Contents
Space change approvals process description and flowchart
- Requests to change space occupied by a service and care group can be requested for many reasons, such as:
- a change in strategic priorities
- staffing level changes
- new programmes and services
- change of use of existing space.
- Requests to change space occupation might come from:
- the chief executive
- care group managers
- The Workforce team
- trust directors
- change request forms
- clinicians
- third parties
- These requests will be considered and managed by the space utilisation group who report into the estates and sustainability group. They will consider:
- benchmarking
- clinical cases
- funding availability
- income stream
- space audit and availability data
- current use of space
- proposed use of space
- cost benefit analysis
- The space utilisation group will also consider the estates strategy, estate plan and consult the capital monitoring group if considered appropriate.
- If the request is approved, but no funds are available, the request will be returned pending funds becoming available.
- If the request is rejected it will be returned with an explanation of the reasons for its rejection.
- If the request is approved and funding is available, it will be referred to the estates sustainability group for final approval and confirmation.
- When the project starts the estates property register (terrier) will be updated.
- once a change has been completed the property manager will monitor the use of the space and, if it is not being used effectively may allocate it to someone else in the future.
1 Introduction
- The trust faces significant pressures in respect of the allocation, occupancy, and utilisation of space for both clinical and non-clinical functions and compliance with the Carter report and the Naylor report (both of which set targets around space occupancy and disposal of surplus space).
- Future service sustainability; reducing the cost of our real estate; the adoption of flexible working patterns and new methods of working (including agile and remote working) and the implementation of new information technological solutions will fundamentally change the trust’s working practices.
- Whilst this policy is primarily aimed at supporting Rotherham, Doncaster and South Humber Foundation Trust (RDaSH) “backbone” services to assist in their support of our clinical services, the space utilisation group (SUG) will assist with clinical moves and changes whenever required.
- A key requirement underpinning this policy is the need to ensure that the existing estate utilisation is optimised and where appropriate consider alternative configurations of the estate that can support and enhance future patient care.
2 Purpose
- The key aim of this space utilisation and allocation policy is to ensure the appropriate occupancy and utilisation of space within the RDaSH estate to optimise patient care.
- This policy will provide the necessary framework for the management of space across RDaSH, both retained estate and leased property. (Where relevant and appropriate this will include living accommodation and on-site “on-call” rooms).
- The policy not only drives future efficiency in the utilisation of estate but seeks to appropriately meet the diverse needs of our service population and all colleagues.
- The policy objectives will be to provide the framework for:
- controlling, and monitoring, the change of use of space
- the allocation of additional space
- the release of space
- enabling the trust to offer flexibility in the utilisation of its estate to reflect changes in service provision
- addressing both suitability and affordability of the trust estate
- ensuring access to all as per the equality agenda
- encouraging innovation in new ways of working that deliver flexibility in working arrangements and thus reducing space requirements
- responding to the changes of colleagues’ function and, or location.
3 Scope
This document applies to and is relevant across all colleagues, stakeholders, services or departments or care groups, contractors and third parties:
It will be applied in respect of all new requests, reprovision and release or surrender of workspace.
Decisions will be based on a set of clearly defined criteria, centred on the functional requirements of the various care groups and corporate areas, taking account of any reasonable adjustments identified.
4 Responsibilities, accountabilities and duties
- The following section outlines the roles and responsibilities of those involved in providing and managing space, who may be called upon to adjudicate in the decision-making process or working in space owned by the trust in accordance with this policy.
4.1 Position, role and responsibilities
4.1.1 Chief executive
The chief executive has overall responsibility to provide a safe working environment, ensuring compliance with the requirements of The Health and Safety at Work Act (1974), any subsequent amendments, and the requirements of this policy. The chief executive has over-arching responsibility for all aspects of the estate, including the management and control of assets; and overall responsibility for the safety of any patient, visitor, or contractor whilst they are on trust premises.
The chief executive has overall responsibility for the trust and the quality and utilisation of space within. This responsibility is delegated to the head of estates and development
4.1.2 Head of estates and development
The head of estates and development will assume the corporate landlord role for the trust and ensure delivery of the trust strategic intent through effective space management and provide measurable deliverables and support the future optimisation of the estate. This will include:
- technical assessment and capability in reviewing the current estate occupancy and utilisation
- recommending options for maximising the estate occupancy and utilisation and its functionality
- input to the development of business cases that consider alternative use of space
- monitoring of the space occupancy and utilisation
- provision of cost base analysis.
The execution of this policy is delivered through the head of capital projects and the property manager (estates) as the corporate landlord function.
4.1.3 Directors and managers
All directors (executive and non-executive) and those in roles with managerial responsibility are bound to provide a safe working environment under health and safety legislation. They are responsible for exercising the trust duty of care and shall ensure adequate arrangements are in place via their designated deputies for implementing this policy and associated safe systems of work within their respective authority.
