Compliance Framework

HTM 03-01

Health Technical Memorandum 03-01 sets the design, installation, validation and operational requirements for specialised ventilation in healthcare premises – sitting alongside TR19 for clinical estates.

Purpose

HTM 03-01 governs specialised ventilation supporting clinical, theatre, isolation and pharmacy environments. It places explicit duties around annual verification, AE(V) involvement and Authorised Person oversight.

Core requirements

  • Annual verification of critical ventilation systems
  • Authorised Person (Ventilation) and Authorising Engineer roles
  • Validation against design air change rates and pressure regimes
  • Documented control of changes and remedial works
  • Inspection of cleanliness in line with TR19 principles

Responsibilities

  • Trust Board / CEO as the ultimate Duty Holder
  • Designated Person – strategic oversight
  • Authorised Person (V) – operational management
  • Estates and IPC teams – day-to-day operation and assurance

Compliance implications

  • Infection control risk where validation lapses
  • CQC and NHSE assurance findings
  • Operational impact on theatre and clinical capacity
  • Estates audit and ERIC reporting exposure

Recommended inspection frequencies

Risk / classificationSuggested cadence
Critical clinical systemsAnnual verification
Operating theatresAnnual and on intervention
Non-critical extractTR19 risk-based
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