Review Date 01/01/2017 Director of Estates and Facilities Expiry Date 14/01/2018 Withdrawn Date

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1 Policy No: RM70 Version: 3.0 Name of Policy: Work at Height Policy Effective From: 05/02/2015 Date Ratified 15/01/2015 Ratified Health and Safety Committee Review Date 01/01/2017 Sponsor Director of Estates and Facilities Expiry Date 14/01/2018 Withdrawn Date This policy supersedes all previous issues. Working at Heights Policy v3

2 Version Control Version Release Author/ Ratified By/ Date Reviewer Authorised By 1.0 Jan 2010 J Simpson H & S Committee 05/01/2010 Changes /08/2012 J Simpson H & S Committee 10/07/2012 Minor changes to comply with OP /02/2015 K Smeaton H & S Committee 15/01/2015 Minor Changes to Reflect Qe Facilities Working at Height Policy v3 2

3 CONTENTS 1 Introduction Policy Scope Aims of the Policy Duties, Roles & Responsibilities Definitions Procedure to be Adopted When Working at Height Risk Assessment Requirements Factors in Assessing the Risk Developing a Safe System of Work Training Equality & Diversity Monitoring & Compliance with the Policy Consultation & Review Implementation of Policy (Including Raising Awareness) References Associated Documentation... 9 Page No. Working at Height Policy v3 3

4 Work at Height Policy 1 Introduction The Work at Height Regulations 2005 applies to all work at height where there is a risk of a fall liable to cause personal injury. They place duties on employees, the self employed, and any person that controls the work of others (e.g. Facilities Managers or building owners who may contract others to work at height). This policy outlines the steps to be taken by Gateshead Health NHS Foundation Trust to ensure that staff or others do not work at height where this can be avoided, and where working at height cannot be avoided, that the risks are identified and measures put in place to prevent falls. Any work at height needs to be properly planned in advance of the work activity, appropriately supervised and carried out in a safe manner. Careful consideration should be given to the selection and use of work equipment. The Trust will limit the need to work at height where possible by appropriate design and selection of materials and equipment in all capital projects and refurbishment schemes. Where access at height is required to maintain buildings, permanent safety systems shall be incorporated into the finished project to facilitate any future maintenance requirements which are reasonably practicable. 2 Policy Scope This policy applies to all employees of Gateshead Health NHS Foundation Trust, and all contractors and sub contractors employed by the Trust. The safe access to structures to carry out maintenance works and the prevention of falls is the responsibility of all Trust managers who direct work activities. These managers need to be familiar with all current legislation and good working practice, including access systems and working at height. 3 Aims of the Policy The aim of the policy is to: Avoid working at height when possible by incorporating design feature into buildings that do not need regular maintenance at elevated positions. Ensure when maintenance at height is unavoidable, permanent safety feature shall be designed into new capital developments to facilitate the maintenance works. Ensure when work is carried out to existing buildings where permanent safety features are not incorporated into the structure full risk assessments shall be carried out to determine the safest way of undertaking the work and any temporary safety devices/access systems shall be deployed to promote safe working and access. Trust wide systems are developed and maintained to ensure staff, patients and others are not unnecessarily exposed when working at height is being carried out. Staff are aware of their responsibilities when working at height. The risks from working at height are minimised. Staff receive training and guidance in complying with current legislation. Best practice is regularly promoted and monitored throughout the process. Working at Height Policy v3 4

