Item 6
Estates and Capital
projects six monthly
report
Produced by:
Chris Harding – Director of Estates & Facilities
Presented by:
Rob Elek – Director of Strategy & Business Development
Board of Directors Meeting
20th November 2014
Action for Board:

For information

For consideration

For decision

Estates & Facilities biannual report – October 2014
1.
Executive Summary
2
2.
Backlog Maintenance
4
3.
Capital works at City Road
5
4.
Satellite Sites
6
5.
Estates & Facilities directorate report
7
a)
Development of 5 Year Estates and Facilities Strategy
b)
Estates Compliance
10
c)
Estates Services
12
d)
Clinical Technical Services (CTS)
13
e)
Security
14
f)
Sustainability
15
g)
Telecoms
15
h)
Portering
17
i)
Interpreting Services
17
j)
Transport Services
18
k)
Domestic Services
18
l)
Catering & Hospitality
19
m)
n)
Waste Management
Water dispensers
Page 1
7
20
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Estates & Facilities biannual report – October 2014
1. Executive Summary
This report includes an update on the Estates and Facilities directorate for the six months from
April 2014 to October 2014, and includes progress reports for:

The backlog maintenance programme and major capital projects;

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; and

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.
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 backlog maintenance programme has been successfully tendered for 2014/15 and good
progress is being made on all components of the programme.
Capital works have delivered major improvements to the patient experience, service capacity and
organisational resilience across a range of projects; these include:

Expansion of paediatric ocular prosthetics;

The creation of a new laser suite (to be completed in early 2015);

Significant enhancements to the main entrance corridor at City Road;

Moorfields at Ealing expansion; and

Moorfields at St Ann’s femto-phako laser suite (due for completion in late 2014.
The Moorfields at St George’s project initially envisaged the provision of a stand-alone building that
reprovided and expanded all our current accommodation. The board is aware of the issues
surrounding the recent change in direction, and discussions with the host hospital are on-going
with respect to both the new interim and longer-term solutions. This represents the key strategic
estates risk at present.
The estates & facilities directorate section includes detailed reports for each area, the following are
the key issues for the board to note:

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.

Security: The NHS Protect Self Review Tool (SRT) work plan section 2014-15, has been
completed and agreed with the Security Management Director (SMD). This has been
forwarded to NHS Protect. The full SRT document will be completed in full and forwarded to
NHS Protect by November 30th 2014 in accordance with NHS Protect guidance and advice.

Catering: The Costa outlet has been successfully running for almost 12 months and a great
deal of positive feedback has been received. The outlet is generating revenues for
reinvestment in patient services.
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Estates & Facilities biannual report – October 2014

