UCLH Asbestos Management Plan. July 2017

Transcription

1 UCLH Asbestos Management Plan July 2017 Out of Hours and Emergency contacts: Larne Fuller Tel: Mob: Joe Beesley Tel: Mob: lucionservices.com Review Date: July 2017 UCLH-RED-ZZ-ZZ-HS-Z-004-AP01-Asbestos_Management_Plan_Jul y_2017

2 Document Basics Title Reference Author(s) Check(s) UCLH Asbestos Management Plan UCLH-RED-ZZ-ZZ-HS-Z-004-AP01-Asbestos_Management_Plan_July_2017 Joe Beesley - Lucion John Clucas Next Review Date October 2017 Prepared by Lucion Services on behalf of UCLH NHS Foundation Trust in association with John Clucas, Construction Programme Manager and Asbestos Lead - Capital, Estates & Facilities Department. Document History D Ref Comments 10/09/09 UCLH/S27764/AMP/001 Draft issue Asbestos Management Plan for comment 19/10/09 UCLH/S27764/AMP/002 Amended Asbestos Management Plan 14/03/10 UCLH/S27764/AMP/003 HSG264 update to Management Plan 19/07/11 UCLH/S52147/AMP/004 Review and update 02/11/11 UCLH/S56696/AMP/005 Review and update draft for comment 12/01/12 UCLH/S56696/AMP/006 Contact details updated 16/04/12 UCLH/S56696/AMP/007 Contact details updated 19/04/12 UCLH/S56696/AMP/008 6 month review draft for comment 22/06/12 UCLH/S56696/AMP/009 6 month review 22/12/12 UCLH/S56696/AMP/010 6 month review 03/06/12 UCLH/S56696/AMP/011 6 month review 23/12/13 UCLH/S56696/AMP/012 6 month review- organisation update 23/10/14 UCLH/S56696/AMP/013 6 month review- post 10/04/15 UCLH/S56696/AMP/014 6 month review 02/12/15 UCLH/S56696/AMP/015 6 month review Contact information refinement, no significant change 14/02/16 UCLH/S56696/AMP/016 Update to Redhills contact details 31/10/16 24/04/17 UCLH-UCH-ZZZ-ZZ-ZZ-A-001-P1-B- AMP UCLH-RED-ZZ-ZZ-HS-Z-003-AP01-A sbestos_management_plan_april _ month review and update to Redhills contact details 6 month review and update contact details Asbestos Management Plan Page 2 of 47

3 29/07/2017 UCLH-RED-ZZ-ZZ-HS-Z-004-AP01-A sbestos_management_plan_july_ 2017 Addition of a flow chart process for MICAD drawing updates Quality Control Name Date Prepared by: Heather Kane 2 November 2011 Authorised by: Joanne Cooke 9 November 2011 Updated report prepared and issued by: Joe Beesley 29 July 2017 Contents Page Document Basics 2 Document History 2 Important information about this management plan 4 Scope of Plan 5 Section 1 INTRODUCTION 6 Asbestos Management Plan 6 Principles of Asbestos Management 6 Asbestos Regulations 6 Asbestos Management Plan Scope 7 Section 2 STRATEGY FOR COMPLIANCE 8 Current Provision 8 Future Provision 8 Section 3 ASBESTOS RECORDS 9 Current Asbestos Records 9 Further Asbestos Records 9 Updating Information 10 Section 4 ASSESSMENT OF ASBESTOS 11 Initial Assessment 11 Special Assessment 11 On-going Assessment 12 Section 5 TRAINING 13 Training 13 Facilities Management Service Providers and Minor Works 13 Contractors 14 Those who plan and manage work 14 Section 6 DISSEMINATION OF INFORMATION 15 How information is disseminated 15 Section 7 SAFE SYSTEMS OF WORK 16 Maintenance and Minor Works 16 Asbestos Management Plan Page 3 of 47

