Heating and ventilation systems

Health Technical Memorandum

03-01: Specialised ventilation for
healthcare premises
Part B: Operational management and performance
verification
DH INFORMATION READER BOX

Policy Estates
HR / Workforce Performance
Management IM & T Estates
Planning Finance
Clinical Partnership Working

Document Purpose Best practice guidance

ROCR Ref: 0 Gateway Ref: 8949
Title Health Technical Memorandum 03-01: Specialised ventilation for
healthcare premises. Part B - Operational management
Author Department of Health / Estates and Facilities Division
Publication Date November 2007
Target Audience PCT CEs, NHS Trust CEs, SHA CEs, Care Trust CEs, Foundation
Trust CEs , PCT PEC Chairs, NHS Trust Board Chairs, Special HA
CEs

Circulation List Department of Health libraries, House of Commons library,

Strategic Health Authorities, UK Health Departments, Directors of
Estates and Facilities,

Description The document gives comprehensive advice and guidance to

healthcare management, estates managers and operations managers
on the legal requirements, maintenance and operation of specialised
ventilation in all types of healthcare premises.

Cross Ref N/A

0
Superseded Docs Health Technical Memorandum 2025
0
Action Required N/A
0
Timing N/A
Contact Details Ken Holmes
Department of Health/Estates and Facilities Division
Quarry House, Quarry Hill
Leeds
LS2 7UE
email: [email protected]
0
0
For Recipient's Use
Heating and ventilation systems
Health Technical Memorandum 03-01:
Specialised ventilation for healthcare premises

Part B: Operational management and performance verification

London: The Stationery Office

Heating and ventilation systems – HTM 03-01: Specialised ventilation for healthcare premises – Part B

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© Crown copyright 2007

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ii
Preface

About Health Technical Memoranda main source of specific healthcare-related guidance for
estates and facilities professionals.
Engineering Health Technical Memoranda (HTMs)
give comprehensive advice and guidance on the design, The core suite of nine subject areas provides access to
installation and operation of specialised building and guidance which:
engineering technology used in the delivery of healthcare. • is more streamlined and accessible;
The focus of Health Technical Memorandum guidance • encapsulates the latest standards and best practice in
remains on healthcare-specific elements of standards, healthcare engineering;
policies and up-to-date established best practice. They are
applicable to new and existing sites, and are for use at • provides a structured reference for healthcare
various stages during the whole building lifecycle. engineering.

Figure 1 Healthcare building life-cycle

DISPOSAL CONCEPT

RE-USE
DESIGN & IDENTIFY
OPERATIONAL OPERATIONAL
MANAGEMENT REQUIREMENTS

Ongoing SPECIFICATIONS
MAINTENANCE TECHNICAL & OUTPUT
Review

PROCUREMENT
COMMISSIONING

CONSTRUCTION
INSTALLATION

Healthcare providers have a duty of care to ensure that Structure of the Health Technical
appropriate engineering governance arrangements are in Memorandum suite
place and are managed effectively. The Engineering
Health Technical Memorandum series provides best The series of engineering-specific guidance contains a
practice engineering standards and policy to enable suite of nine core subjects:
management of this duty of care. Health Technical Memorandum 00
It is not the intention within this suite of documents to Policies and principles (applicable to all Health
unnecessarily repeat international or European standards, Technical Memoranda in this series)
industry standards or UK Government legislation. Where Health Technical Memorandum 01
appropriate, these will be referenced. Decontamination
Healthcare-specific technical engineering guidance is a Health Technical Memorandum 02
vital tool in the safe and efficient operation of healthcare Medical gases
facilities. Health Technical Memorandum guidance is the

iii
Heating and ventilation systems – HTM 03-01: Specialised ventilation for healthcare premises – Part B

Health Technical Memorandum 03 Electrical Services – Electrical safety guidance for low
Heating and ventilation systems voltage systems
Health Technical Memorandum 04 In a similar way Health Technical Memorandum 07-02
Water systems will simply represent:
Health Technical Memorandum 05 Environment and Sustainability – EnCO2de.
Fire safety
All Health Technical Memoranda are supported by the
Health Technical Memorandum 06 initial document Health Technical Memorandum 00
Electrical services which embraces the management and operational policies
from previous documents and explores risk management
Health Technical Memorandum 07
issues.
Environment and sustainability
Some variation in style and structure is reflected by the
Health Technical Memorandum 08
topic and approach of the different review working
Specialist services
groups.
Some subject areas may be further developed into topics
DH Estates and Facilities Division wishes to acknowledge
shown as -01, -02 etc and further referenced into Parts A,
the contribution made by professional bodies,
B etc.
engineering consultants, healthcare specialists and
Example: Health Technical Memorandum 06-02 Part A NHS staff who have contributed to the review.
will represent:

Figure 2 Engineering guidance

FIC DOC
H SPECI UM
L T EN
A TS
HE
HTM 08
HTM 01
Specialist
Services Decontamination

S T R Y S TA N D A
DU RD
IN S
& EUROPEAN
NAL ST
HTM 07
IO HTM 02
T

AN
NA

Environment & Medical

DA
H E A LT H S P E

INTER

CUMENTS

Sustainability Gases
RDS

HTM 00
RDS
INTER

Policies and
Principles
DA
NA

AN

IO
ST
T

NA
DO

HTM 06 L& N HTM 03

Electrical
IN EUROPEA S Heating &
DU D
C

Services STR AR Ventilation

IF I

IC

Y S TA N D Systems
IF
C

EC
D

HTM 05 HTM 04
O

Fire
SP

U Water
C

M Safety Systems H
EN T
TS AL
HE

iv
Executive summary

Preamble Who should use this guidance?

Health Technical Memorandum 03-01 – ‘Specialised This document is aimed at healthcare management,
ventilation in healthcare premises’ is published in two estates managers and operations managers.
parts: Part A deals with the design and installation of
ventilation systems; Part B covers operational Main recommendations
management.
• All ventilation plant should meet a minimum
The document gives comprehensive advice and requirement in terms of the control of Legionella
guidance on the legal requirements, design implications, and safe access for inspection and maintenance.
maintenance and operation of specialised ventilation in
all types of healthcare premises. • All ventilation plant should be inspected annually.

The guidance contained in this Health Technical • The performance of all critical ventilation systems
Memorandum applies to new installations and major (such as those servicing operating suites) should be
refurbishments of existing installations. verified annually.

Health Technical Memorandum 03-01 supersedes all

previous versions of Health Technical Memorandum
2025 – ‘Ventilation in healthcare premises’.

v
Contents

Preface
Executive summary
Acknowledgements
Chapter 1 Introduction 1
Preamble
Ventilation in healthcare premises
Statutory requirements
Health and Safety at Work etc Act 1974
COSHH
Fire regulations
Plants installed in units manufacturing medicinal products
Plants installed in laboratories
Codes of practice and guidance
Management responsibilities – general
System information
Frequency of inspections and verifications
Chapter 2 Functional responsibilities 4
Management responsibilities
Designated staff functions
Management
Designated Person
Authorising Engineer (Ventilation) (AE(V))
Authorised Person (Ventilation) (AP(V))
Competent Person (Ventilation) (CP(V))
Infection Control Officer
Plant Operator
User
Contractor
Records
Training
Specific health and safety aspects
Chapter 3 Ventilation systems – minimum requirements 6
General requirements
Location and access
Basic requirements
AHU intakes and discharges
AHU drainage system
Dampers
Fan drives
Heater-batteries
Cooling coils
Humidifiers
Filtration
High-efficiency filters – HEPA and ULPA

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Heating and ventilation systems – HTM 03-01: Specialised ventilation for healthcare premises – Part B