5 4 Duties, Roles & Responsibilities The Trust Board The Trust Board of Directors, as the employer, are ultimately responsible for fulfilling all duties assigned to them in current UK Health and Safety Legislation. This includes having a robust system of Corporate Governance within the organisation and ensuring that there is a systematic process for the development, authorisation and management of policies. The Chief Executive The Chief Executive has overall responsibility for working at height and will ensure that Directors, Managers and staff are aware of, and carry out the roles and responsibilities identified in this policy. This policy is applicable within all premises owned and operated by the Trust. Director of Estates & Facilities The Director of Estates and Facilities is responsible to the Chief Executive for the planning, organisation, control, monitoring and review of all work carried out at height. He is also responsible for the appraisal of all new legislation and guidance, as well as new procedures and technology available to help reduce the risk associated with working at height. Leading and giving advice and guidance on all aspects of this policy. Ensuring that the Trust manages working at height in accordance with this policy. The revision of this procedure on a bi annual basis or more frequently if required. The carrying out of audits in conjunction with the Health and Safety Department. Contingency planning in the event of an emergency. Senior Managers (Qe Facilities) Senior Managers are responsible for: Ensuring that every effort is made to avoid working at height. Ensuring that, when working at height cannot be avoided, a suitable and sufficient assessment of the risks to health has been carried out. Ensuring employees and their representative are consulted when assessing the risks connected with working at height. Providing suitable work equipment or other measures to prevent falls where working at height cannot be avoided. Ensuring all equipment used whilst working at height is appropriate for the work and is properly inspected and tested. Ensuring that prior to working at height, a written safe system of work, including emergency and rescue procedures, has been developed, and, where necessary, a permit to work issued. Ensuring that all staff involved in working at height are aware of this policy, understand its content, and comply with local procedures and safe systems of work. Ensuring all staff who work at height are fit to do so. Ensuring that all staff who work at height, and those who issue permits to work, have appropriate information, instruction, training and supervision. Ensuring all contractors employed are competent to work at height and are appropriately managed when on site. Incidents or accidents involving working at height are reported via Datix and comprehensive investigations are carried out. Staff are made aware that unsafe practice will constitute misconduct under the Trust s Disciplinary Policy. The general public and patients are protected when work at height is being undertaken. The inspection and approval of all temporary equipment is carried out before any work at height is commenced, e.g. scaffolding. Working at Height Policy v3 5

6 Line Manager and Supervisors (Qe Facilities) Line Manager and Supervisors are responsible for: Assessing all associated risks involved in working at height, (see section for risk factors associated with working at height). Developing a safe system of work. Ensuring all necessary precautions, including emergency procedures are taken. Checking safety at each stage of the work. Acting upon any report of an activity or defect likely to endanger safety. Checking the workplace before it is used. Checking work equipment installed or assembled prior to use. The issue of the permit to work and its cancellation, if appropriate. Managing contractors whilst they are on site. Employees (Qe Facilities) Employees are responsible for: Assisting with the assessment of risks. Complying with any safe system of work developed through risk assessment and any requirements of a permit to work. Using any safety equipment supplied. Following training and instruction. Informing their managers if they suspect that the system of work in place is ineffective or inadequate. Reporting any activity or defect likely to endanger safety. Reporting all incidents, (including any near misses), and any defects in equipment using Datix. 5 Definitions A place is at height if (unless the Regulations are followed) a person could be injured falling from it, even if it is at or below ground level. Work includes moving around at a place of work, but not travel to and from a place of work. 6 Procedures to be Adopted When Working at Height 6.1 Risk Assessment Requirements In the event that working at height cannot be avoided, a suitable and sufficient risk assessment must be carried out and written safe system of work developed, including the provision of emergency procedures. A permit to work at height will be required for any work of an unusual nature or involving the placing or lifting of large heavy elements of structure or equipment. 6.2 Factors in Assessing the Risk When assessing the risks, use must be made of all the information available about the work to be carried out. All foreseeable hazards and risks must be considered in advance and the following issues may need consideration: Work at height can include, but is not exclusively limited to: Working at ground level adjacent to an excavation. Working on roofs. Working at Height Policy v3 6