4.1.4 Chief operating officer
The chief operating officer is responsible for assessing any changes to the estate and the impact on operational service delivery and the future occupancy and utilisation of space in accordance with delivering the trust clinical strategy.
The chief operating officer is responsible for (but not limited to):
- promoting the policy.
- encouraging care groups to consider new ways of working and supporting those managers tasked with implementing the policy.
4.1.5 Care Group and Corporate Management teams
All managers are accountable for implementing and monitoring the policy within their specific area of responsibility and for ensuring premises are maintained to appropriate standards and well utilised. Where change is required, however minor, Senior Leadership teams must ensure that:
- there is a case for change that is robust and cost effective
- revenue and capital funding is available to facilitate the change
- risk assessments in relation to the accommodation changes are carried out by the service manager in conjunction with estates and clearly documented (fire, workplace, safety, working practices, safety)
- there is an operational policy that shows how the service will operate within the premises including named individuals with day-to-day control of the premises, health and safety, fire wardens and first aiders
- the process for requesting additional accommodation is fully implemented
- the change request forms are completed (even if the request is simply to change one room to an alternative use).
4.1.6 All employees
All employees have an individual responsibility for the management of the accommodation that they work in or occupy. The Health and Safety at Work Act places a duty on employees to:
- co-operate with the trust management in the implementation of the policy
- report any deficiencies and defects to their line manager
- report any area of under-utilisation or overcrowding to their line manager
- maintain a safe environment and safe working practices.
4.1.7 Space utilisation group
The space utilisation group (SUG) ensures appropriate and equitable management of the allocation and monitoring of space in line with the trust’s priorities.
The process for application for, change of or release of space is detailed within this policy.
In cases where more senior input is required the SUG will seek guidance from the head of estates and development, in the first instance and, if necessary, onward referral to the operational management group (OMG) and clinical leadership executive (CLE).
The membership of the group will be:
- head of estates and development (vice chair)
- head of capital and planning (vice chair)
- property manager (chair)
- representative of strategy
- representative of IT
- representative of children’s care group
- representative of Doncaster adult mental health and learning disabilities care group
- representative of physical health and neurodiversity care group
- representative of Rotherham adult mental health care group
- representative of North Lincolnshire adult mental health and talking therapies care group
- administrative support
- representative of finance
Should a panel member be unable to attend meetings, they will nominate a deputy to attend on their behalf
4.1.8 Property manager
The property manager will have delegated authority to act as proxy for, and in the absence of the head of estates and development and head of capital and planning, in respect of:
- corporate landlord responsibility
- referring and recommending in respect of cases which are subject to deadlock
- making recommendations to interested parties, in respect of space related matters.
- other matters to be confirmed
5 Procedure or implementation
5.1 Accommodation
5.1.1 Ownership of accommodation
The trust itself is ultimately the owner of the estate and as such has the responsibility to allocate space as appropriate for the delivery of its service in consultation with clinical and operational colleagues. The head of estates and development is appointed as the corporate landlord to document, control and manage the utilisation of the estate and will delegate some authority to the head of capital and planning and the property manager in respect of this control, management, and utilisation. Any over or under-utilised space will be discussed within space utilisation group for re-allocation. The head of estates and development holds the authority to implement reallocation.
The trust will formalise the occupancy arrangements of third-party occupiers.
5.1.2 Principles of office usage and allocation
As office accommodation occupies a high percentage of trust space it is necessary to establish principles for allocation and utilisation of office space. This is especially important in delivery of the estate efficiency and clinical reconfiguration of services across the property portfolio.
When considering change, managers will be expected to consider new ways of working such as hot-desking, mobile working and shared use of accommodation. In this respect regard should be taken of the agile and hybrid working policy.
The space utilisation group will allocate space based on applying the following principles:
- office space will be allocated depending on the job role and function. This will include reasonable adjustments where required
- care groups should provide hot desk facilities where possible to support colleagues working in an agile way, this may reduce the requests for additional space
- where an office is within a new build area, an area which is refurbished, or the use changed it will be based on the best arrangement for the service function
5.1.3 Clinical accommodation
Where there is a significant change in a clinical service due to new ways of working, an increase or decrease in activity levels or change in service contract, then the under and over utilisation of clinical space must be reported using the space change request form (appendix A).
5.1.4 Accommodation for non-trust colleagues
The trust does not generally provide accommodation for non-trust colleagues unless one or more of the following apply:
- it generates income over and above expenditure.
- it is part of an integrated service with external agencies managed by the trust or is a necessary part of service delivery.
- the provision of accommodation has been approved by the Executive team.
- there is an inter-trust service level agreement signed by the chief executive.
- there is a formal lease, licence, or occupation agreement.
