
rectification
Average Cleaning Results ‐ Pre‐
rectification
Average Cleaning Results ‐ Post‐
rectification
Training (actual versus planned)
Rapid Response within the agreed timescales
Quarter 2
Quarter 3
Quarter 4
Target KPI Apr‐14 May‐14 Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15 KPI Average
95
98.2%
97.1%
97.6% 97.8% 97.5% 98.0%
97.6%
95
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
100.0%
95
98.4%
97.3% 98.4% 97.7% 97.6%
97.6%
95
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
100.0%
95
97.1%
95.1% 96.6% 97.0% 96.6%
96.1%
95
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
100.0%
95
97.3%
98.2% 96.7% 96.7% 96.6%
96.2%
95
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
100.0%
95
97.7%
97.0% 97.4% 97.2% 97.2%
97.0%
95
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
100.0%
90
97.2%
93.8% 100.0% 100.0% 96.8% 89.2% 91.8% 100.0% 95.0% 96.0% 83.3%
94.8%
90
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
100.0%
Overall average
98.28%
98.3%
96.5%
95.5%
96.9%
94.7%
97.3% 97.2% 97.8% 97.6% 97.5% 97.5%
96.5% 97.7% 97.6% 97.5% 97.2% 97.4%
94.4% 96.8% 96.0% 95.3% 96.5% 95.9%
94.3% 96.4% 93.8% 96.4% 96.8% 95.9%
96.6% 97.0% 96.3% 96.7% 97.0% 96.7%
The standards we set are higher than the required NHS standards. This is to ensure we maintain a
high standard for our patients and processes such as PLACE and CQC visits.
3rd Party Auditing
We have now engaged with a 3rd party cleaning audit company, British Institute of Cleaning
Science (BICS), to monitor the cleaning standards at City road and this will also be rolled out
across a number of the satellite sites. We have already undertaken this audit at City Road and
satisfactory scores were received. Below is a chart and a tabular version of the results. This will
continue to be monitored.
P a g e 10
nnual reportt
Estates & Faacilities bian
According to the docu
ument Natio
onal Specificcations for cleanliness
c
in the NHS
S states thatt “External
audits are not an intrin
nsic part of the auditing
g process but
b are recommended aas good pra
actice since
e
they provid
de an indep
pendent view
w of cleanlin
ness and va
alidate the NHS
N
trust’s own internally
awarded scores.”
hroom
Toile t & Wash
Clinical
Circulation
Facilities
Noveember
96.89%
96.50%
96.57%
Ap
pril
96.11%
96.25%
97.27%
Acceptaance level
96%
966%
9
96%
All of the a
areas at Cityy Road have
e passed. T
This will con
ntinue to be monitored and audited
d on a
quarterly b
basis.
4.7 Porte
ering
Portering Software
A Portering
g software system
s
has now been implemente
ed. The softtware enablles the rapid
d entry and
allocation o
of jobs, provvides an ‘att a glance’ vview of the operational status of pportering acttivities to
enable ma
anagement to
t focus on the most urrgent requirrements.
The system
m is currenttly being bedded in and
d customise
ed to best fitt the organiisation. Onc
ce we are
happy with
h the system
m working effectively
e
an
nd efficientlly then we will
w review oour processes, service
levels and communica
ate out to all City Road
d staff.
P a g e 11
1
Estates & Faacilities bian
nnual reportt
To supportt this processs we now have a ded icated porte
ering team member
m
maanning the portering
p
desk who iis currently located at the
t main recception des
sk. The new
w system annd the portering desk
are now be
eing fully ma
anned to im
mprove our ccustomer se
ervice profille.
ge
4.8 Postag
Postage iss still on an upward tren
nd. We are looking at the
t operatio
onal impact of processing mail in
a different way to provvide more in
nformation o
on postage used by de
epartment.