Energy recovery
Attenuation
Identification and labelling
Pressure stabilisers
Chapter 4 Annual inspection and verification requirements 10
Ventilation systems inspection
Critical ventilation systems
Definition of a critical system
Annual verification
Fabric of the area served
Critical ventilation systems – verification standards
Vertical ultra-clean operating theatres
Horizontal ultra-clean operating theatres
Category 3 and 4 laboratories and rooms
Pharmacy aseptic suites
Sterile services department – inspection and packing rooms
LEV systems
Critical system verification failure
Chapter 5 Inspection and maintenance 14
General
Inspection and maintenance of critical systems
AHU drainage
Filter changing
Changing extract filters containing hazardous substances
Ventilation system cleaning
Chilled beams
Split and cassette air-conditioning units
Portable room air-conditioning units
Self-contained mobile filter and/or ultraviolet (UV) light units
Inspection and maintenance records
Appendix 1 Annual inspection of critical ventilation systems – AHU and plantroom equipment 17
Definition of terms used on survey form
General condition
Annual inspection of critical ventilation systems – AHU and plantroom equipment
Appendix 2 Operating suite annual verification 22
Definition of terms used on survey form
Annual verification of theatre ventilation systemsTheatre suite information
References 25
Acts and regulations
British Standards
Department of Health publications
Other publications

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Heating and ventilation systems – HTM 03-01: Specialised ventilation for healthcare premises – Part B

Acknowledgements

Malcolm Thomas – Consulting Engineer – Lead Author CIBSE Healthcare Group

IMechE/ASHRAE
Principal contributors
IHEEM
Craig Macintosh – Principal Clinical Scientist - Wirral
Hospitals NHS Trust HEFMA
Andy McGrath – BSRIA Instrument Solutions BSI
Helen & Philip Sturdy – DSSR consultancy Faber Maunsell consultancy
Richard Gatley – Apreco Couch Perry Wilkes consultancy
Russell Pitman - Henderson Green consultancy DSSR consultancy
Kevin Reynolds – Deputy Head of Estates – Sandwell Howorth Airtech
and West Birmingham NHS Trust
Medical Air Technology/Thermo Electric
Ian Fraser – Department of Health
BPG Medical
Main Steering Group and Working Groups Admeco/Trumpf Medical Systems
comprising representatives from:
Volkes SPX
Department of Health
Weiss Klimatechnik
Welsh Health Estates
Sound Research Laboratories
NHS in Scotland
NHS Security Management Service
Health & Social Services, Northern Ireland
Pennine Acute NHS Trust
Health Protection Agency (HPA)
Hospital Infection Society (HIS)
Building Research Establishment (BRE)
Central Sterilising Club
Building Services Research and Information Association
HEVAC – Air-handling Unit Manufactures Group
(BSRIA)
University of Leeds

vi
1 Introduction

Preamble Statutory requirements

1.1 Health Technical Memorandum 03-01 – Increased health risks to patients will occur if
‘Specialised ventilation in healthcare premises’ is ventilation systems do not achieve and maintain the
published in two parts: Part A deals with the design required standards. The link between surgical site
and installation of ventilation systems; Part B infection and theatre air quality has been well
covers operational management. established.
1.2 The document gives comprehensive advice and If the ventilation plant has been installed to dilute
guidance to healthcare management, design or contain harmful substances, its failure may expose
engineers, estates managers and operations people to unacceptable levels of contamination. Proven
managers on the legal requirements, design breaches of the statutory requirements can result in
implications, maintenance and operation of prosecution and may also give rise to a civil suit against
specialised ventilation in all types of healthcare the operators.
premises.
1.3 The guidance contained in this Health Technical Health and Safety at Work etc Act 1974
Memorandum applies to new installations and
major refurbishments of existing installations. 1.7 The Health and Safety at Work etc Act 1974 is
the core legislation that applies to ventilation
1.4 Health Technical Memorandum 03-01 supersedes installations. As these installations are intended
all previous versions of Health Technical to prevent contamination, closely control the
Memorandum 2025 – ‘Ventilation in healthcare environment, dilute contaminants or contain
premises’. hazards, their very presence indicates that potential
risks to health have been identified.
Ventilation in healthcare premises
COSHH
1.5 Ventilation is used extensively in all types
of healthcare premises to provide a safe and 1.8 The Control of Substances Hazardous to
comfortable environment for patients and staff. Health (COSHH) Regulations 2002 place upon
More specialised ventilation is provided in areas management an obligation to ensure that suitable
such as operating departments, critical care areas measures are in place to protect their staff and
and isolation facilities for primary patient others affected by the work activity. These methods
treatment. may include both safe systems of work and the
provision of a specialised ventilation system. In
1.6 It is also installed:
laboratories the requirements are often met by the
• to ensure compliance with the quality assurance provision of fume cupboards and microbiological
requirements of items processed in pharmacies safety cabinets.
and sterile services departments;
1.9 Where specialised ventilation plant is provided as
• to protect staff from harmful organisms and part of the protection measures, there is a statutory
toxic substances (for example in laboratories). requirement that it be correctly designed, installed,
commissioned, operated and maintained. The local
exhaust ventilation (LEV) section of COSHH
requires that the system be examined and tested at
least every 14 months by a competent person and

1
Heating and ventilation systems – HTM 03-01: Specialised ventilation for healthcare premises – Part B

that management maintain comprehensive records Codes of practice and guidance

of its performance, repair and maintenance.
1.16 All ventilation systems should conform to
1.10 Certain substances have workplace exposure limits the principles set out in the Health and Safety
(WELs) set out in the Health and Safety Executive’s Commission’s Approved Code of Practice and
(2005) Guidance Note EH40 – ‘Workplace guidance document ‘Legionnaires’ disease: the
exposure limits: containing the list of workplace control of Legionella bacteria in water systems’
exposure limits for use with the Control of (commonly known as L8), and Health Technical
Substances Hazardous to Health Regulations 2002 Memorandum 04-01 – ‘The control of Legionella,
(as amended)’. If specialised ventilation systems are hygiene, “safe” hot water, cold water and drinking
provided in order to achieve these standards, they water systems’.
will be subject to the COSHH Regulations as
above. 1.17 The Department of Health publication
‘The Health Act 2006: code of practice for the
Fire regulations prevention and control of healthcare associated
infections’ is a code of practice that has been
1.11 The fire regulations require that, if ventilation brought out to help NHS bodies to plan and
ductwork penetrates the fabric of a building, implement how they can prevent and control
it should be designed and installed so as to healthcare-associated infections. It sets out criteria
contain the spread of fire (see Health Technical by which managers of NHS organisations are
Memorandum 05-02 – ‘Guidance in support of to ensure that patients are cared for in a clean
functional provisions for healthcare premises’ for environment and where the risk of healthcare-
further guidance). associated infections is kept as low as possible.
1.12 It is management’s responsibility to ensure that the Specialised ventilation systems often play a central
standards applied during the design and installation role in achieving this objective.
are not reduced during the subsequent operation
and maintenance of the equipment. Management responsibilities – general
1.18 It is a management responsibility to ensure that
Plants installed in units manufacturing medicinal
inspection, service and maintenance activities are
products
carried out safely without hazard to staff, patients
1.13 Plants installed in units manufacturing medicinal or members of the public.
products to the standards set out in the current
1.19 Those required to monitor and/or maintain
European guide to good manufacturing practice
ventilation equipment will need to show that they
(http://ec.europa.eu/enterprise/pharmaceuticals/
are competent to do so (see Chapter 2).
eudralex/homev4.htm) may also be subject to
particular legislation with regard to their operation 1.20 Maintenance procedures should be reviewed
and maintenance. periodically to ensure that they remain appropriate.
1.14 There are specific requirements under the
Medicines Act 1968 to maintain accurate records System information
of plant performance, room conditions and 1.21 When new ventilation systems are accepted
maintenance events. Such records would need to for use, full information as to their designed
be preserved for up to 35 years as part of a quality mode of operation together with recommended
assurance audit trail. maintenance procedures should be provided as part
of the handover procedure.
Plants installed in laboratories
1.22 In many existing systems, original design and
1.15 Specialised ventilation plants installed in commissioning information will not be available.
laboratories dealing with research, development It will therefore be necessary to determine a suitable
or testing, whether involving drugs, animals or level of system performance based on the function,
genetically modified organisms, may be subject to purpose and age of the installation.
particular legislation with regard to their operation
in addition to that mentioned above. 1.23 Part A of this Health Technical Memorandum gives
design parameters for new installations.