4 Construction / Refurbishment Projects 18 Section 8 MONITORING AND REVIEW OF THIS PLAN 21 Section 9 ROLES AND RESPONSIBILITIES 23 Overview of Roles and Responsibilities 23 Section 10 ACTION PLAN 26 Action Plan 26 Section 11 EMERGENCY PROCEDURES 27 The following procedure should be followed in the event of accidental disturbance of known or presumed asbestos: 27 APPENDIX 1 SURVEY TYPE SPECIFICATION 28 Management Survey 28 Refurbishment and demolition surveys 28 APPENDIX 2 ASSESSMENT ALGORITHMS 30 Material Assessment 30 Priority Assessment 31 Category Codes - Material Assessment 32 Category Codes - Priority Assessment 33 Risk Assessment Summary 33 APPENDIX 3 GLOSSARY OF TERMS 34 Important information about this management plan This Asbestos Management Plan is a document with legal status IT SHOULD REMAIN ON THE TRUST INTRANET AT ALL TIMES If you need help understanding the requirements of this document contact: Asbestos Coordinator: Unit 22, Salbrook Road Asbestos Management Plan Page 4 of 47

5 Industrial Estate Redhill, Surrey RH1 5DY Tel: / Web: uclh@lucionservices.com Primary Contact: Joe Beesley Tel: / Mob: uclh@lucionservices.com Secondary Contact: Larne Fuller Tel: / Mob: uclh@lucionservices.com Scope of Plan UCLH NHS Foundation Trust recognises its duty under the Health and Safety at Work Act, 1974 and the Control of Asbestos Regulations 2012 and all associated Approved Codes of Practices and is committed to the effective management of asbestos. The Trust recognises its responsibility to contractors and others involved in building and maintenance projects established through the Construction (Design and Management) Regulations 2015 and its duties as the Duty Holder of Trust owned buildings as defined by Regulation 4 of the Control of Asbestos Regulations This Asbestos Management Plan sets out the Trust s strategy for compliance of all relevant Health and Safety legislation regarding asbestos. This document details what steps will be undertaken by the Trust; to ensure that the risk from known or suspected Asbestos Containing Materials (ACMs) within Trust owned or controlled buildings is adequately managed, so that as far as reasonably practicable no one can come to any harm from asbestos. It also details the responsibilities of the Trust and its employees, contractors and regular building users. All procedures outlined below are mandatory for all parties involved. This document and the procedures outlined require the cooperation of all employees, all staff, building users and contractors who also have responsibilities to ensure a safe and healthy working environment is maintained at all times. Asbestos Management Plan Page 5 of 47

6 Section 1 INTRODUCTION Asbestos Management Plan This Asbestos Management Plan has been designed with the sole purpose of managing the risk from Asbestos Containing Materials (ACMs) identified within UCLH NHS Foundation Trust so that as far as reasonably practicable no one can come to any harm from ACMs on the premises. It is an integral part of the Trust s strategy for compliance of all current Health and Safety legislation regarding asbestos. Principles of Asbestos Management The main principles of asbestos management are to Assess, Record, Inform and Monitor. ASSESS : Asbestos in premises does not necessarily create an unacceptable risk. Asbestos is the hazard; the risk can only be defined when this hazard is assessed within the environment in which it is found. This assessment must take into account the activities carried out near or on the asbestos for the assessment to be able to present viable recommendations. It may take the form of a desktop study, a full asbestos survey, or a combination of the two. RECORD : All assessments and the location and condition of any known or presumed asbestos containing materials must be recorded, updated and regularly reviewed. Similarly, any changes to the condition or location of any known or suspected ACMs, any training, any controlled removal works, reinspection, etc., must all be recorded. It is imperative that all asbestos documents are kept up to date, are coherent and are accessible. INFORM : All asbestos records gathered must be made available to all relevant people at a suitable time. All staff, contracted workers, regular building users and maintenance staff, etc. may require access to asbestos records held for each site and so they must be made available to anyone who may require them. Additionally, a system of training, seminars and question and answer sessions should be adopted where appropriate to ensure that everyone is kept informed about asbestos and that the information they have access to is relevant, accurate and understandable. MONITOR : All asbestos records, procedures, training and safe systems of works must be regularly monitored and reviewed ; this is an Approved Code of Practice (ACoP) requirement. The purpose of this ongoing monitoring is to ensure that the aims of the asbestos management strategy are being met, that all systems are efficient and workable and that no one is being exposed to asbestos. Asbestos Management Plan Page 6 of 47