Telecoms: the new call management system (Netcall 59R) has been successfully
implemented at City Road, leading to a significant improvement in switchboard performance
and to the accessibility of detailed information relating to call handling at sub-speciality level –
this will assist in targeting areas for improvement over the coming period.
The board requested information relating to call handling at our other locations and the
following is a summary of the current position:
 None of our other sites currently have the equivalent capability of Netcall 59R;
 We are unable to interrogate host hospital’s call handling systems; and
 There is a great deal of variability in how telephone communications are handled by
our services in other locations; i.e. some have direct lines whilst some are only
accessible through a switchboard.
In response to these issues, we have started negotiations with Netcall and have been
advised that Netcall59R can be implemented on external lines going direct to sites, and on
any lines going out over our N3 links.
We are currently drafting a review to fully understand these issues and to develop plans to
improve our ability to control communications at all our sites.
A potential solution could entail diverting existing phone numbers to route all incoming calls
for any Moorfields site into the City Road Netcall system, which would then transfer the call
to the relevant phone (including mobiles), thereby giving us full functionality across the
network.
The board is asked to consider the progress made in the delivery of the backlog maintenance
programme and capital projects, and the overall performance of the Estates & Facilities directorate.
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Estates & Facilities biannual report – October 2014
2. Backlog Maintenance
The backlog maintenance programme is refreshed on an annual basis, and continues to deliver
real improvements to our estate as well as ensuring we maintain appropriate standards for patient
and staff safety.
The end of year estates report will include full details of the workstreams, alongside the
programme for the following year.
The main backlog works undertaken in the last six months are summarised below.
1. Fire alarm upgrade.
Works to install the new sounders and sensors commenced on 9th December 2013 and
completed in May 2014. Software system upgrading and snagging / training continues,
with completion planned within Q4.
2. External façade and roofs.
Works to repair all roofs, rectify façade defects and install fall arrest systems commenced
on site on 3rd February and completed on 19th May 2014.
3. Fire doors and compartmentation upgrade to upper floors.
The initial high priority works were completed in earlier phases of the backlog programme,
lower priority works commenced in October 2014 and will complete in February 2015. All
fire related backlog works are fully coordinated with the Fire Brigade, and our revised
4. Emergency lighting and Disability Discrimination Act (DDA) works package.
A full DDA audit was completed in 2013 and final designs were approved earlier this year,
works are programmed to commence and complete in Q4.
5. Lift upgrade works.
Following the refurbishment of the main patient lifts a programme to upgrade all City Road
lifts started in late 2013. Despite problems with the initial contractor, lift 1 (by the old main
entrance) and lift 3 (by outpatients) have been completely refurbished. Works to lift 6 (the
goods lift) will be undertaken as part of the 2014/15 programme.
The overall programme and scope of all backlog works is adjusted to ensure that expenditure
remains within the approved affordability envelope allocated by the Capital Planning & Oversight
Group (CPOG).
The Estates department has also been addressing significant numbers of the smaller, discrete
backlog maintenance issues through its minor works programme.
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Estates & Facilities biannual report – October 2014
3. Capital works at City Road
1. Medical Gases
This project has successfully delivered a new Liquid Oxygen Compound in the goods yard.
Previously the hospital’s oxygen supply was provided from bottled gas, this facility now
operates as a standby unit. This project has mitigated a significant health & safety risk as the
oxygen bottles required frequent changing by porters, and a business continuity risk as the
hospital did not have resilience in supply.
2. Expansion of paediatric ocular prosthetics
The expansion to the paediatric ocular prosthetics department was completed in June 2014. This was a
complex project entailing a crane-lift for the modular build and intricate phasing to minimise the impact of
works on the goods yard. The expansion includes striking artwork that has been a big hit with the children,
and adults, visiting the department.
3. Private patient laser suite
A new laser suite will be created on the 4th floor. This project has just started on site and will complete in
early 2015.
4. Friends of Moorfields information desk
The main entrance corridor to the outpatient area represented a somewhat confusing
environment for patients, and was in some need of updating. Accordingly, the Friends of
Moorfields base has been moved to a more logical location by the main entrance and the
porter’s desk has been removed. The new information desk has been widely welcomed as a
much needed improvement to how we support and guide patients into the hospital, as well as
greatly enhancing the appearance of the hospital.
5. Health Information Hub
The purpose of this completed project is to provide patients with an area to access general
patient information via leaflets or to browse our information screens, in a calm and welcoming