2
 1 Introduction

1.24 Chapter 3 of this document sets out the minimum Frequency of inspections and
standards for all air-handling units (AHUs) and
verifications
their air distribution systems.
1.28 All ventilation systems should be subject to, at
1.25 Ventilation system records and logbooks should
least, a simple visual inspection annually.
be kept of the commissioning information,
operational management routine, monitoring and 1.29 Ventilation systems serving critical care areas should
maintenance. The Health and Safety Executive and be inspected quarterly and their performance
other interested bodies have a statutory right to measured and verified annually. The quarterly
inspect them at any time. All records should be inspection should be a simple visual check; the
kept for at least five years. annual verification will be a more detailed
inspection of the system together with the
1.26 In the event of a reportable incident connected
measurement of its actual performance.
with ventilation equipment or the area that it
serves, all records and plant logbooks will need to 1.30 The LEV section of the COSHH regulations
be collected as evidence. contains a statutory requirement that systems
installed to contain or control hazardous substances
1.27 A set of specimen maintenance checklists is given
be examined and tested at least every 14 months by
in Appendix 1.
a competent person.
1.31 Regular tests, at intervals agreed with the local fire
prevention officer, will need to be carried out in
order to demonstrate the continuing efficiency of
the fire detection and containment systems. These
may be in addition to the inspections detailed
above. Records of these tests should be kept.

3
Heating and ventilation systems – HTM 03-01: Specialised ventilation for healthcare premises – Part B

2 Functional responsibilities

Management responsibilities Authorising Engineer (Ventilation) (AE(V))

2.1 Clear lines of managerial responsibility should 2.8 The AE(V) is defined as a person designated by
be in place so that no doubt exists as to who is Management to provide independent auditing and
responsible for the safe operation and maintenance advice on ventilation systems and to review and
of the equipment. witness documentation on validation.
2.2 A periodic review of management systems should Authorised Person (Ventilation) (AP(V))
take place in order to ensure that the agreed
standards are being maintained. 2.9 The AP(V) will be an individual possessing
adequate technical knowledge and having received
2.3 Those required to inspect, verify or maintain appropriate training, appointed in writing by the
ventilation equipment will need to show that they Designated Person (in conjunction with the advice
are competent to do so. As a minimum they should provided by the AE(V)), who is responsible for
have sufficient knowledge of its correct operation to the practical implementation and operation of
be able to recognise faults. Management’s safety policy and procedures relating
2.4 It is anticipated that training in the validation and to the engineering aspects of ventilation systems.
verification of specialised healthcare ventilation
systems for Authorised Persons and Competent Competent Person (Ventilation) (CP(V))
Persons will become available during the life of this 2.10 The CP(V) is defined as a person designated by
Health Technical Memorandum. Management to carry out maintenance, validation
and periodic testing of ventilation systems.
Designated staff functions
Infection Control Officer
2.5 A person intending to fulfil any of the staff
functions specified below should be able to prove 2.11 The Infection Control Officer (or consultant
that they possess sufficient skills, knowledge and microbiologist if not the same person) is the
experience to be able to safely perform the person nominated by management to advise on
designated tasks. monitoring the infection control policy and
microbiological performance of the systems.
Management
2.12 Major policy decisions should be made through an
2.6 Management is defined as the owner, occupier, infection control committee. The infection control
employer, general manager, chief executive or other committee should include representatives of the
person who is ultimately accountable for the safe user department and estates and facilities or their
operation of premises. nominated representative (that is, the Authorised
Person).
Designated Person
2.7 This person provides the essential senior Plant Operator
management link between the organisation and 2.13 The Plant Operator is any person who operates a
professional support. The Designated Person ventilation installation.
should also provide an informed position at board
level. User
2.14 The User is the person responsible for the
management of the unit in which the ventilation

4
 2 Functional responsibilities

system is installed (for example head of Specific health and safety aspects
department, operating theatre manager, head of
laboratory, production pharmacist, head of research 2.21 Staff engaged in the service and maintenance
or other responsible person). of extract ventilation systems from pathology
departments, mortuaries, laboratories, source-
Contractor protected isolation facilities and other areas
containing a chemical, biological or radiation
2.15 The Contractor is the person or organisation hazard may be particularly at risk. In these cases,
responsible for the supply of the ventilation the risk should be identified and assessed.
equipment, its installation, commissioning or
validation. This person may be a representative of a 2.22 The means by which the system can be rendered
specialist ventilation organisation or a member of safe to work on should be determined, and a
the general manager/chief executive’s staff. permit-to-work on the system implemented.
2.23 Training in the exact procedures should be given to
Records all staff involved.
2.16 A record should be kept of those appointed to carry 2.24 Some healthcare facilities may contain specialised
out the functions listed above. The record should units that are subject to access restrictions (for
clearly state the extent of the postholder’s duties example pharmacy aseptic suites). Estates or
and responsibilities, and to whom they are to contract staff requiring access may need additional
report. training or to be accompanied when entering the
2.17 Substitute or replacement staff should be
unit.
designated in order to cover for sickness, holidays See also the following guidance published by the
and staff transfers. Health and Safety Commission’s Health Services
Advisory Committee:
Training
a. ‘Safe working and the prevention of infection in
2.18 Routine inspection and maintenance procedures clinical laboratories and similar facilities’;
can cause risks to the health of staff carrying out
the work and those receiving air from the plant. All b. ‘The management, design and operation of
those involved should be made aware of the risks, microbiological containment laboratories’;
and safe systems of work should be agreed. Suitable c. ‘Safe working and prevention of infection in the
safety equipment should be provided as necessary, mortuary and post-mortem room’.
and training in its use should be given.
2.19 Any training given should be recorded, together
with the date of delivery and topics covered.
2.20 Training in the use of safety equipment and a safe
system of work will need to be repeated periodically
in order to cater for changes in staff.

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Heating and ventilation systems – HTM 03-01: Specialised ventilation for healthcare premises – Part B

3 Ventilation systems – minimum requirements

General requirements that combustible material is not kept in the

plantroom.
3.1 All ventilation systems should be inspected
annually to ensure conformity with minimum
requirements, which are designed to:
Basic requirements
3.11 The plant must not contain any material or
a. ensure safe access when carrying out routine
substance that could support the growth of
service and maintenance activities;
microorganisms.
b. prevent or control risks associated with
3.12 The plant must not contain any material or
Legionella and other potential hazardous
substance that could cause or support combustion.
organisms;
3.13 Access to items that require routine service, such as
c. check that the system remains fit for purpose.
filters, fog coils and chiller batteries, should be via
3.2 Every effort should be made to ensure that all hinged doors.
AHUs achieve the minimum requirement set out
3.14 Items requiring infrequent access such as
below.
attenuators may be via clipped or bolted-on lift-off
panels.
Location and access
3.15 All doors and panels should be close-fitting and
3.3 AHUs should be secured from unauthorised access. without leaks.
3.4 Units located on roofs should have a safe and 3.16 Every effort should be made to ensure that access
permanent means of access. Suitable precautions is via fixed ladders and platforms or pulpit-style
must be in place to prevent personnel or equipment movable steps.
from falling during maintenance activities.
3.17 Electrical and mechanical services should not
3.5 Units located outside at ground level should restrict or impede access to those parts of the AHU
be secured within a compound to prevent that require inspection.
unauthorised access. Vehicles should be excluded
from the vicinity to ensure that exhaust fumes will 3.18 Viewing ports and internal illumination should be
not be drawn into intakes. fitted in order to inspect filters and drainage trays.
3.6 All parts of the AHU should be easily and safely 3.19 Internal illumination should be provided by
accessible for routine inspection and service. fittings to at least IP55 rating. Fittings should be
positioned so that they provide both illumination
3.7 The area around an AHU within a building should for inspection and task lighting.
be tanked to prevent water penetration to adjacent
areas, and should be adequately drained. 3.20 A single switch should operate all of the lights in a
unit.
3.8 Fire precautions should be in accordance with
Firecode.
AHU intakes and discharges
3.9 Combustion equipment must not be located
3.21 Intake and discharge points should not be situated
in a fire compartment that houses air-handling
where they will cause vitiated air to be drawn into a
equipment.
system (see paragraphs 3.57–3.68 in Part A, which
3.10 Plantrooms that house AHUs should not be used give detailed information). In existing systems, it
for general storage. Care should be taken to ensure may be necessary to extend the intake or discharge
point to a suitable position.