7 Asbestos Regulations There are many health and safety regulations that either directly or indirectly places a duty on the employer with regards to asbestos. The key facts of these regulations have been set out below: The Health & Safety at Work etc. Act 1974 (HSW): requires employers to conduct their work in such a way that their employees will not be exposed to health and safety risks and to provide information to other people about their workplace which might affect their health and safety. Section 3 of the HSW Act contains general duties on employers and the self-employed in respect of people other than their own employees. Section 4 contains general duties for anyone who has control, to any extent, over a workplace; The Management of Health and Safety at Work (Amendment) Regulations 2006: (the Management Regulations) requires employers and self-employed people to make an assessment of the risks to the health and safety of themselves, employees and people not in their employment, arising out of or in connection with the conduct of their business and to make appropriate arrangements for protecting those people s health and safety. Any assessment made for the purposes of the Asbestos Regulations will not need to be repeated for the Management Regulations; The Workplace (Health, Safety and Welfare) Regulations 1992: requires employers to maintain workplace buildings so as to protect occupants and workers; The Construction (Design & Management) Regulations 2015: require the client to pass on information about the state or condition of any premises (including the presence of hazardous materials such as asbestos) to the CDM Coordinator before any work begins and to ensure that the health and safety file is available for inspection by any person who needs the information. The Defective Premises Act 1972 in England and Wales or the Civic Government (Scotland) Act 1982 in Scotland: places duties on landlords to take reasonable care to see that tenants and other people are safe from personal injury or disease caused by a defect in the state of the premises. Any premises in such a state as to be prejudicial to health constitute a statutory nuisance under section 79 of the Environmental Protection Act An abatement notice can be served by the local authorities on the owner or occupier of premises requiring prevention or restriction of the nuisance; The Control of Asbestos Regulations 2012: requires employers to prevent the exposure of their employees to asbestos, or where this is not practicable, to reduce the exposure to the lowest possible level. Regulation 4 specifically requires duty holders to: a) Take reasonable steps to find materials in premises likely to contain asbestos and to check their condition; b) Presume that materials contain asbestos unless there is strong evidence to suppose that they do not; c) Make a written record of the location and condition of asbestos and presumed asbestos-containing materials (ACMs) and keep the record up to date; d) Assess the risk of the likelihood of anyone being exposed to these materials; and Asbestos Management Plan Page 7 of 47

8 e) Prepare a plan to manage that risk and put it into effect to ensure that: i. Any material known or presumed to contain asbestos is kept in a good state of repair; ii. Any material that contains or is presumed to contain asbestos is, because of the risks associated with its location or condition, repaired or if necessary removed; and Information on the location and condition of the material is given to anyone potentially at risk Asbestos Management Plan Scope This Asbestos Management Plan relates to all buildings and premises owned or controlled by UCLH NHS Foundation Trust. The Asbestos Management Plan does not cover properties which the Trust occupies but where duty holder responsibility remains with the landlord. This Asbestos Management Plan should be read in conjunction with the Asbestos Registers held. This Asbestos Management Plan has been prepared especially for UCLH NHS Foundation Trust. It is a working document and should be regularly updated and amended to ensure it remains valid and as accurate as possible. This Asbestos Management Plan will replace any management plans that may already be in circulation for the Trust. Section 2 STRATEGY FOR COMPLIANCE This Asbestos Management Plan outlines how UCLH NHS Foundation Trust is planning to manage the risk from any known or suspected asbestos within the Trust. Current Provision In 2015, Redhills (later to become Lucion Services) were formally reappointed by the Trust to act in the capacity as the Trust s Asbestos Coordinator. As part of this role all responsibilities identified within this management plan to be undertaken by the Asbestos Coordinator will be undertaken by Lucion Services. The role also includes advice on policy / management plans and review, MICAD data input, annual reinspections, verification of third party information, vetting of contractors, advice on LARC costs, evaluation of asbestos removal tenders, asbestos training and monthly meetings. Additional services will be provided on an ad hoc basis. Over the years a number of surveys have been undertaken throughout the Trust. These include refurbishment and demolition surveys ahead of planned refurbishment and demolition works. Asbestos reinspections have also been undertaken annually. Asbestos information is held on the MICAD database. MICAD is a system that stores asbestos information and reports in an easily accessible format allowing access by multi-users over an internet browser. Access has been made available to all those who plan and manage works which may affect or be affected by asbestos. An Asbestos Management Plan is a requirement of Regulation 4 of the Control of Asbestos Regulations This document has Asbestos Management Plan Page 8 of 47