environment. The hub was funded by the Friends of Moorfields, who also support patients
seeking information in the hub; though the Director of Nursing & Allied Health Professionals is
reviewing the PALS / ECLO services with a view to potentially having full-time staff based in
the hub.
6. Piano
The changes in the main entrance corridor have also enabled us to divide the former Friends
‘hutch’ into an office for the outpatient matron and to create a much needed space for a grand
piano. The board will recall that our grand piano, previously housed in the City Road
boardroom, has been in storage for some time. We have been fortunate in that a grateful
supporter of the hospital has donated a better piano, and this new addition is now installed in
the main entrance corridor.
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Estates & Facilities biannual report – October 2014
4. Satellite Sites
Estates maintenance strategy for satellite sites
The responsibility for estates maintenance for satellite sites, and the quantum of services, varies
from one location to another - ranging from the landlord (host hospital) providing all or no
maintenance, and the City Road estates department directly supporting a number of sites. This
inconsistent approach is confusing for operational staff, and is not an efficient or effective means of
providing such a key service. As the board is aware, we piloted an improved service model at St
Ann’s and Northwick Park and following the success of the pilot, we undertook a formal tender
process for the supply of the planned maintenance services and the contract was awarded to
Lorne Stewart on 1st May; this contract also includes the flexibility to add our other satellite sites.
Some aspects of maintenance at our satellite sites that are the responsibility of our landlords have
created some concern about quality. The Director of Estates & Facilities has now appointed a
Compliance Manager to follow through with all relevant landlord estates departments a list of
statutory works for confirmation by the landlord that these issues have been properly addressed
(as required under the landlord and tenants act), and to ensure that Moorfields has complied with
its duty of care to our staff and patients. Where this is believed to fall below the required statutory
standard, or if information is not forthcoming, internal audit tests have been carried out by
Moorfields estates and results shared with the landlord to action. These are then monitored to
compliance completion.
Moorfields @ Northwick Park
Medical gas systems were removed from the original Northwick Park expansion project prior to
construction. These systems are required to expand the scope of surgical procedures undertaken
in the theatre – a key objective to enable the “repatriation” of further work from City Road and the
development of new local services.
Negotiations with the host hospital have been in progress for some considerable time as our
preferred solution, to connect into the existing site medical gas system, did not appear to be
achievable and the landlord appeared reluctant to give permission for Moorfields to deliver a standalone local system.
The host hospital has very recently agreed that we can connect into the existing system and the
project has been re scoped and submitted for approval by CPOG of a business case and proposed
installation early 2015.
Moorfields @ St George’s Hospital (SGH)
The board approved the St George’s business case in October 2013 and positive discussions have
continued with SGH around the key clinical requirements (access to main theatre space etc.) and
the finalisation of the development agreement and lease documentation.
These discussions have flagged up a number of clinical issues and operational constraints, around
anaesthetic support to a free-standing building, the increasingly complex case-mix of our activity at
this site, and the impact of SGH’s designation as a regional trauma centre. The consequence of
these issues is that SGH have stated that the planned development cannot proceed in its current
form. SGH have proposed an alternate, interim, solution for the vacation of Duke Elder ward that
includes outpatient expansion space, and have invited Moorfields to comment on this revised
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Estates & Facilities biannual report – October 2014
proposal. Meetings are being progressed with the key clinical and estates representatives to
progress this proposal; however suitable commercial agreements will also need to follow.
At present, it is not possible to state with any certainly what the longer term solutions may entail,
though SGH have revised their position and there is an expectation that a complete Moorfields unit
will be provided within SGH clinical accommodation.
Moorfields @ Ealing Expansion
The long awaited expansion to the Moorfields @ Ealing service was successfully completed in
August, with occupation by services in September 2014. This £660k project included lease
arrangements for the modular build’s location.
Ealing and North West London Hospitals have now merged to create London North West
Healthcare NHS Trust; this will enable us to reopen discussions around the occupancy provisions
for the main Ealing accommodation.
Moorfields @ St Ann’s – femto-phako laser suite
The estates works to create an appropriate facility to house a new femto-phako laser at St Ann’s
are underway with completion planned by the end of the calendar year.
5. Estates & Facilities directorate report
a) Development of 5 Year Estates and Facilities Strategy
Over the next reporting period, we will be developing a 5 Year Estates & Facilities Strategy. As
part of this development we will create:

5 year forward Estates & Facilities vision and documented strategy for the period April 2015March 2020

Key strategic objectives framed into a Balanced Scorecard

Business planning SMART measures
The development of a Moorfields Estates & Facilities Strategy will take into account NHS initiatives
such as Payment by Results, Patient Choice and especially the Privacy and Dignity agenda. As
such it is essential for the Estate to meet patient expectations by providing a quality environment
for treatment and healthcare service delivery, at all our sites.
The overall purpose of the Estate & Facilities Strategy will be to show how the estate is being used
and how this resource can be used in the future to support the Trust in delivering its key objectives.
The Estate & Facilities Strategy will need to flow from the Trust’s Service Strategy and Business
Plans, which in turn reflect Government and local initiatives for the delivery of healthcare services.
It will also demonstrate the priority given to achieving compliance with Standards for Better Health
and statutory health and safety legislation as part of the drive to improve quality.
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Estates & Facilities biannual report – October 2014
Overall the completed Estate Strategy aims and objectives will include:

Maximise use of the built resources available

Enable development of high quality, fit for purpose and well placed buildings

Ensure that all capital investment is linked to the Trust strategic direction

Create standard approaches to project management and business case development

Coordinate the environmental response to the needs of all

Act as an information resource across the Trust

Develop shared learning
Approach:
The approach to undertaking the strategy development will be a based on the following three
stages:
1
2
3
•Where are we now? Baseline Assessment (Gathering Evidence)
•Conduct full Maturity survey across Key Estates & Facilities functions to establish a Baseline
•Where are we going? Develop Strategic Objectives
•Planning with Leadership team to establish a concept vision, mission and strategic objectives for the
Estates that are fully aligned with the Moorfields Hospital corporate strategy
•How will we get there? Engagement and Business Planning
•Translating strategic objectives into SMART measures linked to a Balanced Scorecard
This approach is aligned to the proven methodology already used for the development of our
Corporate Strategy as detailed below.
Stage 1 – Baseline (Gathering Evidence and Analysis):
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Estates & Facilities biannual report – October 2014
Initially we will establish a robust baseline from which future objectives can be measured against.
This baseline will provide a reality check into whether aspirational strategic objectives can actually
be achieved and at what cost to the organisation.
An “In-Depth” assessment of the 14 Elements of our Estate & Facilities Management function will
focus on the strategic, operational and tactical aspects of each component of the service.
The baseline elements are detailed on the Maturity Matrix as below:
1)
Strategy, Leadership and Organisational Design
2)
Asset and Maintenance Management
3)
Risk Management
4)
Compliance and Statutory Maintenance
5)
Safety Management
6)
Supplier Relationship Management
7)
Service Delivery
8)
Customer Service
9)
Cost and Financial Management
10)
Help Desk and Processes
11)
Sustainability
12)
Estates & Facilities People Management
13)
Client (Stakeholder) Management
14)
Innovation and Change Management
The Gap Analysis will be referenced against Best Practice and will be supported through a detailed
SWOT and PESTLE analysis.
Stage 2
Strategic Objectives (Synthesis):
The Estates & Facilities Strategy will be aligned to the Moorfields core business strategy. Using
the Moorfields “Our Vision of Excellence” document as a guiding template, we will undertake
strategic planning workshops with key Team members.
These workshops will be used to:

Present the “Our Vision of Excellence” document and establish how this impacts and links
into a future Estates & Facilities strategy

Review findings from the Maturity Matrix baseline

Review detailed SWOT and Pestle Analysis

Establish a realistic and draft Estates & Facilities vision and mission

Establish strategic objectives around a Balanced scorecard
Stage 3
Page 9
Engagement (Business Planning):
Estates & Facilities biannual report – October 2014
A vital part of any strategic development is the engagement of key stakeholders and planning. Key
stakeholders and their broad needs will include:

Moorfields executive and board who will need to approve the Estates & Facilities Strategy
and particularly the proposed strategic objectives

Estates team members who will need to translate the Strategic Objectives into quantified
SMART measures

Client stakeholders who will need to gain an understanding of the strategic objectives and
SMART measures and how they will enhance service provision, reduce or mitigate risk, and
be aligned with associated cost drivers
In order to achieve the above, we propose a further three workshops with key Estates team
members to transform the key Balanced Scorecard Strategic Objectives into SMART annual
objectives.
Project Planning:
The following key milestones will be used to monitor progress.


14th October Workshop
–
Develop SWOT and PESTLE Analysis
–
Commence Maturity Matrix Data Gathering
11th November Workshop
–