6
 3 Ventilation systems – minimum requirements

3.22 Each intake and discharge point should be fitted 3.29 Traps fitted to plant located outside or in unheated
with corrosion-resistant weatherproof louvres or plantrooms may need to be trace-heated in winter.
cowls to protect the system from driving rain. The The trace heating should be checked for operation
inside of the louvres should be fitted with a mesh of and must not raise the temperature of water in the
not less than 6 mm and not more than 12 mm to trap above 5°C.
prevent infestation by vermin and prevent leaves
3.30 Water from each trap must discharge via a clear
being drawn in.
air gap of at least 15 mm above the unrestricted
3.23 The duct behind a louvre should be self-draining. spill-over level of either an open tundish connected
If this is not practicable, it should be tanked and to a drainage stack via a second trap, or a floor
provided with a drainage system. Cleaning access gully (or channel). A support should be provided
must be provided either from the outside via to ensure that the air gap cannot be reduced. More
hinged louvres or by access doors in the plenum than one drain trap may discharge into the tundish,
behind the louvre. Where a common plenum is providing each has its own air break.
provided, cleaning access should be via a walk-in
3.31 Drainage pipework may be thermoplastic, copper
door.
or stainless steel. Glass should not be used. The
pipework should be a minimum diameter of
AHU drainage system 22 mm and have a fall of at least 1 in 60 in the
3.24 All items of plant that could produce moisture direction of flow. It should be well supported, and
must be provided with a drainage system. The located so as not to inhibit access to the AHU.
system will comprise a drip-tray, glass trap, air
break and associated drainage pipework. Dampers
3.25 Some existing units may not have been mounted 3.32 AHUs serving critical areas and those areas that
far enough above the floor to permit the correct are shut down out of hours should be fitted with
installation of a drainage system. If the AHU motorised low-leak shut-off dampers located
cannot be raised to an adequate height, an immediately behind the intake and discharge of
alternative arrangement (such as a pump-out each supply and extract system.
system) must be provided.
3.26 The drip-tray should be constructed of a corrosion- Fan drives
resistant material (stainless steel is preferred) and 3.33 Fan-drive trains, whether supply or extract, should
be so arranged that it will completely drain. To be easily visible without the need to remove access
prevent “pooling”, it is essential that the drain covers. Protecting the drive train with a mesh guard
connection should not have an up-stand and that is the preferred option. For weatherproof units
a slope of approximately 1 in 20 in all directions designed to be located outside, the fan drive should
should be incorporated to the drain outlet position. be enclosed. It should be easily visible through a
The tray must be completely accessible or, for viewing port with internal illumination and be
smaller units, easily removable for inspection and accessed via a lockable, hinged door.
cleaning.
3.34 The motor windings of induction-drive “plug”
3.27 Each drip-tray should be provided with its own motor arrangements and in-line axial fans having a
drain trap. The drain trap should be of the clear pod motor within the air stream must be protected
(borosilicate) glass type. This permits the colour of from over-temperature by a thermistor and lock-
the water seal to be observed, thus giving an early out relay.
indication of corrosion, biological activity or
3.35 It is necessary to ensure that – should the computer
contamination within the duct (see Table 3).
control system or its software develop a fault –
3.28 The trap should have a means for filling and should the fan can be switched to a direct start with fixed
incorporate couplings to facilitate removal for speed and manual operation. This is particularly
cleaning. It should be located in an easily visible important for critical care systems serving operating
position where it will not be subject to casual suites, high dependency care units of any type,
knocks. The pipework connecting it to the drainage isolation facilities, laboratories and pharmaceutical
tray should have a continuous fall of not less than production suites.
1 in 20.

7
Heating and ventilation systems – HTM 03-01: Specialised ventilation for healthcare premises – Part B

Heater-batteries air-conditioning systems within healthcare facilities.

Water humidifiers, if fitted, should be removed.
3.36 Access for cleaning must be provided to both sides
of all fog coils and heater-batteries. 3.46 Self- and locally-generated steam humidifiers must
be supplied with potable water. The installation
3.37 Where auxiliary wet heater-batteries are located in should be capable of being isolated, drained and
false ceilings, they should be fitted with a catch tray cleaned. Chapter 4 in Part A of this Health
and leak alarm. The catch tray should be installed Technical Memorandum gives further details.
under both the battery and the control valve
assembly to protect the ceiling from leaks. 3.47 Some steam generators are of a type that requires
A moisture sensor and alarm should be fitted regular cleaning and descaling. The installation
in the tray. should enable them to be physically isolated from
the air duct in order to prevent contamination of
Cooling coils the air supply by cleaning agents.

3.38 All cooling coils – whether with the AHU or 3.48 The humidifier control system should fully
with a branch duct – must be fitted with their own conform to the standard set out in Chapters 4 and
independent drainage system as specified above. 6 of Part A.
A baffle or similar device must be provided in the
drip-tray to prevent air bypassing the coil, and the Filtration
tray should be large enough to capture the moisture 3.49 Filters must be securely housed and sealed in
from the eliminator, bends and headers. well-fitting frames that minimise air bypass.
3.39 The cooling-coil control valve should close upon Air bypass significantly reduces filter efficiency;
selection of low speed, system shut-down, low air the higher the filter grade, the greater the effect.
flow or fan failure. Mounting frames should be designed so that the
air flow pushes the filter into its housing to help
3.40 Where auxiliary wet-cooling coils are located in minimise air bypass.
false ceilings, they should be fitted with a catch tray
and leak alarm. The catch tray should be installed 3.50 All filters should be of the dry type. Panel filters are
under both the battery and the control valve generally used as prefilters and should be positioned
assembly to protect the ceiling from leaks. A on the inlet side of the supply fan, downstream of
moisture sensor and alarm should be fitted in the the frost coil. Where required, secondary filters
tray. (these will be bags or pleated paper) should be on
the positive-pressure side of the fan.
Humidifiers 3.51 The filter installation should provide easy access to
3.41 Humidifiers are not generally required. Where they filter media for cleaning, removal or replacement;
are fitted, but have been out of use for a significant therefore, a hinged access door should be provided.
period of time, they should be removed. All The upstream side of the filter should be visible for
associated pipework should also be removed back inspection through a viewing port with internal
to its junction with the running main. illumination.