We have im
mplemented
d 2nd class postage, exxcept where
e 1st class is
ssue has beeen requestted. During
this implem
mentation we
w are still experiencing
e
g an increas
se volume of
o mail goingg out of the
e business,
which is ne
egating the savings. June 2015 s aw an incre
ease of clea
an mail to thhe value of £11k.
£
This
equates to
o £132k per annum if maintained.
m
T
The Head of
o Facilities will be meeeting with Royal
R
Mail
in due course to discu
uss this to see
s if our org
ganisation can
c save more
m
within tthis area to negate the
sheer volume of post being sent.
To cope w
with this inccreased volume Estattes have ha
ad to move
e a secondd person form generall
patient porrtering to co
over the po
ost room de
emand of ou
utgoing mail. This has had an imp
pact on the
e
general po
ortering se
ervice. Consideration needs to be given to either chhanging the way the
e
organisatio
on works th
hat require so
s much m
mail being se
ent out or employing
e
m
more porterring staff to
o
cover the d
demand.
There is a
also another alternative
e such as the use of the Netcall telecoms system tha
at could be
e
used to contact our pa
atents by ph
hone.
4.9 Secu
urity
Summary,, update ke
ey points re
elating to s
security.
 The NH
HS Protect Self Revie
ew Tool (SR
RT) which is
i part of th
he NHS Coontract was completed
d
and ag
greed with th
he Security Manageme
ent Directorr (SMD) then forwardedd to NHS Protect.
 The NH
HS Protect Organisatio
onal Crime Profile 2015-16 has been
b
compleeted and fo
orwarded to
o
NHS P
Protect.
P a g e 12
2
Estates & Facilities biannual report

The NHS Protect Reported Physical Assaults (RPA) statistics for 2014-15 were compiled and
forwarded to NHS Protect.
All of the above were completed and forwarded to NHS protect within the relevant time frames
The Security Manager/LSMS has agreed protocols with the Local Counter Fraud Specialist (LSMS)
that includes information sharing and regular meetings where any security or fraud issues are
discussed and advice/guidance is given.
The CCTV policy was approved at MANEX as was the Violence and Aggression policy. The
lockdown policy is being reviewed and updated. The lone worker policy has been reviewed ready
for presentation at the next Risk and Safety committee (September 2015).
The CCTV at City Road is now being updated in stages. This is a mixture of new cameras
covering areas previously not covered, or additional cameras in those areas where weaknesses
were identified, as well as any replacements. The plan is to complete this work during this financial
year.
Review of security and CCTV at Kemp House identified risks which have now been resolved with
the installation of CCTV and access control within MEH areas and public areas within the building.
Security awareness is ongoing with 24 staff induction sessions receiving the 30 minute security
presentation, 14 security related articles/advice in staff communications bulletin, security advice
and guidance displayed on posters in clinics and public areas, security advice and guidance on
digital display screens in and around MEH.
Work with Risk & Safety and Clinical Governance staff has been undertaken, including walkabouts,
where staff can discuss any all concerns with the team. A report is then produced and forwarded to
relevant managers.
Work has been undertaken with the Trust Emergency Planning lead and Metropolitan Police
Counter Terrorism and Security Adviser (CTSA), organised two
“Stay Safe” presentationssessions aimed at all front line staff after a successful Project ARGUS event held previously
Nineteen visits were made to satellite sites to either make enquiries into a reported incident, or a
general visit to meet staff and discuss security issues or concerns. Required reports have been
completed and recommendations actions forwarded to the relevant mangers.
Evidence and statements have been supplied by the security manager to police and senior
managers which resulted in sanctions being taken against staff.
Nine warning letters were sent to patients in incidents of verbal aggression/abuse against staff.
One staff assault case (outside of hospital when leaving work) is ongoing at Crown Court.