9th December Workshop
–

Develop Balanced Scorecard Strategic Objectives (Circa 4-8)
Develop SMART Measures for each Strategic Objective
13th January Workshop
–
Present Final Strategy
–
Propose Change and Transformation Plan
b) Estates Compliance
An Estates and Facilities 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.
The Head of Estates and Maintenance and E&F Compliance Manager have started to strengthen
relationships with our host sites, resolving issues that had not been concluded and supporting
representation at each site from City Road.
The host trust of each of our satellite site locations have been requested to provide information to
support the validation of statutory compliance of occupied areas within their site. All reports are
now stored on EMIS, the bespoke Estates Management Information System which is now to be
utilised to its fullest potential.
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Estates & Facilities biannual report – October 2014
Lease management: The Director of Estates and Facilities and E&F Compliance Manager are
currently in negotiation with Croydon University Hospital re service charge and Barnet Enfield and
Haringey Mental Health NHS Trust (St Ann’s Hospital) in relation to lease renewal.
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 Ann’s
St Georges
Validation
2013/2014
27/08/2014
Pass/Fail
Validation
2014/2015
07/06/2014
27/05/2014
Fail
23/05/2014
24/08/2013
Pass
Pass
14/10/2013
Pass
14/04/2014
Not received
19/08/2014
18/10/2014
22/04/2014
04-05/06/2014
15-19/09/2014
06/05/2014
Pass/Fail
Pass
Fail
Validation due
Pass
Scheduled
Scheduled
Pass
Air flows
requested
Scheduled
Fail
Legionella Control: 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, information has been requested in relation to their regimes to test for
legionella. Not all sites have responded to the initial request to obtain this information, but this will
be covered in the meeting program which will be set up with each host site as part of our ongoing
compliance validation.
Fire Risk Assessment: The annual fire risk assessments have been completed in the majority of
our satellite sites. The newer sites including Croydon, Darent Valley, Purley and Stratford have not
yet been visited. City Road is scheduled to be undertaken. Recommendations have been
forwarded to the relevant host trust for review and action. The mandatory Fire Safety Working
Group has been reinstated and met for the initial meeting on 1st August 2014.
Policies: The following policies have been taken to the next Risk and Safety Committee for
approval:
 Fire Safety (including Theatre Evacuation Plan) – Revised and updated
 Management of Contractors – New policy
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Estates & Facilities biannual report – October 2014
c) Estates Services
The 2014 statutory insurance inspections are up to date.
The Estates department, previously located outside the main hospital, has now been centralised
and is located in the lower ground floor of the main hospital building, this now also includes
Estates, Facilities, CTS and Capital Projects. To accommodate the increased number of clinical
services provided, representation from the Estates department is on-site seven days a week.
An Estates Manager has been recruited, replacing the former Maintenance Manager and is
operationally responsible for the estate and supporting our satellite site functions on matters
concerning Mechanical and Electrical services.
Two members of the team have been awarded Employee of the Month – Kate Kosa, Catering
Administrator and Garry Auger, Head of Estates and Maintenance.
Approved persons: The Trust now has responsible persons in place, as outlined below:
Appointed persons for medical gases
Appointed person (limited authority
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
Andrew Taylor, Maintenance Supervisor
Dean Carter, Electrical Craftsperson
Garry Auger, Head of Estates and Maintenance
Garry Auger, Head of Estates and Maintenance
Completed projects:
 Conversion of Central Stores into a new Health Records office, housing 33 people.
 Conversion of the maintenance workshop into the Estates and Facilities office.
 Conversion of the boiler house into a new workshop for the maintenance team.
 Refurbished ASU, 205-207 City Road (2nd and 3rd floors), John Saunders Suite and HR
offices
 The CHP plant is now exporting electricity and credit is now being received from the
electricity board for this.
 Energy saving projects as detailed in the annual sustainability report
 Automated and computer controlled taps for legionella control and water quality.
 Installation of new hand hygiene work stations that have received positive feedback.
 Trialled new digital taps in Mackellar, Day Care and Sedgwick wards.
 Updated medical gas and medical air alarms
.
Current schemes:
 Refurbishment of eight theatres at City Road to be compliant under HTM 03-01.
 Refurbishment and reallocation of the Estates Helpdesk.
 New chiller plant being installed that will provide sufficient capacity for 24 hour cooling
across the building.
 E-Permits; All contractors requiring a Permit to Work will be required to submit a request
with supporting documentation prior the commencement of works.
 Asset tracking and management
o Physical assets
o Patient safety and throughput
o Staff safety and work flow optimisation
 A new module of EMIS named Agility is being rolled out, a new computerised maintenance
management system recording all assets and their location.
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Estates & Facilities biannual report – October 2014
d) Clinical Technical Services (CTS)
CTS have made huge progress in understanding and verifying the management of specialist
ophthalmic medical equipment enabling compliance in maintenance, repairs and procurement. The
year to date has seen a material increase in the completeness of inventory records leading to
stronger internal controls, greater accountability and fact based future capital spending.
During this reporting period the following are the key actions underway or completed.















