POLICY /PROCEDURE: CONTROL OF ASBESTOS

Transcription

1 SECTION: 16 HEALTH & SAFETY POLICY /PROCEDURE: NATURE AND SCOPE: SUBJECT: POLICY AND PROCEDURE - TRUST WIDE CONTROL OF ASBESTOS This Policy has been produced in line with the health and safety requirements that govern the Trust s duties and management responsibilities for control of asbestos on Premises occupied by the Trust. DATE OF LATEST RATIFICATION: RATIFIED BY: HEALTH AND SAFETY COMMITTEE IMPLEMENTATION DATE: FEBRUARY 2019 REVIEW DATE: FEBRUARY 2022 ASSOCIATED TRUST POLICIES & PROCEDURES: Reporting of Accidents, Untoward Incidents & Near Miss Situations Trust Health, Safety & Welfare Policy Electrical Safety Policy Control of Substances Hazardous to Health (COSHH) Policy Radiation Safety Policy Control of Contractors Policy Hand Hygiene Policy & Procedure.

2 NOTTINGHAMSHIRE HEALTHCARE NHS FOUNDATION TRUST CONTROL OF ASBESTOS POLICY CONTENTS 1.0 Scope 2.0 Introduction 3.0 Statement of Intent 4.0 Definitions 5.0 Roles and Responsibilities 5.1 Chief Executive 5.2 Associate Director Estates & Facilities 5.3 General Managers and Heads of Service 5.4 Estates Manager 5.5 Estates Contracts and Operational Manager 5.6 Capital Service s Manager. 5.7 Corporate HIS Manager 5.8 Project/Supervising Officers 5.9 Estates Contracts, Governance and Compliance Manager 5.10 Directly Employed Trade Staff 5.11 Site Managers 6.0 Risk Assessment 7.0 Implementation 8.0 Trust Asbestos Register 9.0 Asbestos Management Plan (AMP) 10.0 Training 11.0 Target Audience 12.0 Monitoring and Compliance 13.0 Equality Assessment Impact 14.0 Legislation Compliance 15.0 Record Keeping 16.0 Review Date 17.0 Champion and Expert Writer Appendix 1 Appendix 2 Equality Impact Assessment Record of Changes to Policy

3 NOTTINGHAMSHIRE HEALTHCARE NHS FOUNDATION TRUST CONTROL OF ASBESTOS POLICY 1.0 SCOPE 1.1 This policy covers all Trust owned, leased or informally occupied premises throughout Nottinghamshire, these can be solely occupied or shared with other organisations. Where properties are not owned by the Trust, the Duty Holder with regards to asbestos will ensure that the landlord fulfils their obligations under the Control of Asbestos Regulations INTRODUCTION 2.1 Nottinghamshire Healthcare NHS Foundation Trust (the Trust) recognises its responsibilities in accordance with Regulation 4 of the Control of Asbestos Regulations 2012 to manage asbestos containing materials within Trust premises. 3.0 STATEMENT OF INTENT 3.1 The Trust accepts its duty to ensure so far as is reasonably practicable the health, safety and welfare of all staff, patients and visitors to our sites. The objective of this Policy is to give clear guidance on Legislative duties under the control of Asbestos Regulations The aim of this Policy is to ensure that asbestos containing material (ACM) within Trust premises are effectively managed to prevent fibre release and exposure to people employed by the Trust, its Service Users, visitors, contractors and members of the public. 3.3 The Trust accepts that in order to achieve and maintain a high standard in health and safety performance there will be funding implications which it will endeavour to adequately resource. 3.4 The Trust is committed to effective quality management throughout the Trust, in accordance with this the Asbestos Control Policy shall be reviewed an annual basis. 4.0 DEFINITIONS 4.1 Trust premises applies to all buildings, sites, work areas and grounds owned by the Trust with the exception of Highbury PFI building and Byron House Newark PFI building. 4.2 Landlord Premises applies to all buildings sites, work area and grounds where Trust staff occupy on a lease or informal basis, including Highbury PFI building and Byron House Newark PFI building. 4.3 Method Statement applies to the official document provided by an asbestos removal contractor relating to works on ACMs. The method statement outlines how the contractor intends to conduct work on ACMs while as far as reasonably practicable reducing the risk of an uncontrolled release of asbestos fibres. A copy of the Method Statement and Risk Assessment will be sent to the HSE as part of a fourteen day notification which is required by law, prior to any work on ACMs commences. 4.4 HSE refers to the Health & Safety Executive, the governing body for asbestos contractors. 4.5 Project/Supervising Officer shall be taken to mean the employee who commissions a contractor to undertake works on a Trust premises. 4.6 A Safe System of Work is a method for undertaking hazardous tasks to minimise the risks associated with the tasks hazards. It is a prerequisite for the prevention of accidents.