3.42 Where humidifiers are fitted and their use is 3.52 All filters should be provided with a means of
still required, they should fully conform to the checking the differential pressure across them.
installation standard set out in Chapter 4 of Part A. Direct-reading dial-type gauges marked with clean
and dirty sectors are preferred.
3.43 The section of ductwork containing the humidifier
may need to be periodically decontaminated. High-efficiency filters – HEPA and ULPA
Hinged access doors with viewing ports and
internal illumination should be provided. 3.53 Where fitted, HEPA filters should be of the
replaceable-panel type with leak-proof seals. Their
3.44 All humidifiers must be fitted with their own installation should permit the validation of the
independent drainage system as detailed above. filter and its housing.
3.45 Only steam-injection humidifiers, whether mains 3.54 HEPA filters are sometimes used in extract systems
fed or locally generated, are suitable for use in for the containment of hazardous substances or

8
 3 Ventilation systems – minimum requirements

organisms. They may be fitted with prefilters to Attenuation

extend their service life.
3.59 Cleaning access should be provided at both ends of
3.55 When used for the containment of hazardous any attenuator unit.
substances, the installation should incorporate
design provision for the subsequent safe removal Identification and labelling
and handling of contaminated filters by
maintenance staff. 3.60 All supply and extract ventilation systems should be
clearly labelled. The label should identify both the
Energy recovery AHU and the area that it serves. The lettering
should be at least 50 mm high and be mounted in
3.56 Energy recovery, where fitted, will require cleaning an easily visible place near the fan of the unit. Any
access to both sides of the device. subsystems and the principal branch ducts should
3.57 Whichever type of energy recovery device is fitted, be similarly labelled.
the extract side should be protected by a G3 filter 3.61 The direction of air flow should be clearly marked
and provided with a drainage system to remove on all main and branch ducts.
condensate.
3.62 All air-flow test-points should be clearly identified,
3.58 The heat-recovery device should be controlled in and the size of the duct given.
sequence with the main heater-battery, and may
need to incorporate a control to prevent the Pressure stabilisers
transfer of unwanted heat when the air-on
condition rises above the plant’s required set-point. 3.63 Pressure stabilisers should be unobstructed and
silent in operation.

9
Heating and ventilation systems – HTM 03-01: Specialised ventilation for healthcare premises – Part B

4 A
 nnual inspection and verification
requirements

Ventilation systems inspection b. patient isolation facility of any type;

4.1 All ventilation systems should be subject to at least c. critical care, intensive treatment or high-
a simple visual inspection annually. dependency unit;
4.2 The purpose of the inspection is to establish that: d. neonatal unit;
a. the system is still required; e. Category 3 or 4 laboratory or room;
b. the AHU conforms to the minimum standard f. pharmacy aseptic suite;
(see Chapter 3); g. inspection and packing room in a sterile services
c. the fire containment has not been breached; department;
d. the general condition of the system is adequate h. MRI, CAT and other types of emerging
for purpose; imaging technologies that require particularly
stable environmental conditions to remain
e. the system overall is operating in a satisfactory within calibration;
manner.
j. any system classified as an LEV system under
4.3 It is recommended that a simple check sheet the COSHH Regulations;
be used to record the result of the inspection.
Examples are given in Appendices 1 and 2. k. any other system that clearly meets the
definition.
Critical ventilation systems 4.8 The loss of service from such a system would
4.4 All critical ventilation systems should be inspected seriously degrade the ability of the premises to
quarterly and verified at least annually. In some deliver optimal healthcare.
circumstances the verification may need to be
carried out more frequently. Annual verification
4.5 The quarterly inspection should be as detailed in 4.9 The annual verification is intended to establish
paragraphs 4.1–4.3. that:
4.6 The purpose of the annual verification will be to a. the system is still required;
additionally ensure that the system: b. the AHU conforms to the minimum standard
a. achieves minimum standards specific to the (see Chapter 3);
application; c. the fire containment has not been breached;
b. is operating to an acceptable performance level; d. the general condition of the ventilation system
c. remains fit for purpose. is adequate;
e. the fabric of the area served is satisfactory;
Definition of a critical system
f. the system performance is adequate with respect
4.7 Ventilation systems serving the following are to the functional requirement – this will require:
considered critical:
(i) a full measure of the supply and extract
a. operating theatres of any type, including rooms air-flow rates;
used for interventional investigations (for
example catheter laboratories);

10
 4 Annual inspection and verification requirements

(ii) the calculation of room air-change rates if Critical ventilation systems –

applicable;
verification standards
(iii) the measurement of room differential
4.16 Unless otherwise specified below, the ventilation
pressures if applicable;
system should achieve not less than 75% of the
(iv) the measurement of room noise levels; design air-change rate given in Appendix 2 of
Part A, or its original design parameters.
(v) air-quality checks if appropriate;
4.17 The pressure regime should achieve not less than
(vi) a check on the control functions.
75% of the design value given in Appendix 2 of
4.10 An assessment should then be made as to whether Part A, or its original design parameters; and the
the system overall is fit for purpose and operating pressure gradient relationships with regards to
in a satisfactory manner. surrounding areas must be maintained.
4.18 The sound levels given in Table 2 are maximum
Fabric of the area served permissible levels and should not be exceeded.
4.11 The building elements in the room or rooms Measurements should be made using at least a
served by a critical ventilation system should also Type 2 sound meter fitted with a muff. Its accuracy
be suitable for the function. As an example, in a should be checked using a calibration sound source
suite of rooms comprising an operating theatre before use.
complex, the following elements should be
checked: Vertical ultra-clean operating theatres
a. the ceiling should be complete and, if tiled, all 4.19 The following additional measurements should be
tiles should be clipped down and sealed; taken:
b. the walls and floors should be free from • the average air velocity at the 2 m level under
significant construction and finish defects; the canopy: it should achieve a minimum
average of 0.38 m/s for a partial wall system
c. windows and their trickle vents should be sealed and 0.3 m/s for a full wall system;
and locked shut;
• the air velocity within the inner zone at the
d. the doors should close completely and the door 1 m level: every reading should achieve a
closers should be correctly adjusted to hold minimum velocity of 0.2 m/s.
them against the room pressure;
4.20 The air velocity measurements are to be taken using
e. all service penetrations and access panels should the equipment, test grid and method set out in
be sealed to prevent uncontrolled air flow Chapter 8 of Part A.
between rooms and service voids;
f. steps should have been taken (if necessary) to Note
prevent portable equipment and stock items
There is no requirement to carry out filter scanning or
from obstructing low-level supply, transfer or
entrainment tests at the annual verification unless the
extract air-flow paths.
HEPA filters or recirculating air fans are changed, or
4.12 Failure to achieve a suitable standard will render the system is in some other significant way disturbed
even the most sophisticated ventilation system or altered. Changing the filters in the AHU or
ineffective. recirculating air filters does not constitute a significant
disturbance to the ultra-clean ventilation (UCV) unit.
4.13 All fire dampers should be tested as part of the
annual verification.
4.21 Should the UCV terminal fail to achieve a suitable
4.14 LEV systems will be subject to an examination standard, resulting in the need to disturb or replace
and test by a competent person at least every the HEPA filters or recirculating air fans, the unit
14 months. should be revalidated using the procedure given in
Chapter 8 of Part A.
4.15 Table 1 provides a model for the verification of
critical ventilation systems.