We procured, commissioned and installed medical equipment at three new sites, Croydon,
Purley and Darent Valley; and commissioned and installed new medical equipment purchased
by host site at Sir Ludwig Guttman Health & Wellbeing Centre in Stratford, all in a timely
manner to ensure service delivery.
Ghana Korle bu Hospital medical equipment commissioning project delayed.
61% increase of registered medical devices input into our medical equipment database eQuip
since March 2012 (1960 devices). Current recorded inventory is 3211 devices.
We procured, commissioned and installed new equipment for the Ealing expansion
development in a timely manner to ensure service delivery.
We procured, decommissioned, installed and commissioned 18 Carl Zeiss HFAs and 11
upgrades funded through Moorfields Eye Charity in compliance with Personal Confidential Data
(PCD) procedure.
All devices at City Road, St Georges, Mile End, St Ann’s, Barking, Loxford and Purley have
been digitally photographed and uploaded to the CTS e-drive.
Progress has been made in relation to managing devices requested by our Medical
Consultants for evaluation and trial. In total we have supported and managed 11 medical
equipment trails including lasers, OCT, IOLs, Phacoemulsifier, Vitrectomy and non-mydriatic
cameras.
17 training sessions for medical equipment were organized by CTS with good attendance for
all clinical staff and recorded on My Learning Centre.
57 medical devices were decommissioned following the process for decommissioning and
information governance systems procedures ensuring Personal Confidential Data (PCD)
compliance.
102 medical devices were procured, commissioned and installed during this period. We have
added a new task to our commissioning procedure which includes “Smart Water Forensically
Coded” watermarking of devices as a deterrent to theft of Trust equipment.
Jobs logged per month by Estates Helpdesk have tripled since January 2012 demonstrating
that our internal processes are working. We continue to encourage staff to complete and
submit the Medical Equipment Job Form located on the Trust intranet homepage with good
effect. Consultant Ophthalmologists and Nurse Managers have responded positively to this
change enabling increase data input, accuracy of the data providing evidence to support
decision making.
Employment of 3 Clinical Engineers into substantive posts has significantly increased our
ability to repair in-house enabling quick turnaround of working equipment back into service.
We now average 45 repairs a month compared to 4 per month during the same period in 2012.
We achieved 100% score in our recent internal audit of our maintenance and repair procedures
demonstrating high level of compliance.
Planned preventative maintenance (PPM) for medical equipment is on target.
Internal Audit NHSLA 6 monthly (January to June 2014) CTS report (excluding theatre data)
submitted to Medical Devices Committee August 2014.
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Estates & Facilities biannual report – October 2014
e) Security
Below are the summary of key points relating to the security service
The NHS Protect Self Review Tool (SRT) work plan section 2014-15, has been completed and
agreed with the Security Management Director (SMD). This has been forwarded to NHS
Protect. The full SRT document will be completed in full and forwarded to NHS Protect by
November 30 2014 in accordance with NHS Protect guidance and advice.
The NHS Protect Organisational Crime Profile 2014-15 has been completed and forwarded to
NHS Protect.
The 2013-14 Security Manager & LSMS Action Plan was reviewed by the SMD and LSMS,
updated to take into account the work that had been completed during this period and the work
to be completed during 2014-15. This revised action plan was agreed with the Trust SMD
The NHS Protect Organisational Crime Profile has been completed and forwarded to NHS
Protect.