9 been prepared by Lucion Services on behalf of the Trust. As in accordance with the Control of Asbestos Regulations 2012 and its associated Approved Code of Practice, L143 (Managing and Work with Asbestos), asbestos awareness training is required to be undertaken by all those who plan and manage works which may affect asbestos. To further compliment this it is recommended that an asbestos management course is undertaken. Future Provision Within the next six months to one year UCLH NHS Foundation Trust aims to have the following aspects of its provision for asbestos management completed; 1. On-going programme of survey works to be scheduled for accessible areas of previous No Access. 2. Identify asbestos materials requiring remediation and plan remedial works or implement management options as appropriate. 3. On-going programme of training to be made available to relevant Trust Staff, including identified groups Capital, Estates & Facilities Department, Medical Physics Department and ICT Department. 4. Ensure that instruction and training is made available to relevant trust staff using the MICAD database. 5. Ensure that the MICAD database is kept up to date and made available to all those who plan and manage works which may affect or be affected by asbestos (including all those who can commission third party contracted works). 6. Label all back of house items known to contain asbestos as part of reinspections where appropriate. Undertake a six monthly review of the Asbestos Management Plan Asbestos Management Plan Page 9 of 47

10 Section 3 ASBESTOS RECORDS Current Asbestos Records The following summarises what asbestos information is held by the Trust. ASBESTOS MANAGEMENT PLAN: The Control of Asbestos Regulations 2012 requires all duty holders as a part of their ongoing asbestos management to have a written Asbestos Management Plan ( this document ). This document details which steps should be taken to effectively manage all items of asbestos; it is specifically written for all UCLH NHS Foundation Trust owned or controlled premises and cannot be transferred. It will also detail all assessments made of ACMs and will give recommendations, priorities and deadlines for action. The Asbestos Management Plan will be available for reference and use to all those who plan, supervise or carry out maintenance works or special projects within any part of the Trust. In addition, it will also be made available for staff and contractors upon request. The Asbestos Management Plan will be published on the Trust intranet. A copy will also be available on the MICAD database. ASBESTOS REGISTER: Information regarding the location and condition of asbestos at various Trust properties has been recorded in the Asbestos Register. This Asbestos Management Plan should be read in conjunction with the Asbestos Register. The Asbestos Register can be accessed via the MICAD database. MICAD DATABASE: The MICAD database is the primary way in which asbestos information is passed to those who undertake works which may affect or be affected by asbestos. Access to the Micad database can be obtained via contacting the Asbestos Coordinator, who will provide the necessary register information. Log on and access arrangements to Micad or the Micad Register Portal can be obtained by contacting the UCLH Estates Information Manager directly: George Gebski via George.Gebski@uclh.nhs.uk or telephone Any print outs /paper copies of the asbestos register should not relied upon for any length of time and be regularly updated as the Trust s register is constantly being updated; amendments via Micad may supersede any information held at the time of the printing out within a short period of time. Further Asbestos Records The following summarises what information should be collated and maintained by the Trust. Asbestos Management Plan Page 10 of 47