4.10 Laundry/Linen
A new supplier has been appointed to manage our linen cleaning. There has been focus to reduce
the stock items we have on site and be more efficient on how we manage our stock levels. As part
of this service we have implemented a barcode tracking system to facilitate the return of staff
uniforms after submission to the laundry service. When fully implemented an automated
notification systems will be implemented to liaise directly with the user to allow items to be
collected within agreed timescales.
P a g e 13
Estates & Faacilities bian
nnual reportt
The Laund
dry/Linen room
r
has now
n
been refurbished
d to ensure
e a much cleaner an
nd hygienicc
environme
ent to suppo
ort this proce
ess.
ment
4.11 Waste Managem
Waste man
nagement still
s remains
s effective a
at Moorfields
s with the diversion of 998% of our waste
streams fro
om landfill, 80% recycled and 18%
% to waste to
t energy in
ncineration.
w details the
e waste vol umes and segregation
s
n percentagees as from April 2014
The waste chart below
015.
– March 20
The segre
egation of th
he cardboa
ard waste sstream has now been removed. T
The previous processs
showed no
o financial benefits. Cardboard
C
n
now goes into
i
the general wastee stream, this
t
is then
n
recycled a
at the transsfer station. This has created much
m
neede
ed extra sppace within the waste
e
compound and will se
ee annual sa
avings with the reduction of contra
acted mainttenance cos
sts.
4.12 Trans
sport Serviices
The Head
d of Facilities implemented a S upplier Relationship Managemeent (SRM) process to
o
improve th
he overall pe
erformance
e of the tran
nsport contrract. Over th
he past 12 months we have seen
n
a major im
mprovementt of service
e as a resu
ult of this strategy
s
and
d rigorous contract managementt
reviews en
ngaging within clinica
al stakehold
ders. On average
a
we are trans porting 160
00 patientss
(inbound) a
and 1500 patients (outtbound) perr month. Thiis equates to
t 37,906 joourneys perr annum.
Below is an overview of activity and
a perform
mance for the patient tra
ansport conntract for the
e past 12
months:
Table 1 - L
Late failure
es (inbound
d numbers)
s)
P a g e 14
4
Estates & Faacilities bian
nnual reportt
Late failure
es (outboun
nd numberrs)
Table 2 - L
90
80
70
60
50
40
30
20
10
0
Latee Failures Outtbound
As can be seen from the
t above table there h
has been a major decliine in failurees despite a 14%
increase in
n patient numbers. This
s will contin
nue to be ma
anaged effe
ectively movving forward
d.
preting Serrvices
4.13 Interp
urced interp
preting and translation framework agreement continues tto provide a high
The outsou
quality com
mmunication
n support to
o our patien
nts with no KPI
K failures reported, aacross all sittes.
A strategy is being de
eveloped witth the outco
ome to mov
ve over to te
elephone intterpreting which
w
would
d
uction in spe
end whilst maintaining
m
the service level agree
ements. Wee are due to
o start
see a redu
trialling at Moorfields over
o
the next two montths. Once complete
c
a plan will bee developed to roll out
across the Trust wherre possible.
4.14 Frontt of House – Switchbo
oard and R
Reception
The Front of House de
epartment continues
c
to
o be perform
ming adequately in all aareas.
Telecoms
o the teleco
oms perform
mance year--to-date.
Below is a summary of
Total calls per annum = 237,775
Total calls answered = 222,964 (94%)
(
d = 14,811(6
6%)
Total calls abandoned
SLA1 – Ca
alls answere
ed within 15
5 seconds = 69%
SLA2 – Ca
alls answere
ed within 60
0 seconds = 92%
4 calls were
e abandoned
d within the first 60 secconds of wa
aiting. This
It is important to note that 11,914
ator that the
ese calls we
ere abandon
ned for one
e of the following reasoons:
is an indica
P a g e 15
5
nnual reportt
Estates & Faacilities bian
 Callls not being
g answered
d by individu
ual staff members/depa
artments annd ending back at
main reception
n
ansferred ba
ack to the m
main receptiion
 Callls being tra
 Voiice recognittion issues
ging System
m
Crash Pag
Due to a ffew faults with
w the crash paging ssystem we have now implement a primary, secondaryy
and back u
up process. The prima
ary and seccondary are
e the same system annd the back-up system
m
utilises the
e DECT pho
ones.