Satellite visits have been carried out in accordance with the Security Manager & LSMS
action plan and where security weaknesses are identified reports produced and forwarded
to the general manager with actions recommendations for their consideration.
Security visits to “new satellite sites” prior to becoming operational have been carried out at
MEH Ludwig Guttmann, MEH Purley, MEH Croydon and MEH Dartford.
Security risk review carried out at Upper Wimpole Street after burglary reported at the
building.
A review of CCTV system at City Road has been completed, and a business plan agreed. A
budget for the new CCTV system has been agreed. The expectation is that this will be
installed and operational by the end of 2014
Meeting with senior staff Moorfields Pharmaceuticals regarding security issues, policies and
procedures. Agreement to “oversee” security risk review
Policies
 CCTV policy has been agreed at the Risk & Safety committee and approved by Man Ex.
 Violence and Aggression policy agreed at the Risk and Safety Committee, approve by Man
Ex.
 Draft Lockdown policy under review for presentation at Risk and Safety Committee
The Head of Security LSMS is fully engaged with:
 Full engagement with NHS Protect processes and procedures, attendance at NHS Protect
quarterly meetings. All NHS Protect requirements at this time have been met and relevant
information and documents sent. SRT Work plan, Organisational Crime Profile 2014-15,
Violence Against Staff figures (VAS)
 Attendance at Risk and Safety Committee meetings.
 Attended all corporate induction sessions, presenting on security related matters. Two
Hundred and Twenty Three (223) attendees 2013-14. Attendees during this period one
hundred and eighty seven (187)
 Liaison and partnership working with the police to provide evidence and statements.
 Working with EPL and local police to arrange Project ARGUS event.
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Estates & Facilities biannual report – October 2014
f) 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:
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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 and a meeting will take place at the start of October. Following this, the Sustainability Steering
Group will be reinstated to lead this process. Progress will be reported in the six-monthly/annual
Board Reports and Boards Sustainability Papers.
g) Telecoms
Following the implementation of the new system (Netcall 59R), switchboard performance has
improved against the two key measures (KPI 1 - 80% calls to be answered within 15 seconds, KPI
2 - 100% of calls to be answered within 60 seconds)
Implementation of 59R and
additional staff member
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Estates & Facilities biannual report – October 2014
We were previously asked to provide 2 additional staff members to support this activity however, to
achieve this we would have to spend around £16k upgrading the operators console system. With
this in mind we trialled one additional member of staff, restructured current staff and with the
implementation of Netcall 59R we have seen an increase in monthly performance for KPI 1 from
48% to 74% and KPI 2 from 70% to approximately 94%. These measures have been consistent
month-on-month and we do occasionally hit the required service levels. If we want to exceed this
on a regular basis then an additional person will need to be brought into this area - this would
increase the output on this KPI to about 85-90% of calls being answered within 15 seconds.
Abandoned calls
On average the switchboard are receiving approximately 20,000 calls per calendar month; of these
approximately 1200 calls (5.6%) of calls are abandoned. Please note this was approximately 10%
of calls prior to the implementation of 59R.
Following a detailed review into these 1200 abandoned calls, it would appear that approximately
1000 of these calls are abandoned within 60 second - which suggests that patients are using the
automated service effectively but that calls are not being answered in the departments and
bounced back to the switchboard at which point the caller hangs up directly. Below gives a
summary of the abandoned call detail:
A report was completed for August:
Seconds
0-60
60-120
120 +
Total abandoned calls
Abandoned
934
91
68
Abandoned Percentage
85.4%
8.3%
6.2%
1093
We are currently working on the additional 12 call centres that went live mid-September. The
departments effected by the change are:
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Booking centre
Outpatients (9 different mini-call centres)
Medical enquiry line; and
Optometry
It is important that consideration is now given to recruiting of a telecoms supervisor / manager to
support the current new call centres, future call centres and help support the telecoms strategy that
needs to be developed this coming year. (Unify (previously Siemens) will not be supporting the
current phone systems we have at City Road, Provost and Ebenezer St from 2016).
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Estates & Facilities biannual report – October 2014
h) Portering
The former porters desk was removed as part of the reconfiguration in the main entrance corridor
area; this was enabled by the planned implementation of a portering software system – Portertrac;
this is used in over 100 NHS and enables the rapid entry and allocation of jobs, provides an ‘at a
glance’ view of the operational status of portering activities to enable management to focus on the
most urgent requirements.
Additional wheelchairs have also been purchased to support patient transfer from front of house to
clinics.
Postage spend is on an upward trend. We are looking at the operational impact of processing mail
in a different way to provide more information on postage used by department. Consideration is