11 REINSPECTIONS: Regulation 4(9) of the Control of Asbestos Regulations 2012 states that: (9) The measures to be specified in the plan for managing the risk shall include adequate measures for (a) monitoring the condition of any asbestos or any substance containing or suspected of containing asbestos.. Any ACMs identified or suspected will be reinspected (inspected) at regular intervals to check that it has not changed, deteriorated or been damaged in any way. As in accordance with the Approved Code of Practice, L143 (Managing and work with Asbestos) this reinspection should be undertaken every six to twelve months as a minimum. Reinspection records are accessible via MICAD. TRAINING RECORDS: These records are collated as training is undertaken / received. They will detail the training given to each employee and be signed or verified by the employee themselves. Any training certificates received will be held centrally as a full record of who has received which training and when. These records will be treated as confidential to each member of staff and be kept in a controlled location. Each employee will, however, have access to their own records upon request. A list of those who have attended relevant training is held by the Asbestos Coordinator. LABORATORY REPORTS: All reports received from independent laboratories such as Airborne Fibre monitoring Reports (this would include clearance, background and testing) or any Bulk Sampling Certificates, etc. will be held on MICAD. The Asbestos Coordinator will ensure that MICAD is updated upon the receipt of all laboratory reports. TRUST APPROVED CONTRACTORS: The Trust will also ensure that records of approved contractors contains information regarding the licence details, insurance, Health and Safety Policy, together with training records and other relevant information which will be checked prior to a contract being awarded. ASBESTOS REMEDIATION: All details of asbestos removal or remedial works undertaken within the Trust will be recorded. The MICAD database will be updated by the Asbestos Coordinator following all remedial works. RECORDS OF EXPOSURE / INCIDENTS: These records will be collated if necessary to detail the nature and known extent of any exposure to asbestos that has occurred in any area of UCLH Trust or to a Trust employee. Whilst every step has been taken to ensure exposure to asbestos does not occur, it is vital good record keeping is maintained. These records will be treated as confidential to each member of staff and be kept in a controlled way by the Trust. Each employee will have access to their own records upon request. Updating Information It is imperative that all asbestos records are regularly updated with any new information that becomes available. Records will be updated covering; Asbestos Asbestos Management Plan Page 11 of 47

12 Any remedial or removal works on known asbestos containing materials. Any reinspections undertaken. Any training carried out. Any accidental disturbance of any known or suspected ACMs. Any further asbestos information that becomes available, such as additional surveys or samples. Any assessments carried out prior to a task being undertaken. Any changes made to the contact details for the Asbestos Coordinator. Any changes to the organisational structure of the Trust which may affect asbestos management facilities. Any new procedures adopted. Asbestos Management Plan Page 12 of 47

13 The below flow chart describes the process for modifying the MICAD database when changes to the As Built drawing records occur: Asbestos Management Plan Page 13 of 47

14 Section 4 ASSESSMENT OF ASBESTOS Initial Assessment Within the Trust an assessment has been undertaken, in the form of a number of asbestos surveys throughout the property portfolio. When properties are acquired the Trust will ensure that they are in receipt of all asbestos information relating to the property upon point of sale. The Asbestos Coordinator will then undertake an assessment of the current level of asbestos compliance and will ensure that the information is brought in line with other documents held by the Trust. If any properties are disposed of the Trust will ensure that all relevant asbestos information is provided to the purchaser. Special Assessment PLANNED WORKS : Any planned maintenance activities, refurbishment, demolition works or works which may impact upon known or suspected asbestos will not take place until a task assessment has been carried out by a competent person, in accordance with Regulation 6 of the Control of Asbestos Regulations All planned tasks which may disturb the structure or fabric of the building or disturb known or suspected asbestos containing materials are checked against the MICAD database to establish whether or not asbestos will affect works. It is the responsibility of the FM Service provider or those managing the works to ensure that this task is undertaken and the information provided to those undertaking the planned works. An audit will be audited taken by the Asbestos Coordinator in conjunction with the Trust to ensure that these assessments are being undertaken. More information on task assessments is given in Section 7, Safe Systems of Work of this Asbestos Management Plan. The Trust Capital, Estates and Facilities Department are responsible for maintenance works and general minor refurbishments. The Capital, Estates & Facilities Department are able to commission third party contracted works and are responsible for ensuring that asbestos records are made available to FM Service providers and that they are aware of the requirement to check the asbestos records prior to commencing the planned works. The Capital, Estates & Facilities Department is responsible for all construction and major refurbishment projects, and for ensuring that any Capital, Estates & Facilities contractors commissioned are provided with all relevant asbestos information and are working in accordance with Trust procedures. All staff that may be affected by asbestos must follow established UCLH safe working practices and procedures in order to minimise the risk of exposure and the release of asbestos fibres in the air. Employees and contractors should be made aware that areas listed as No Access on any Asbestos Register must be presumed to contain asbestos unless there is strong evidence to the contrary. Procedures for those working near known asbestos, including emergency procedures, should also be clearly communicated. UNPLANNED INCIDENTS: The Asbestos Coordinator will undertake an assessment following any accidental disturbance of material known or suspected of containing asbestos : all staff will be made aware that any incident, no matter how small, which MUST be reported to the Asbestos Coordinator as soon as possible. Any necessary safety measures will then be taken. More detail as to what to do if known or suspected asbestos is disturbed is given in Section 11, The Emergency Procedure. Asbestos Management Plan Page 14 of 47