5.2 Space allocation process
- All accommodation within the trust whether owned or leased is the property of the trust.
- As space is vacated within a care group or corporate directorate, the decision about how the space will be used remains that of the trust (corporate landlord),
- Care groups and corporate functions wanting to change the use of space will require approval via the space change request form to be discussed at the SUG (appendix A).
- Future service developments with a defined space impact will be required to apply to the space utilisation group as part of the development of their feasibility and business case approvals process, this applies to both new build and retained estate developments.
- The space utilisation group will review all space change requests in accordance with the trust’s strategic and operational priorities, compliance with regulatory standards, impact of estate efficiency, affordability and availability of capital funding and risk. It will also consider such matters as storage requirements for confidential data, access and adjacency needs.
- The approvals process is illustrated at the beginning of this document
5.3 Surplus accommodation
- Where a building, department, or space is identified as surplus to requirements the space change request form (appendix A) must be completed and submitted at the earliest opportunity.
- The estates department may carry out a space utilisation survey (with, or without the use of movement sensors) of any trust property at any time and refer it to the space utilisation group for consideration as alternative use in order to increase estate efficiency through consultation with relevant care and corporate groups.
- A department or service vacating premises as part of an agreed decommissioning plan will be responsible for ensuring that all rooms within the premises are cleared (for example, of furniture, paper, records, and all rubbish and left clear clean, particularly in respect of vacated clinical areas and wards). Plans for vacating space and disposal of equipment will need to be agreed as part of any change in use of space. Any cost associated with the disposal of waste materials and redundant equipment and furniture, and for the rendering safe of any space will be required to be built into the business case for change.
- The estates department will ensure that any vacated accommodation is left safe and secure, services disconnected and sealed until its future is confirmed.
- The estates department will, with guidance, support, and assistance from the property manager, keep up-to-date records of space occupancy
5.4 General principles
- If a directorate and care group receives charitable donations to upgrade and improve accommodation, this should be discussed at the space utilisation group
- Management and negotiation of leases and licences, or third-party accommodation occupancy, for whatever reason, will be dealt with by the property manager and, or the head of capital and planning. The space utilisation group will agree the principle of any third-party occupancy.
- No other NHS organisations can exchange or change the use of any accommodation occupied (for example, patient area to offices), in the trust without approval of the space utilisation group and appropriate amendments to the lease and licence.
5.4.1 Meeting and conference rooms
- Meeting and conference rooms, throughout the trust should be available for anyone, from any service to book.
5.5 Appeals against decisions
- If a team disagrees with the outcome of the SUG decision, they may appeal to the head of estates and development
- The appeal must include the original application, the outcome of the application and the reasons for the appeal.
- The head of estates and development will decide on whether the original decision was valid and make recommendations on how to proceed.
- If the dispute cannot be resolved the head of estates and development will refer the issue to the clinical leadership executive, or relevant sub clinical leadership executive who will make a final decision.
6 Training implications
“There are no specific training needs in relation to this policy, but all colleagues and managers, with a responsibility for implementing the contents of this policy, will need to be familiar with its contents.
As a trust policy, all colleagues need to be aware of the key points that the policy covers.
7 Monitoring arrangements
7.1 Compliance with policy
- The space utilisation group will, regularly, review this space utilisation and allocation policy and ensure that it meets the requirements of the trust.
- The space utilisation group will work in partnership with the estates team to ensure consistency of approach and a coordinated approach to the future asset base of the trust.
8 Equality impact assessment screening
- Our aim is to provide a safe environment free from discrimination and treat all individuals fairly with dignity and appropriately according to their needs.
- As part of its development, this policy and its impact on equality have been reviewed. A reasonable adjustment will be considered when space is allocated.
8.1 Privacy, dignity and respect
The NHS constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.
As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).
8.1.1 How this will be met
No issues have been identified in relation to this policy.
8.2 Mental Capacity Act (2005)
Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.
Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.
9 Links to any associated documents
- Agile and hybrid working policy
- Information security, remote working policy
- Moving to alternative premises policy
- Space change request pro forma
10 Appendices
10.1 Appendix A Space change request form
10.2 Appendix B Equality impact assessment form
Please, complete for any space change application and submit them together to rdash.estates-and-facilities-admin-team@nhs.net.
Document control
- Version: 1.1
- Approved by: Estate and sustainability clinical leadership executive group.
- Date approved: 10 December 2024.
- Name of originator or author: Property manager.
- Name of responsible committee or individual: Director of finance and estates.
- Unique reference number: 1096.
- Date issued: 8 January 2025.
- Review date: 31 December 2026.
- Target audience: All management groups and individuals who occupy space within the trust property portfolio from which to provide their services.
Page last reviewed: January 17, 2025
Next review due: January 17, 2026
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