being given to tightening processes around 1st and 2nd class mail, and alternate forms of
communication.
90,000
Postage spend - per month
80,000
70,000
60,000
50,000
40,000
30,000
20,000
10,000
0
i) Interpreting Services
The outsourced interpreting and translation framework agreement continues to provide a high
quality communication support to our patients with no KPI failures reported, across all sites. It is
noted that the interpreting budget is held by Facilities but controlled by clinical users
We are currently reviewing the Interpreting services at Moorfields. A savings proposal has been
submitted by 'thebigword' and is currently being reviewed by the Head of Facilities. The Facilities
department will focus on:
Telephone interpreting
Capping visits to 3 hours
Language days
The Director of Nursing and Allied Health Professionals is leading the strategic review of
interpreting services.
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Estates & Facilities biannual report – October 2014
j) Transport Services
The transport contract continues to deliver higher volumes that anticipated.
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Inbound
Total Inward Journeys
Indicative number of journeys
Over activity number
Over activity percentage
1495
1414
81
5.4%
1769
1414
355
20.1%
1631
1414
217
13.3%
1577
1414
163
10.3%
1687
1414
273
16.2%
1760
1414
346
19.7%
Late failures Nos
Late failures %
69
4.6%
64
3.6%
68
4.2%
39
2.5%
57
3.4%
66
3.8%
1357
1414
-57
-4.20%
1584
1414
170
10.73%
1513
1414
99
6.54%
1445
1414
31
2.15%
1566
1414
152
9.71%
1627
1414
213
13.09%
36
2.7%
50
3.2%
82
5.4%
80
5.5%
55
3.5%
68
4.2%
Outbound
Total Outbound Journeys
Indicative number of journeys
Over activity number
Over activity percentage
Late failures Nos
Late failures %
Facilities have adopted a supplier relationship management process (SRM) whereby contract
meetings and performance reviews are managed effectively. Whilst there is some flexibility with
Medical Services within the SLA’s and KPI’s the failures are being reviewed with close scrutiny to
support improving late failures. Trend analysis forms part of the contract review meetings and over
the next few months we will be implementing a continuous improvement programme (CIP) and will
be expecting Medical Services to deliver performance improvements over the coming months.
k) Domestic Services
The domestic service continues to be of a satisfactory standard. We are currently discussing the
use of an external auditor to review the cleaning standards at City Road and possibly satellite sites.
This proposal will be developed over the next six months.
The annual Patient-Led Assessment Care Environment took place on Monday 24th March 2014.
The assessment covered four key areas as outlined below, which shows the national average
score in line with the Trust score
Cleanliness
Food and Hydration
Privacy Dignity and Wellbeing
Condition Appearance and Maintenance
2014 - Score
National
Average
97.25%
88.79%
87.73%
91.97%
2014 - Score
Moorfields
Eye Hospital
99.62%
100%
88.31%
99.10%
2013 – Score
Moorfields
Eye Hospital
93.69%
100%
89.33%
89%
Due to Moorfields being an ambulatory care hospital, the score for food and hydration, although
internally recognised as receiving a percentage score, will not be published to a wider audience.
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Estates & Facilities biannual report – October 2014
l) Catering & Hospitality
Below is summary of the key points within catering over the reporting period.
The full supply chain within catering has now been added to the eProcurement system, ensuring
that we get the best price from suppliers. The reporting dashboard is shown below for information.
A food hygiene inspection, undertaken by an external body has recently been completed. This
audit included a physical inspection of the main kitchen, restaurant, ward areas and children’s café.
This also included an audit of the Hazard Analysis and Critical Control Point (HACCP) Food Safety
Management Programme and documentation systems.
The key messages from this inspection are that all standards, systems and process are of a good
standard, and have significantly improved in all areas over the past 12 months. A plan of action
was put in place to resolve areas identified as needing attention. All outstanding actions have been
completed. This will be an ongoing process to ensure full compliance within the trust.
The Costa outlet has been running successfully for almost 12 months and all complaints /
comments for this area have been resolved. The outlet has provided over £40k in turnover share in
the first 6 months of the calendar year, over and above the base rent, for reinvestment in patient
services.
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Estates & Facilities biannual report – October 2014
m) Waste Management
The retendering of the general and clinical waste has now been completed and the new contracts
are now in place. General waste is now managed by Bywaters and clinical waste was renewed
with SRCL. These will deliver combined savings of approximately £54,500 per annum based on
historic waste volumes. The new compactor will deliver vastly improved hygienic storage of waste
pending collection.
The chart below details the waste volumes and segregation percentages as from April 2014 to
date.
n) Water dispensers
The Estates and Facilities department has now taken over the management of the water machines
at Moorfields. This will mean that clinical staff will no longer have to raise purchase requests on an
annual basis. There are currently 70 water machines which would require 70 purchase requests to
be raised, and processing of numerous invoices. This has now been consolidated to one invoice
per annum and two service visits.
Chris Harding
Director Estates and Facilities
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