15 On-going Assessment On-going assessment of known or suspected ACMs within the Trust will take the form of periodic reinspection surveys as in accordance with the Control of Asbestos Regulations It is imperative that both known and presumed asbestos containing materials are effectively monitored and that all asbestos information is as up to date and accurate as possible. REINSPECTION: All items that have been positively identified will undergo regular, ongoing reinspections at 12 monthly intervals from the date of the last inspection / survey. The purpose of undertaking the reinspection is to ensure that Material and Priority Assessments are still current. i.e. that the material has not deteriorated in any way and that the use of the building has not changed. Any change to either criterion will result in the overall Risk Assessment being invalid and therefore a new assessment will be required. This will in turn be recorded. Reinspections are a requirement of ACoP L143, (Management and Work with Asbestos) and will be undertaken by adequately trained personnel in accordance with the Control of Asbestos Regulations MICAD updates will be undertaken at the end of any reinspections by the Asbestos Coordinator or other appointment competent persons. MONITOR AND REVIEW: This Asbestos Management Plan will be regularly reviewed and revised within every 6 months to ensure that all information is correct and that the plan achieves its objectives. More information regarding how this Asbestos Management Plan will be monitored and reviewed is given in Section 8 Asbestos Management Plan Page 15 of 47

16 Section 5 TRAINING Training Asbestos training will be made available for relevant building users; the purpose being to provide all relevant personnel with the skills and knowledge necessary to understand the hazards and risks involved when working in or near an area where asbestos has been identified. Training will be provided for all relevant Trust employees. Asbestos information will be provided for all contractors by the person managing the works. This training / information will be provided prior to any persons commencing work to enable people to work safely. The Asbestos Coordinator will provide training to relevant Trust staff, issue a certificate of attendance and keep records of who has received training and when. A full list of those who have attended training and when is held by the Asbestos Coordinator and uploaded onto Huddle, the trust file sharing platform. Any training provided to Trust employees will incorporate general asbestos awareness that is not only site specific but will also incorporate general asbestos knowledge and advice that can be used across Trust owned properties. Within the Trust it is envisaged that there are three main user groups who require regular training / information; 1. FACILITIES MANAGEMENT SERVICE PROVIDERS & MINOR WORKS CONTRACTORS: It is expected that any company commissioned by the Trust to undertake maintenance works will have undertaken asbestos awareness training 2. THIRD PARTY CONTRACTORS: Asbestos information relevant to any planned works will be provided to contractors by whoever is managing the works (typically this would be coordinated by the Project Manager for the works). 3. THOSE WHO PLAN AND MANAGE WORK: It is expected that information will be made available in the form asbestos management training for who are involved in planning, ordering or supervising works which may affect or be affected by ACMs. It is not envisaged that any training is required for administration or general staff within the Trust or for any general visitors to the site where their works will not be affected by any asbestos present. Facilities Management Service Providers and Minor Works As in accordance with the ACOP L143, Managing and Work with Asbestos, employees whose work could foreseeably expose them to asbestos should be provided with compulsory asbestos awareness training. This includes all those who carry out routine Asbestos Management Plan Page 16 of 47