ew complaints receive
ed regarding
g messages
s not being clear at ceertain time the Head off
Due to a fe
Facilities commission
ned a com
mplete wa
alk round of the en
ntire site uusing Athe
ena Mobile
e
manufactured on the Moorfields Site Frequ
uency. This was to identify any arreas of poo
or coverage
e
using the existing tra
ansmitter network. It w
was found that the tw
wo existing transmitterrs provided
d
adequate ccoverage from the 1st and 2nd Flo
ver the signal started too degrade once
o
on the
e
oors howev
Ground Flo
oor (A&E an
nd RDCEC)) and in the Basement areas.
d the system
m to ensure consistent coverage across
a
the whole
w
hosppital would cost
c
around
d
To expand
£32k. Follo
owing a review of this report
r
a Bussiness Case
e can be su
ubmitted if reequired.
4.15 Caterring
ummary of the key points within ccatering ove
er the reportting period.
Below is su
e-Procure
ement
The eProcurement syystem contin
nues to dem
monstrate co
osts savings
s for the Truust. Below is a 12
month repo
ort. Below iss a snap sh
hot of the m ain dashboard flowed by a 12 moonth breakdo
own of
savings ma
ade to the Trust
T
P a g e 16
6
Estates & Facilities biannual report
Below is the latest spends and rebates of procured foods.
Date May‐15 Apr‐15 Mar‐15 Feb‐15 Jan‐15 Dec‐14 Nov‐14 Oct‐14 Sep‐14 Aug‐14 Jul‐14 Jun‐14 Total Spend £13,695.26 £14,578.97 £14,489.47 £12,803.10 £15,167.79 £20,629.29 £15,790.82 £15,036.06 £15,892.92 £14,278.38 £18,517.09 £12,436.41 Client Rebate £ £3,348.53 £3,459.07 £3,359.74 £2,777.15 £3,574.52 £3,528.37 £3,774.00 £3,317.40 £3,909.31 £3,302.71 £4,634.23 £2,563.25 Client Rebate % 24.5% 23.7% 23.2% 21.7% 23.6% 17.1% 23.9% 22.1% 24.6% 23.1% 25.0% 20.6% TOTAL £183,315.56 £41,548.28 22.8% Food Hygiene Audit
There have been no EHO visits in the past 12 months or nothing to report on in terms of any
operational or compliance risks within this area.
A catering audit was completed in February 2015 with no issues identified that are a cause of
concern. A program to rectify issues was implemented and will be continually monitored.
This will be an ongoing process to ensure full compliance against all polices and processes within
the trust.
Retail
Below is the annual summary statement for the Costa Coffee Shop.
Month
April
May
June
July
August
September
October
November
December
January
February
March
PTotal
a g e 17
From
To
27/03/14
24/04/14
22/05/14
26/06/14
24/07/14
21/08/14
26/09/14
30/10/14
27/11/14
01/01/15
29/01/15
26/02/15
23/04/14
21/05/14
25/06/14
23/07/14
20/08/14
20/08/14
29/10/14
26/11/14
31/12/14
28/01/15
25/02/15
01/04/15
Turnover
Turnover Rent @15% Base Rent
57,734.66
41,446.42
43,462.91
52,808.65
40,120.87
40,011.80
51,660.03
57,063.13
44,997.43
50,396.99
44,870.58
45,770.67
8,660.20
6,216.96
6,519.44
7,921.30
6,018.13
6,001.77
7,749.00
8,559.47
6,749.61
7,559.55
6,730.59
6,865.60
5,416.67
5,416.67
5,416.67
5,416.67
5,416.67
5,416.67
5,416.67
5,416.67
5,416.67
5,416.67
5,416.67
5,416.67
570,344.14
85,551.62
65,000.00
Turnover rent due:
20,551.62
Estates & Facilities biannual report
4.16 Telecoms
Following on from implementing Call Centres within Private Patients and replacing the main
Switchboard, Contact Centre 59R was expanded to the following departments:





Booking Centre
Moorfields Direct
Optometry
Outpatients
Private Patients
Additional to the above we will be soon be going live with Contact Centre 59R within the Portering
and Transport Departments to improve communication with our services.