4 4.7 UKAS accreditation (UKAS) - is the sole national accreditation body recognised by the British Government to assess the competence of organisations that provide certification, testing, inspection and calibration services. It evaluates these conformity assessment bodies and then accredits them where they are found to meet the internationally specified standard. 4.8 Notifiable Non Licensed Work - New notification system introduced in 2012 for non-licensed works where the Asbestos Containing Material will be deteriorated during the works. This requires notification to the Enforcing Authority before work begins and that anyone doing this type of work has a medical examination every 3 years. Full details are to be found in the Approved Code of Practice for the Control of Asbestos Regulations ROLES AND RESPONSIBILITIES 5.1 Chief Executive The Chief Executive has overall responsibility for ensuring the Trust meets its statutory obligations and that effective arrangements for the management of health and safety are put in place. 5.2 Associate Director Estates & Facilities Has responsibility for complying with the requirements of the policy, in order that staff and contractors can discharge their duties under this policy. 5.3 General Managers and Heads of Service Individual Directors, General Managers and Heads of Services are responsible for ensuring that systems have been identified for reporting of damage to buildings etc ensuring procurement of contractors follows appropriate guidance. 5.4 Estates Manager Responsible for: Ensuring that Asbestos Management Plans are in place and requirements of this Policy are observed and adequately resourced. Commissioning an appropriate UKAS accredited company to undertake Asbestos Management Surveys of all Trust premises under his/her reemit The Production of an asbestos register of known ACMs Maintenance of the Asbestos Register Provision of training to relevant staff in asbestos awareness Ensuring that the procedures contained within the Trust Asbestos Management Plan are adhered to Ensure that the Control of Asbestos Regulations 2012 is adhered to in Landlord hosted properties occupied by Trust staff.

5 5.5 Estates Contracts and Operational Manager Shall ensure that all directly employed trades staff are aware of the location and content of the Asbestos Register and act accordingly where work involves invasive practices where it is known that asbestos exists or where it has not been determined that asbestos does not exist. Trade staff are to follow the content of the relevant Asbestos Management Plan for safe working practices. Responsible for ensuring that the asbestos register is observed, and the content of this Policy, and the Asbestos Management Plan are followed at all times by both directly employed maintenance managers, estates officers, trades staff and contractors employed to provide maintenance services to the Trust s freehold and lease hold sites. Responsible commissioning contractors to undertake asbestos removal or remedial works and for the production of works specifications. 5.6 Capital Services Manager Responsible for ensuring all capital schemes, new works jobs and RAW (requested additional works) are procured and managed in accordance with this Policy and Asbestos Management Plan and consultation of the asbestos register at all times. Shall ensure that all appropriate action has been undertaken in relation to asbestos prior to contractors or subcontractors undertaking any form of invasive work. Shall ensure that the necessary health and safety requirements are incorporated within any specification utilised for the procurement of works. Where removal of asbestos is required prior to any intrusive works commencing the Estates & Capital Services Manager shall commission contractors to undertake the removal in accordance with the Trust AMP. 5.7 Corporate HIS Manager Responsible for ensuring that the requirements of this Policy, the Asbestos Management Plan, and content of the Asbestos Register are observed and adhered to in all related work carried out by their staff and contractors appointed and managed by their department. 5.8 Project/Supervising Officers Supervising officers shall be responsible for ensuring that the content of the Asbestos Register and requirements under the Asbestos Management Plan are considered and followed when undertaking refurbishment/demolition surveys as required. Ensure that all consultants are familiar with the content of this Policy, the Asbestos Management Plan and the Asbestos Register. Original documentation shall be passed on to the Estates Team upon completion of any works involving asbestos, to allow full maintenance of the Trust Asbestos Register. 5.9 Estates Contracts, Governance and Compliance Manager Responsible for ensuring Landlord occupied premises where Trust staff work from and our patients and visitors using these premises are covered by a Landlord Asbestos Management Plan ensuring compliance with Regulations 2012 for Asbestos.

