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The Standard For Maintenance
Mike Ralph
Head of UK Healthcare Engineering

Who is Mike Ralph?
1. Director of Estates and Facilities at Great Ormond Street
Hospital and Croydon Healthcare
2. Head of UK Healthcare Engineering Sodexo
3. Working in collaboration with BESA
4. Experienced in serious fires in hospitals including:
1. Oxygen cylinder fire and explosion at GOSH
2. Fire at Croydon from faulty equipment in Imaging department
3. Arson Attack which destroyed MRI and accommodation at Croydon
2 –
Who is Sodexo?
1. Started in Marseille in 1966 by Pierre Bellon as a catering
2. One of the world’s largest multinational corporations with
420,000 employees
3. Present at 34,000 sites in 80 countries.
4. Now facilities management is as important as catering in
the UK
5. Provides facilities management at nine UK hospitals.
3 –
Great Ormond Street Hospital 2008
4 –
Croydon hospital fire
5 –
What is SFG20?
6 –
SFG20 is Unique
The essential tool for;
facilities managers
building owners
Stay compliant,
save time, energy
and money
7 –
The Building Engineering Services Association
The Building Engineering Services Association is the UK’s
leading trade organisation for building engineering services
representing the interests of firms active in the
design, installation, commissioning, maintenance, control and
management of engineering systems and services in
8 –
What is SFG20?
Developed and maintained by the Building
Engineering Services Association (formally
Originally launched in 1990
Recognised as the industry standard for
maintenance specifications
A web-based service, accessible via
Library of maintenance specifications for the
building services sector
Growing Library of over 400 schedules
9 –
SFG20 facilitates compliance
Legislation and best
practise reviewed on
an on-going basis by
our Technical
Technical bulletins
keep you informed and
up to date
Schedules reviewed
and amended as
required to keep you
10 –
SFG20 aids costs control
Identify maintainable
Create Service Models
Colour-coded critical
statutory vs.
discretionary activities
Provides the
benchmark for
optimum maintenance,
avoiding over or under
maintaining of assets
11 –
Why SFG20?
Specify maintenance activities
Benchmark service delivery
Align your Planned
Preventative Maintenance
against the industry standard
Understand your obligations
Control costs & defend
Keeps you updated
Ensures your assets
‘Maintained & Compliant’
12 –
SFG20 Ensuring compliance, saving time and money
13 –
SFG20 Healthcare, how does it work
Overarching Introduction ensures:
Statutory Compliance
Points to Consider during Maintenance Works
Maintenance of Systems
Proprietary Equipment
Efficiency and Emissions
14 –
SFG20 Healthcare specific subjects included
00-01 Overarching Introduction
HTM05-00 Management of maintenance for fire safety services within Healthcare premises
HTM05-01 Fire Risk Assessments in Healthcare Premises
HTM05-02 Fire Training and Fire Safety Audits
HTM05-03 Fire Drills
HTM05-04 Daily, Weekly and Monthly tasks – Healthcare premises
HTM05-05 Structural Fire Protection and Fire Compartmentation
HTM05-06 Fire Alarm System – Healthcare premises
HTM05-07 Fire Alarms – Associated Equipment – Healthcare premises
HTM05-08 Fire Alarm – Voice Alarm Systems – Healthcare premises
HTM05-09 Laundries
HTM05-10 Smoke Control Systems Healthcare premises – Weekly, 3 Monthly and Annual Testing
HTM05-11 Fire Strategy documentation checks
15 –
SFG20 Colour coded for ease of reference
SFG20 Risk based approach
Article 17 RRO
Where necessary in order to
safeguard the safety of relevant
persons the responsible person
must ensure…..……..subject to a
suitable system of maintenance and
are maintained in an efficient state,
in efficient working order and in good

PPM Fire Doors- government guidance
HTM 05-03 part K
Monthly tests and checks:
Check that all fire doors are in good working
order and closing correctly, and that the frames
and seals are intact.

The reality
At a large hospital there may be in excess of 8000 fire doors.
Assuming checking around 200 doors a day per person= 40
That is 2 persons doing nothing but check fire doors
That is without carrying out anything other than minor
Most hospitals complete a 6 monthly ppm on fire doors
Is this in line with HTM 05-03 part K?
Does this comply with Article 17?
Example risk assessment for PPM on fire doors
The risk is assessed on three factors:
1. The frequency of use of the door, this is deemed to be
high, medium or low.
2. The criticality of the door, this is based on the dependency
of the patient, that is independent, dependent or very high
3. The likelihood of the door being damaged by impact, that
is likely to be damaged or unlikely to be damaged.

Fire door risk assessment matrix
PPM Frequency matrix
Low (daily) Usage <80x in
Med (daily) Usage 80-200x
in 24hr
High (daily) Usage >200x in
12 monthly 12 monthly 6 monthly
12 monthly 6 monthly 3 monthly
Very High Dependency 6 monthly 3 monthly Monthly

Adjustment for impact
Likely: The frequency is increased to the next level
Unlikely: The frequency is reduced to the next level
Normal: The frequency remains

It is important that any risk assessment is reviewed:
If it is found that doors regularly require maintenance the
frequency of ppm should be increased.
If it is found they never (or very infrequently) require
maintenance, the frequency of ppm should be reduced.
There is no reason that the frequency of ppm cannot be
reduced to greater than 12 months, to several years even, if
the doors are still maintained to Article 17.

Risk based approach
A similar risk based approach can be utilised for other
maintenance elements.
For Instance:
Fire Dampers
Fire Compartmentation

SFG20 Task frequency
Daily, weekly and monthly tasks
The nature of the task
Who performs the tasks

SFG20 weekly fire alarm testing
SFG20 link to BS
Refers to BS for specific tasks.
Simplifies SFG20

Includes a skilling key
AA Not-specified AD Appointed Person AE Authorising Engineer AF Authorising Engineer (Fire)
AG Authorising Engineer (Lifts) AH Authorised Person (HV) AL Authorised Person (LV) AN Authorised Person (Lifts)
AP Authorised Person BL Building Trade CE Controls Engineer CF Competent Person (Fire)
CH Competent Person (HV) CL Competent Person (LV) CM Competent Person (Lifts) CO Contractor
CP Competent Person DH Duty Holder DP Designated Person DQ Designated Persons (Lifts)
E Electrical FC Facilities Coordinator FM Facilities Manager FN Facilities Operative
FO Fire Officer FS Fire Safety Manager GS Gas Safe IC Infection Control Officer
LO Locksmith LS Lift Steward M Mechanical ME M&E
MM Management MN Manager MS Multi-skilled OP Operator
PA Plant Attendant PN Painter PO Prison Officer PP Plumber
PT Pool Attendant RE Refrigeration Engineer SP Specialist TE Technician
U User

SFG20 Advantages
1. Ensures compliance with current standards.
2. All required information in one place or referenced and
easily accessed
3. Tasks are easily scheduled and includes expected time
4. Risk based approach which reduces unnecessary
maintenance and expenditure whilst targeting highest risk.
5. Saves time checking multiple sets of guidance in the form
of Approved Codes of Practice, Approved Documents,
Guidance Notes, HTM, British/EU Standards and Industry
30 –
8 Q&A



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