Facilities have set up a reporting spreadsheet that has now been handed over to Performance and
Information to continue reporting. Such that all departments can now be effectively reported on.
Queue Buster (funded within the main project) has now been implemented within Private Patients
and Moorfields Direct. This allows callers the option to be automatically called back after waiting a
set period of time. This is aimed at improving the patent experience when calling our organisation.
In April 2017 Unify will no longer maintain the main ISDX phone system at City Road. A strategy
and options analysis will be completed and presented in due course. Short and long terms goals
will need to be consider as part of this project.
Voice over IP (VOIP) phones have been implemented within the Kemp House areas.
Contracts have been moved over from BT retail to Southern Communications. Estimated savings
are approximately £25K per annum. This will see an improved service for fault reporting, business
continuity and detailed online reporting. This will also see a mass reduction of invoice processing.
4.17 Mandatory Compliance
Below are the details for the Estates and Facilities mandatory training levels. Overall Facilities are
80.8% complaint.
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
P a g e 18
Catering
Portering
Front of House
Management
Estates & Facilities biannual report
Work is ongoing with the HR Department to clarify the profiles and course requirements for estates
staff and focus is being placed on this area.
4.18 Sustainability
As per the previous report a revised Sustainable Development Strategy for the Health and
Care System 2014 – 2020 was released in January 2014. A review of the process has been
completed and we are now in a position to start engaging key stakeholders within the organisation
to improve our sustainability credentials.
To support these requirements a revised Sustainable Development Management Plan (SDMP) has
been developed and is currently in draft format for review. This document, once reviewed, will be
launched and the implementation phase started.
Within the SDMP it is the intention to use the NHS Good Corporate Citizen Model to ensure that
each aspect of sustainability is embedded within Moorfields Eye Hospital’s operations and
activities. A maturity matrix has been created to gauge current progress, set milestones and track
progress over the coming years.
The Good Corporate Citizen Model covers 11 key activity areas:











Transport;
Procurement;
Facilities Management;
Workforce;
Community Engagement;
Partnership and Planning;
Buildings;
Climate Change Adaptation;
Resource use, scarcity and continuity;
Social and community impacts;
Models of care.
In order to discuss these requirements in detail, a communication to all key stakeholders has been
sent. Following this, the Sustainability Steering Group will be reinstated to lead and manage this
process. Progress will be reported in the six-monthly/annual Board Reports and Boards
Sustainability Papers.
To support this process a full review of all policies and procedures relating to Sustainability has
been completed. These are managed through a Sustainable Management Framework using the
principles of Environment Management System ISO 140001. This includes the following policies:








Environmental Policy;
Energy Policy;
Water Policy;
Food Policy;
Information Technology Policy;
Procurement Policy;
Travel Policy;
Waste Policy.
P a g e 19
Estates & Faacilities bian
nnual reportt
ctivities with
h the roll ouut of LED lig
ghting, plantt
In addition Moorfields continues its carbon rreduction ac
on and the installation of voltage optimisatio
on. In order to measure
re and veriffy predicted
d
optimisatio
energy, ca
arbon and cost
c
savings
s an Energyy Monitorin
ng Dashboa
ard has beeen created. An excerptt
illustrating energy savvings made over the pa
ast three mo
onths can be
b found bellow.
P a g e 20
0