6 5.10 Directly Employed Trades Staff Shall abide by the Trust s Safety Rules for Trades Staff Shall ensure the Trust Asbestos Register is referenced prior to commencing any works Shall report any damage to ACMs or suspected ACMs immediately to their Team Leader or Estates Officer / Manager or their deputy Site Managers Shall ensure that a copy of the Trust Asbestos Register for their site is made available to any contractor or trades staff prior to any work commencing on their site Site managers are also responsible for reporting damage to any ACM or suspected ACM to the Estates Manager. 6.0 RISK ASSESSMENTS 6.1 Where relevant risk assessments must be completed and documented in conjunction with the contractors and line managers and communicated to all relevant persons. Following asbestos re-inspections where the condition of an ACM has changes the Trust shall undertake a revised priority risk assessment for that ACM. 7.0 IMPLEMENTATION 7.1 Implementation of the Policy is intended to reflect fair and consistent practice. It will be monitored under performance management arrangements and a formal review will be undertaken in three years or in the light of Legislative changes. 8.0 TRUST ASBESTOS REGISTER 8.1 The Trust shall provide an Asbestos Register to include all properties owned by the Trust and take appropriate action to ensure that the relevant Asbestos register is made available to occupied premises. The Register shall be maintained and reviewed to take in to account any works undertaken regarding asbestos. The Register shall also be updated in light of any surveys or re-inspections undertaken. Landlord Premises will make available any and all asbestos registers appropriate to each building and site. 9.0 ASBESTOS MANAGEMENT PLAN 9.1 The Trust shall produce an Asbestos Management Plan detailing the roles and responsibilities of all staff involved in dispensing duties under Regulation 4 Control of Asbestos Regulations The plan shall inform all relevant staff how asbestos is identified within Trust owned premise s and how any asbestos identified will be managed to provide a safe environment for staff, patients and visitors to any of our sites. 9.2 Landlord premises management shall inform all relevant staff how asbestos is identified within Landlord premise s and how any asbestos identified will be managed to provide a safe environment for staff, patients and visitors to any of their sites.

7 10.0 TRAINING 10.1 The Trust shall ensure that their staff are for Trust premises fully trained and competent to undertake the tasks assigned to them in the pursuance of complying with this Policy and the Asbestos Management Plan. For Landlord premises the Trust shall ensure that appropriate training and awareness is made available to staff to undertake the tasks assigned to them in the pursuance of complying with this Policy and associated Landlord premises Asbestos Management Plans. They will ensure that persons only work in the sphere of responsibility in which they have the appropriate training, knowledge, experience and understanding TARGET AUDIENCE 11.1 The target audience for this policy is anyone involved in the management of asbestos within the Trust including contractors, trades staff and site managers MONITORING AND COMPLIANCE 12.1 The Policy and relevant Management Plan will be monitored by the Estates Manager Compliance to be monitored at Estates management meeting Compliance to be monitored at six monthly Statutory Compliance Meeting, to identify any weaknesses in Policy procedures and management plan 12.2 Table of Compliance Methods The table in the Asbestos Management Plan will outline how the Trust intends to monitor compliance with this document 13.0 EQUALITY IMPACT ASSESSMENT 13.1 This procedure has been assessed using the Equality Impact Assessment. The outcome of the initial screening assessment was that the Policy could not adversely affect different groups on the grounds of disability, BME, gender, age or sexual orientation LEGISLATION COMPLIANCE 14.1 The Trust has a legal responsibility to comply with a variety of safety Legislation, including but not limited to: The Health & Safety at Work etc Act 1974 The Management of Health & Safety at Work Regulations 1999 The Construction, Design & Management Regulations 2015 The Control of Asbestos Regulations 2012 The Control of Substances Hazardous To Health Regulations 2002 Provision & Use of Work Equipment Regulations RECORD KEEPING 15.1 Original records relating to the removal of asbestos shall be kept for a minimum of forty years, in accordance with the Asbestos at Work Regulations. All original documentation relating to asbestos surveys or removals shall be maintained on the Asbestos Register. Any future inspections and additional records of surveys / work carried out relating to asbestos shall be passed to the Estates Officer (building) inclusion on the Asbestos Register.