7 Working from a ladder. The location in relation to the presence of hazards such as open excavations, overhead services etc. The working environment with regard to weather or lighting. Safe means of access and egress. Lone working. Condition and stability of work surfaces such as fragile materials, slippery surfaces etcetera. Physical capabilities of the workers such as pregnancy or vertigo sufferers. The equipment to be used and its inspection. Falling objects. Prevention of access by unauthorised persons. The risk assessment must be recorded on a standard risk assessment form by a person who is competent to do so. This must be signed by the assessor and by the manager or head of department. The manager must keep a copy of the assessment form in their department. In gathering information for an assessment, managers may need expert advice. Information on working at height is available from the HSE website at or from the Health and Safety Advisor. 6.3 Developing a Safe System of Work 7 Training In the development of a written safe system of work, the information gathered during the risk assessment will be used to construct a document which will give information and instruction to the employees who are to carry out the work. This will include all of the risk control measures and the reason for their application, e.g. the need to use ladder fixing points. It will also detail, where necessary: The means for preventing unauthorised access to the area underneath the work being carried out. Any supervision that may be necessary. Any weather conditions that workers may be exposed to, e.g. icy roofs, slippery surfaces in the rain, wind, etcetera. Any emergency or rescue conditions, e.g. it is not acceptable just to rely on the emergency services, this needs to be covered in the risk assessment and planned prior to the work being carried out. NB: Fall arrest equipment should be the last in the hierarchy of control. Collective protection measures, e.g. guard rails, should be deployed in the first instance rather than personal protection. Training will be required for all operatives required to work at height, and managers or supervisors who issue permits to work. This will enable them to be competent and confident with procedures, legislation and equipment associated with working at height. Training may also include the use of ladders, erection and use of scaffold or use of a cherry picker. Working at Height Policy v3 7

8 Training Records All training records will be maintained by the Trust s OD & Training Department. 8 Equality & Diversity The trust is committed to ensuring that, as far as is reasonably practical, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on the grounds of any protected characteristic (Equality Act 2010). This policy has been appropriately assessed. The policy applies to all staff and patients regardless of their diversity. The Trust risk assessment process will enable reasonable adjustments to be made to meet the needs of pregnant or disabled members or staff. 9 Monitoring & Compliance with the Policy Standard / Process / Issue Monitoring and Audit Method By Committee Frequency Monitoring and reviews of datix records for incidents involving working at height. The audit will identify compliance/non compliance with the working at height policy and promote improvement to the policy and working practice Annual Health & Safety audit of risk assessments and safe systems of work Site inspection of scaffold/access equipment to determine compliance with the policy Audit of Datix incidents Audit of Datix incidents Investigation of all incidents involving working at height Physical inspection and record keeping Health and Safety Advisor/ Head of Estates Qe Facilities Head of Estates Qe Facilities Health & Safety Advisor Qe Facilities Managers and supervisors Health & Safety Committee Estates Senior Staff Group Health & Safety Committee Estates Senior Staff group 4 monthly Annually Annually When scaffolds or access equipment is used 10 Consultation & Review Health & Safety Advisor Capital Development Manager (Qe Facilities) Qe Facilities Department Managers Clinical Ergonomics Department Health & Safety Committee Working at Height Policy v3 8

9 11 Implementation of Policy (Including Raising Awareness) All members of staff will be informed via e mail and individual team meetings, when updated version available on Intranet. When capital designs are undertaken, the avoidance of working at height or minimising the risk from working at height to carry out maintenance tasks shall be considered throughout the process and be documented. 12 References HMSO The Work at Height Regulations 2005 Health & Safety Executive Health and Safety in Roofwork HSG 33 Health & Safety Executive Working on Roofs INDG 284 Health and Safety Executive Management of Health & Safety at Work (Management of Health & Safety at Work Regulations 1999) Approved Code of Practice & Guidance L21 Health and Safety Executive Safe Use of Work Equipment (Provision and Use Of Work Equipment Regulations 1998) Approved Code of Practice & Guidance L22 Health and Safety Executive Personal Protective Equipment at Work (Personal protective Equipment at Work Regulations 1992) Guidance on Regulations L25 Health and Safety Executive Safe Use of Ladders & Stepladders IND G 402 Trust Policy RM04 Incident Reporting & Investigation Trust Policy RM13 Provision & Use of Work Equipment Trust Policy RM17 Personal Protective Equipment at Work Trust Policy RM18 Electrical Equipment 13 Associated Documentation Health and Safety Policy Lifting Equipment Building & Engineering Work Slips, Trips & Falls RM02 RM19 RM28 RM50b Working at Height Policy v3 9