11
Heating and ventilation systems – HTM 03-01: Specialised ventilation for healthcare premises – Part B

Table 1 Operational management and routine verification process model

Step Question Information/standard required Comment
1 Is the system still required? Why was it installed? Is that function still required?
2 Does the AHU achieve the • Health and safety aspects Inspect to ascertain compliance
minimum standard? • Intake/discharge positions with minimum standards set out
• Inspection access in Chapter 3 of Health Technical
• Legionella control and drainage Memorandum 03-01 (Part B)
• Fire and electrical safety
• Leaks, cleanliness and insulation
• Filtration
3 Is the air distribution system • Access Inspect to ascertain continued
satisfactory? • Fire dampers fitness for purpose
• Cleanliness
• Insulation
• Identification
• Room terminals
• Pressure stabilisers
4 Does the measured system • Design air velocities Establish the design values
performance still accord with • Design air-flow rates
Measure the system output to verify
the design intent and achieve a • Room air-change rates
its performance
minimum acceptable standard? • Pressure differentials
• Noise levels
• Air quality
5 Does the control system function • Desired environmental conditions Establish the design requirement
correctly? • Control sequence logic
Inspect/test to verify performance
• Run; set-back; off philosophy
6 Having regard to the foregoing, is the system “fit for purpose” and will it only Yes or No!
require routine maintenance in order to remain so until the next scheduled
verification?
7 What routine service and • Filter changes Decide inspection frequency and
maintenance will be required for • System cleaning maintenance schedule
the system to remain fit for purpose • Performance indication
and function correctly until the • Performance monitoring
next scheduled verification? • Performance measurement

Table 2 Maximum sound levels (service noise only)

Location Design sound level Measured sound level
(NR) (dB(A))
Ultra-clean operating room 50 55
Conventional operating room 40 45
All other non-specified rooms 40 45
Corridors 40 45
Recovery room 35 40
Ward areas; sleeping areas 30 35
Note: Health Technical Memorandum 08-01 gives detailed guidance on acoustics and the measurement of sound

12
 4 Annual inspection and verification requirements

Horizontal ultra-clean operating theatres Pharmacy aseptic suites

4.22 The following additional measurements should be 4.26 Pharmacy aseptic suites should conform to the
taken: requirements of the European guide to good
manufacturing practice (http://ec.europa.eu/
• the discharge velocity test at 1 m, 1.5 m and
enterprise/pharmaceuticals/eudralex/homev4.htm)
2 m in front of the terminal: the average
and the requirements of the Medicine Inspectorate
velocity should be not less than 0.4 m/s.
if a licensed manufacturing unit.
4.23 The measurements are to be taken using the
equipment, test grid and method set out in Sterile services department – inspection and
Chapter 8 of Part A. packing rooms
4.27 Inspection and packing rooms should conform to
Note the requirements of BS EN ISO 14644 and any
There is no requirement to carry out filter scanning additional requirements for the processing of
at the annual verification unless the HEPA filters or medical devices, if applicable (see also Health
recirculating air fans are changed; or the system is Building Note 13 – ‘Sterile services department’).
in some other significant way disturbed or altered.
Changing the filters in the AHU or recirculating air LEV systems
filters does not constitute a significant disturbance to 4.28 LEV systems should conform to the Health and
the UCV unit. Safety Executive’s ‘The maintenance, examination
and testing of local exhaust ventilation’.
4.24 Should the UCV terminal fail to achieve a suitable
standard, resulting in the need to disturb or replace
the HEPA filters or recirculating air fans, the unit
Critical system verification failure
should be revalidated using the procedure given in 4.29 Should a critical system be unable to achieve the
Chapter 8 of Part A. standard set out above, it should be taken out of
service. If healthcare provision needs prevent the
Category 3 and 4 laboratories and rooms system being taken out of service, the senior
4.25 These areas should conform to the requirements manager of the user department should be
of current information published by the Advisory informed in writing that the system performance is
Committee on Dangerous Pathogens and the suboptimal. A copy of the notice should be sent to
Health and Safety Executive: the infection control committee.

• ‘The management, design and operation of 4.30 If a critical system is refurbished in order to bring it
microbiological containment laboratories’; to a suitable standard, it should be subject to the
full validation procedure set out in Chapter 8 of
• ‘Biological agents: managing the risks in Part A or other application-specific guidance as
laboratories and healthcare premises’; and appropriate.
• ‘Biological agents: the principles, design and
operation of Containment Level 4 facilities’.

13
Heating and ventilation systems – HTM 03-01: Specialised ventilation for healthcare premises – Part B

5 Inspection and maintenance

General Table 3 Colour of water in glass trap

5.1 Inspection and maintenance activities should be Colour of water Probable cause and comment
assessed to ensure that they do not create a hazard Normal Satisfactory
for those who undertake the work or for those who Green Copper corrosion of pipework
could be affected by it. Possible leak in battery tubing
5.2 The degree and frequency of maintenance should White Aluminium corrosion of battery fins
relate to the function of the system, its location, its Black General dirt
general condition and the consequence of failure. Filter faulty allowing air bypass
System is overdue for a thorough clean
5.3 Specimen inspection and maintenance checklists
Urgent action required
are given in the Appendices.
Brown/red Iron corrosion (rust) within the duct
May indicate a specific Legionella hazard
Inspection and maintenance of critical Immediate action required
systems Bubbly/slimy Microbiological activity within the duct
5.4 The loss of service of these systems would seriously May indicate a specific Legionella hazard
degrade the ability of the premises to deliver Immediate action required
optimal healthcare. In order to ensure reliable
service provision, it is essential to inspect, verify 5.8 Dirty extract-and-return air filters may pose an
and maintain these systems at appropriate intervals. increased level of hazard. This will relate to the
particular contamination within the air that they
5.5 For many of these systems a permit-to-work will have filtered. Filters handling extract air from
need to be completed to ensure that taking the general areas are unlikely to present a significantly
ventilation system out of service does not greater hazard than that posed by dirty supply air
compromise the activities of the user department. filters.
In any event, it will be necessary to liaise with the
user department when switching the system off to 5.9 Care should be taken to protect staff from inhaling
carry out routine inspection and maintenance. the dust. If there is a need to enter the duct when
changing filters, a dust mask should be worn.
AHU drainage 5.10 Dirty filters should be carefully removed and placed
in the box that contained the replacement filters or
5.6 AHU drainage systems comprise a drainage tray,
in a plastic bag. On completion of the work, the
glass trap, connecting pipework and an air break.
dirty filters should be removed from the plantroom
The system should be inspected to ensure that it is
and disposed of appropriately.
clean and operating correctly. The cleanliness of the
drainage tray and colour of the water in the trap 5.11 The duct in the area of the filter housing should be
will give an indication of a fault condition (see carefully vacuumed before fitting the replacement
Table 3). filters. This will prevent particles (that is, those that
are shed when the dirty filters are disturbed) being
Filter changing blown into the system downstream.

5.7 Dirty supply air filters may pose a general dust 5.12 It is important to ensure that replacement filters are
hazard when being changed. fitted the right way round. Most panel filters are
manufactured with a membrane or wire support
mesh on their downstream side. Alternatively they

14
 5 Inspection and maintenance

may be colour-coded. The manufacturer’s but will typically be in excess of ten years. There
instructions regarding fitting should be followed. is no requirement to clean ductwork annually.
A rapid build-up of visible dirt within a supply
5.13 Bag filters should be fitted with the pockets
duct is an indication of a failure of the filtration or
vertical. Care should be taken to remove any transit
its housing.
tapes and to ensure that the individual pockets are
separate and free to inflate. 5.22 Extract air systems handle unfiltered air. They
should be cleaned as frequently as necessary in
Changing extract filters containing order to maintain their operating efficiency. Room
hazardous substances extract terminals, particularly those sited at low
level in critical care areas, will need regular
5.14 Filters handling extract air from an LEV system will cleaning.
obviously present a hazard and should be subject to
5.23 On completion of cleaning, the ductwork should
a safe system of work.
not be “fogged” with chemicals. This treatment
5.15 Filters used in an extract system for the has no lasting biocidal effect and is responsible for
containment of hazardous substances or organisms initiating the breakdown of the galvanised coating
should incorporate design provision for their safe of ductwork. This will result in accelerated
removal when so contaminated. This may be corrosion of the inside of the duct, with the
achieved by: products of corrosion being shed into the air
a. sealing the hazardous substance into the filter stream. It will also significantly shorten service life.
before it is removed; 5.24 Following duct cleaning, all service hatches should
b. a system to fumigate the filter to kill any be checked to ensure that they have been correctly
organisms; replaced and do not leak.