8 16.0 REVIEW DATE 16.1 This policy will be reviewed in 3 years, or will be reviewed in line with any management or legislative changes CHAMPION AND EXPERT WRITER 17.1 The Champion of this policy is the Associate Director Estates & Facilities. The Expert Writer is Estates Manager.

9 Appendix 1 EQUALITY IMPACT ASSESSMENT (EIA) SCREENING TOOL (Towards an Equality and Recovery Focused Organisation) A. Name of policy/procedure/strategy/plan/function etc. being assessed: B. Brief description of policy/procedure/strategy/ plan/function etc. and reason for EIA: C. Names and designations of EIA group members: D. List of key groups/organisations consulted: E. Data, Intelligence and Evidence used to conduct the screening exercise: Trust Policy Control of Asbestos Carry out review of Policy making additions to take into account Estates and Facilities are now a Corporate Directorate and have gone through a management organisational change. M. Pepper Estates Manager (Trustwide) Estates and Facilities SMT Estates and Facilities Statutory Compliance Accountability Group Independent Consultants for the Control of Asbestos 2012 Management of Asbestos Regulations

10 F. Equality Strand Does the proposed policy/procedure/ strategy/ plan/ function etc. have a positive or negative (adverse) impact on people from these key equality groups? Please describe Race Gender- Including Transgender and Pregnancy & Maternity Disability Including Mental Health, Intellectual and Learning Disabilities Religion/Belief Sexual Orientation- Including Marriage & Civil Partnership Age Are there any changes which could be made to the proposals which would minimise any adverse impact identified? What changes can be made to the proposals to ensure that a positive impact is achieved? Please describe Have any mitigating circumstances been identified? Please describe Social Inclusion* 1 Areas for Review/Actions Taken (with timescales and name of responsible officer) Community Cohesion* 2

11 Human Rights* 3 - Including Safeguarding * 1 for Social Inclusion please consider any issues which contribute to or act as barriers, resulting in people being excluded from society e.g. homelessness, unemployment, poor educational outcomes, health inequalities, poverty etc. * 2 Community Cohesion essentially means ensuring that people from different groups and communities interact with each other and do not exclusively live parallel lives. Actions which you may consider, where appropriate, could include ensuring that people with disabilities and non-disabled people interact, or that people from different areas of the City or County have the chance to meet, discuss issues and are given the opportunity to learn from and understand each other. * 3 The Human Rights Act 1998 prevents discrimination in the enjoyment of a set of fundamental human rights including: The Right to a Fair Trial; Freedom of Thought, Conscience and Religion; Freedom of Expression; Freedom of Assembly and Association; the Right to Education; the Right Not to be Subjected to Torture, Degrading or Inhumane Treatment; and the Right to Enjoy Private, Family and Home Life Without Unjustified Interference from Public Authorities. G. Conclusions and Further Action (including whether a full EIA is deemed necessary and agreed date for completion) No Further action required. H. Screening Tool Consultation End Date I. Name and Contact Details of Person Responsible for EIA (tel. , postal) J. Name of Group Approving EIA (i.e. Directorate E&D Group; Divisional Workforce, Equality & Diversity Group; Trustwide E&D Subcommittee; or Divisional Policy & Procedures Group)

12 APPENDIX 1 EQUALITY IMPACT ASSESSMENT ACTION PLAN Objective Action/Activity Equality & Diversity Strategic or Local Priority Example:- to provide a 1.1 Identify local LGBT Please see your E&D more accessible service to support Adviser if you need support the LGBT community organisations in identifying which 1.2 Commission and Strategic/ Local/ deliver appropriate Forensic/HP Priority your training for staff actions contribute to. 1.3 Ensure that all service user personal details are completed and up to date Location & Named Lead Timescale 1.1 February May July 2014

13 APPENDIX 2 Policy/Procedure for: Control of Asbestos Issue: 02 Status: Author Name and Title: APPROVED Estates Manager Issue Date: February 2019 Review Date: January 2022 Approved by: Distribution/Access: Executive Leadership Team Normal RECORD OF CHANGES DATE 18 December 2018 AUTHOR M Pepper POLICY/ PROCEDURE Issue 1 DETAILS OF CHANGE To reflect Organisational changes in the Estates Management Team and the integration of Forensic and Local services moving into a corporate service