c. housing it in a ”safe change” unit that permits 5.25 Duct-cleaning equipment that uses rotating brushes
the filter to be ejected into a bag and sealed or a vacuum unit can easily damage flexible sections
without staff having to come into direct contact of ductwork. On completion of cleaning, all
with it. flexible duct sections should be checked for rips
and tears. The straps that secure them to rigid duct
5.16 The method chosen should reflect the nature of the sections and air terminals should also be checked to
hazard. ensure that there is no air leakage.
5.17 Filters fitted to remove hazardous substances from
extract air are classed as hazardous waste and should Chilled beams
be handled and disposed of accordingly. 5.26 The efficiency of these units will rapidly decline if
they become blocked with fluff/lint. They should
Ventilation system cleaning be inspected every six months and cleaned as
5.18 The intake section of a ventilation system should appropriate.
be vacuumed-out as necessary to remove visible
particles. Split and cassette air-conditioning units
5.19 AHUs should be vacuumed-out and/or washed 5.27 These units incorporate internal recirculation air
down internally as necessary to remove obvious filters and a drainage system to remove condensate
dust and dirt. from the cooling coil. The systems should be
inspected and cleaned every three months.
5.20 Chiller batteries, humidifier units, energy-recovery
batteries or plates and their drainage systems should
be washed down with hot water annually to remove Portable room air-conditioning units
visible contamination. 5.28 Portable units are sometimes kept in-store or
5.21 Supply air distribution ductwork conveys air that hired-in to cope with temporary local situations
has been filtered. It will require internal cleaning giving rise to excessive temperatures. They typically
only when it becomes contaminated with visible incorporate internal recirculation air filters and a
dirt. The frequency of cleaning will depend on the drainage system to remove condensate from the
age of the system and grade of the AHU final filter

15
Heating and ventilation systems – HTM 03-01: Specialised ventilation for healthcare premises – Part B

cooling coil. The infection control team must be lamp and filter replacement should be closely
consulted before these types of unit are deployed. followed.
5.29 The units should be inspected and thoroughly 5.34 Units that have been used in isolation rooms or
cleaned before being taken into use. Units areas containing infective patients will need to be
that are to be used in areas containing fumigated before being used in other locations, or
immunocompromised patients will, unless new, returned to store.
need to be fumigated before use.
5.35 Filters fitted to remove hazardous substances from
5.30 All portable units should be inspected and cleaned the recirculated room air are classed as hazardous
every week that they remain in use. waste and should be handled and disposed of
accordingly (see also Health Technical
5.31 Units that have been used in isolation rooms or
Memorandum 07-01 – ‘Safe management of
areas containing infective patients will need to be
healthcare waste’).
fumigated before being used in other locations, or
returned to store or to the hirer.
Inspection and maintenance records
5.32 Units employing an internal water reservoir and
wick to promote evaporative cooling must not be 5.36 Records of inspection and maintenance activities
used in healthcare premises. should be kept for at least five years.

Self-contained mobile filter and/or

ultraviolet (UV) light units
5.33 The efficacy of these units is directly related to
their cleanliness. In this respect, the manufacturer’s
instructions regarding service/maintenance and

16
Appendix 1 – Annual inspection of critical
ventilation systems – AHU and
plantroom equipment

Definition of terms used on survey form

General condition
End of useful life
This should be clear from the condition of the AHU and its associated services and plant. The main indicators
will be:
• extensive internal and/or external corrosion of the AHU casing;
• failure of filter housings to prevent air bypass;
• general corrosion of heater and cooling battery fins, attenuator surfaces etc;
• significant failure to meet minimum standards;
• associated plant services and control elements in a poor condition or not able to fulfil their purpose;
• AHU aged 20 years or more.
Action: Urgent replacement indicated.

Poor
Should be fairly apparent but would include an assessment of the degree of corrosion; cleanliness of coils and
batteries; quality of filter mountings and their ability to prevent air bypass; fan and drive train condition; the control
system elements’ ability to fulfil their function; condition of the access doors and inspection covers. The age of the
AHU is generally less important.
Action: Extensive refurbishment or programmed replacement indicated.

Average
Some faults but generally free of significant corrosion, clean internally and conforming to minimum standards.
Action: Faults capable of correction at next maintenance period.

Good
Conforming to the minimum standards, obviously cared for and subject to routine maintenance.
Action: Routine maintenance will preserve standard of the equipment.

Compliance with minimum standards (questions 2 to 23, 32 and 33)

Poor
More than three answers are negative.
Action: Management action required by estates/facilities department.

17
Heating and ventilation systems – HTM 03-01: Specialised ventilation for healthcare premises – Part B

Average
No more than three answers are negative.
Action: Maintenance action required.

Good
No answers are negative, full compliance.
Action: None.

Maintenance quality (questions 5, 12, 26 to 31 and 34 to 40)

Poor
More than three answers are negative.
Action: Management action required by estates/facilities department.

Average
No more than three answers are negative.
Action: Maintenance action required.

Good
No answers are negative.
Action: None.

18
 Appendix 1 – Annual inspection of critical ventilation systems – AHU and plantroom equipment

Annual inspection of critical ventilation systems – AHU and plantroom equipment

Hospital

Plantroom

Air-handling unit Age of unit

Area served by unit

Date of survey Name

General condition: End useful life Poor Average Good

Compliance with minimum standards

(Questions 2 to 23; 32 and 33) Poor Average Good

Maintenance quality
(Questions 5, 12, 26 to 31, 34 to 40) Poor Average Good
No Survey question Yes No Comments
1 Plant running?
2 Is the unit and its associated plant
secure from unauthorised access?
3 Is the unit safely accessible for
inspection and maintenance?
4 Is the air intake positioned to
avoid short circuiting with extract
or foul air from other sources such
as gas scavenging outlets?
5 Are all inspection lights operating?
6 Are motorised dampers fitted to
the intake and discharge?
7 Are fan motor(s) outside of the air
stream?
8 Is the fan drive train visible
without removing covers?
9 Is the cooling coil located on the
discharge side of the fan?
10 Is an energy-recovery system fitted
(state type)?
11 Are condensate drainage systems
fitted to all energy recovery
systems, cooling coils and
humidifiers in accordance with
Chapter 3 of Health Technical
Memorandum 03-01, Part B?

19
Heating and ventilation systems – HTM 03-01: Specialised ventilation for healthcare premises – Part B

No Survey question Yes No Comments

12 Are drainage traps clean and filled
with water? (see Table 3 in Health
Technical Memorandum 03-01,
Part B)
13 Is the drain trap air break at least
15 mm?
14 If a humidifier is fitted, state the –
type
15 Is the humidifier capable of
operation?
16 Is there space to safely change the
filters?
17 Are there test holes in the principal
ducts?
18 Are the test holes capped?
19 What is the general condition of –
the exterior of the AHU?
20 Are the principal ducts lagged?
21 What is the general condition of –
the associated control valves and
pipework?
22 Is the pipework adequately lagged?
23 Is the system clearly labelled?
24 Record prefilter differential –
pressure
25 Record main filter differential –
pressure
Switch plant off. Fit padlock to isolator
26 Did the motorised dampers close
on plant shut-down?
27 Is the vermin/insect screen clean?
28 Is the intake section including the
fog coil clean?
29 Are the prefilters correctly fitted
with no air bypass?
30 Are all drive belts correctly aligned
and tensioned?
31 Is the cooling-coil matrix clean?
32 Are all drip-trays fully accessible or
capable of being removed for
cleaning and have a fall to drain?
33 Are the drainage trays stainless?
34 Are the drainage trays clean?
35 Are there any signs of water
ponding in the AHU?

20
 Appendix 1 – Annual inspection of critical ventilation systems – AHU and plantroom equipment

No Survey question Yes No Comments

36 Is the matrix clean for each
heater-battery?
37 Have the main filters been
correctly fitted with no air bypass?
38 Is AHU and its associated main
ductwork clean internally?
Energise plant
39 Did unit restart satisfactorily?
Test automatic fan-motor change-over, if fitted
40 Did automatic change-over
operate satisfactorily?

Additional comments
(For example: air leaks from access doors; control valves leaking or passing; general cleanliness of the area around the
unit; or any other items of concern.)

Competent Person/Authorised Person .......................................................................

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Heating and ventilation systems – HTM 03-01: Specialised ventilation for healthcare premises – Part B

Appendix 2 – Operating suite annual

verification

Definition of terms used on survey form

Assessment of compliance with Health Building Note 26 and Health Technical Memorandum 03-01
(all questions relevant to the type of theatre)
Poor
Air volumes and hence air-change rate is less than 75% of the design; room pressure differentials do not ensure a
flow from clean to less clean areas; supply or extract air diffusers are not clean; pressure stabilisers not clean and/or
not operating correctly; significant faults or failures of indicators on surgeon’s panel; visible faults in the fabric of the
suite; doors unable to close completely; general air of neglect.
Action: Urgent management action required.

Average
Air volumes and room pressure differentials approximate to the original design values; supply air diffusers clean but
extracts visibly fouled; most pressure stabilisers clean and operating correctly; some of the indicators on the surgeons
panel not working; minor faults in the fabric and décor of the suite.
Action: Maintenance action required.

Good
Better than average.
Action: None.

Maintenance quality (all questions relevant to the type of theatre)

Poor
More than three answers are negative.
Action: Management action required by estates/facilities department.

Average
No more than three answers are negative.
Action: Maintenance action required.

Good
No answers are negative.
Action: None.

22
 Appendix 2 – Operating suite annual verification

Annual verification of theatre ventilation systems

Theatre suite information
Hospital

Theatre name/no. Type of Theatre

Date of survey AHU location & ID

Name

Compliance with HBN & HTM Poor Average Good

Maintenance quality Poor Average Good

No Survey question Yes No Comments
1 Has the annual verification of the
AHU been carried out?
2 Are windows hermetically sealed?
3 Are the ceilings in the theatre and
prep room complete and sealed?
4 Are there any significant faults in
the fabric of the rooms in the
suite?
5 Are room light fittings correctly
sealed?
6 Do all doors close completely and
hold against the room pressure?
7 Are the pressure stabilisers
operating correctly and silently?
8 Are all supply and extract air
terminals and pressure stabilisers
visibly clean?
9 Measure and record the operating –
room temperature
10 Does this accord with that
displayed on the surgeon’s panel?
11 Measure and record the operating –
room relative humidity
12 Does this accord with that
displayed on the surgeon’s panel?
13 Measure and record the supply –
and extract air flow in the
principle ducts
14 Measure and record the air flow at –
all supply and extract terminals
15 Does the derived air-change rate
achieve at least 75% of the design?
16 For UCV units, also measure and –
record the air velocities within the
canopy using the method set out
in Chapter 8 of Health Technical
Memorandum 03-01 (Part A)
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Heating and ventilation systems – HTM 03-01: Specialised ventilation for healthcare premises – Part B

No Survey question Yes No Comments

17 Do the air velocities achieve the
standard appropriate for the type
of canopy?
18 Measure and record the room –
differential pressures
19 Do the room differential pressures
ensure a flow of air from the clean
to the less clean areas?
20 Measure and record the noise –
levels in the principal rooms of the
suite
21 Do the noise levels fall below the
limits set out in Table 2 of Health
Technical Memorandum 03-01,
Part B?
22 Check the operation of all –
ventilation control functions
represented on the surgeon’s panel.
23 Do the indicators accurately
represent the operational state of
the ventilation system(s)?
24 For UCV systems: is the UCV and
AHU interlocked to ensure that
the AHU runs at full speed when
the UCV is at operating speed or
at set-back? (see Table 6 in Health
Technical Memorandum 03-01,
Part A)
25 With the UCV running at set-
back, does the system maintain the
standard of a conventional
operating room?
26 For all theatres: with the system
running at set-back, does it
maintain a flow of air from the
clean to the less clean areas?

Additional comments
(For example: the general décor; are the suite and its ventilation systems suitable for their designated functions?)

Competent Person/Authorised Person .......................................................................

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References

Acts and regulations British Standards

Building Regulations 2000. SI 2000 No 2531. HMSO, BS EN ISO 14644-1:1999. Cleanrooms and associated
2000. controlled environments. Classification of air cleanliness.
www.opsi.gov.uk/si/si2000/20002531.htm
Building Regulations 2000: Approved Document B: Department of Health publications
Fire Safety – Volume 2. Department for Communities (The) Health Act 2006: Code of practice for the
and Local Government, 2005. prevention and control of healthcare associated
Building Regulations 2000: Approved Document F: infections. 2006.
Ventilation. Department for Communities and Local www.dh.gov.uk
Government, 2006. Health Building Note 13 – Sterile services
Building Regulations 2000: Approved Document department. The Stationery Office, 2003.
L2A: Conservation of fuel and power in new buildings Health Technical Memorandum 04-01 – The control
other than dwellings. Department for Communities and of Legionella, hygiene, “safe” hot water, cold water
Local Government, 2006. and drinking water systems. The Stationery Office,
Building Regulations 2000: Approved Document 2006.
L2B: Conservation of fuel and power in existing Health Technical Memorandum 05-02 – Guidance in
buildings other than dwellings. Department for support of functional provisions for healthcare
Communities and Local Government, 2006. premises. The Stationery Office, 2007.
Control of Substances Hazardous to Health Health Technical Memorandum 07-01 – Safe
Regulations (COSHH) 2002. SI 2002 No 2677. management of healthcare waste. The Stationery
HMSO, 2002. Office, 2006.
www.opsi.gov.uk/si/si2002/20022677.htm
Health Technical Memorandum 08-01 – Acoustics.
Health Act 2006. HMSO, 2006. The Stationery Office, 2007.
www.opsi.gov.uk/ACTS/acts2006/20060028.htm
Health and Safety at Work etc Act 1974. HMSO, Other publications
1974. Health & Safety Commission (2000). Approved Code of
Management of Health and Safety at Work Practice, Legionnaires’ disease: the control of
Regulations 1999. SI 1999 No 3242. HMSO, 1999. legionella bacteria in water systems (L8). Health and
www.opsi.gov.uk/SI/si1999/19993242.htm Safety Executive, 2000.
Medicines Act 1968. HMSO, 1968. Health & Safety Executive (1998). The maintenance,
examination and testing of local exhaust ventilation.
Provision and Use of Work Equipment Regulations HSE Books, 1998.
1998. SI 1998 No 2306. HMSO, 1998.
www.opsi.gov.uk/SI/si1998/19982306.htm Health & Safety Executive (2005). Workplace exposure
limits: containing the list of workplace exposure limits
Workplace (Health, Safety and Welfare) Regulations for use with the Control of Substances Hazardous to
1992. SI 1992 No 3004. HMSO, 1992. Health Regulations 2002 (as amended). HSE Books,
www.opsi.gov.uk/si/si1992/Uksi_19923004_en_1.htm 2005.

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Heating and ventilation systems – HTM 03-01: Specialised ventilation for healthcare premises – Part B

Health Regulations 2002 (as amended). HSE Books, Health & Safety Commission’s Health Services Advisory
2005. Committee (2003). Safe working and the prevention of
infection in clinical laboratories and similar facilities.
Health & Safety Commission’s Health Services Advisory
HSE Books, 2003.
Committee (2005). Biological agents: managing the
risks in laboratories and healthcare premises. HSE Health & Safety Commission’s Health Services Advisory
Books, 2005. Committee (2003). Safe working and the prevention of
infection in the mortuary and post-mortem room.
Health & Safety Commission’s Health Services Advisory
HSE Books, 2003.
Committee (2005). Biological agents: the principles,
design and operation of Containment Level 4
facilities. HSE Books, 2005.
Health & Safety Commission’s Health Services Advisory
Committee (2001). (The) Management, design and
operation of microbiological containment
laboratories. HSE Books, 2001.

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