17 maintenance, or regularly access voids or risers, or regularly disturb the fabric of the building. Facilities Management providers undertaking maintenance works on behalf of the Trust must have the following asbestos awareness training as a minimum: 1. the properties of asbestos and its effects on health, including the increased risk of lung cancer for asbestos workers who smoke; 2. the types, uses and likely occurrence of asbestos and ACMs in buildings and plant; 3. the general procedures to be followed to deal with an emergency; and 4. how to avoid the risks from asbestos. Refresher training is completed annual to ensure that all UCLH whose job role requires awareness training is in line with UKATA requirements. Contractors The Trust recognises its responsibilities under regulation 3(4) (a) of the Asbestos Regulations and will ensure that adequate information and instruction is provided to contractors undertaking project / refurbishment works. This information will be provided by those managing the works prior to works commencing. Where works are sub-contracted it will be the responsibility of the person sub-contracting the works to ensure that the sub-contractor is provided with all relevant asbestos information. Contractors who are brought in on a third party basis will be provided with all the relevant asbestos information and informed of their responsibilities with regards to asbestos. This information will be provided prior to commencing work. The information provided should cover; 1. A brief summary of the location of any known or suspected ACMs which may affect, or are local to, the planned works. 2. The types of activities which are prohibited, areas which are controlled access, etc. 3. What to do should they suspect ACMs have been accidentally disturbed along with a contact number. In addition, it is also important to emphasise that any damage to an ACM no matter how minor - MUST be reported to the Asbestos Coordinator as soon as possible. It is the responsibility of contractors commissioned to ensure that their personnel and any persons commissioned on their behalf know and understand the asbestos procedures and work within safe systems of work put in place by the Trust. Asbestos Management Plan Page 17 of 47

18 Those who plan and manage work Asbestos management training will be made available to all Trust staff that order, plan or supervise works. This training will cover: 1. A brief introduction explaining what asbestos is and the hazards associated with it, etc. 2. A brief summary of the information held by the Trust and how to gain access to it 3. A brief summary of products likely to contain asbestos and where they are likely to be found. 4. The types of activities which are prohibited, areas which are controlled access, etc. 5. The main legislative requirements, in particular Regulation 4, of the Control of Asbestos Regulations How to continue the everyday running of the sites and patient care should any planned asbestos works take place. A list of those who have attended training will be held by the Asbestos Coordinator. Asbestos Management Plan Page 18 of 47

19 Section 6 DISSEMINATION OF INFORMATION It is imperative that relevant people actively seek up-to-date asbestos information before starting working in or near an area which is known or presumed to contain asbestos. All relevant staff will be provided with access to the MICAD database. This section covers how asbestos information will be disseminated throughout the Trust. How information is disseminated ASBESTOS RECORDS: All asbestos records for the Trust are held on MICAD. The Asbestos Coordinator will be responsible for ensuring that the asbestos records are kept up to date. The asbestos records will be made available to staff, in particular any employees who carry out maintenance activities, those who order contracted works and those who may disturb asbestos bearing materials during the course of their work. TRAINING: Training will be made available to all Trust staff that plan and manage works which may affect or be affected by asbestos. Training will also be made available to any other persons upon request. Training will be made available to all users of the MICAD database so that database can be interrogated and asbestos information extracted. This training is provided by the Asbestos Coordinator upon request. THIRD PARTY CONTRACTORS: All contractors commissioned to undertake works on behalf of the Trust will be provided with asbestos information relevant to the planned task by those commissioning the works. FM Service providers have been provided with access to the MICAD database via portal. The FM Service Providers are also going to be updated to the new module allowing full MICAD access. FM Service providers are responsible for any contractors that they commission and should ensure that all relevant asbestos information is provided to the contractors before ay works are undertaken. Similarly, any Trust staff who commission works should ensure that the contractor is provided with the relevant asbestos information or access to the MICAD database. The disturbance of ACMs should be avoided if information is communicated effectively, however the name and contact number of the Asbestos Coordinator should be supplied to enable any such disturbance to be reported. MICAD: The asbestos registers are available on MICAD. The MICAD IPR website allows access to the most current asbestos information to those who carry out routine maintenance on a day to day basis and those who access the hospital for projects or for one-off works. UCLH MiCAD Internet Property Register - Asbestos Management Plan Page 19 of 47

20 UCLH MiCAD Asbestos Portal - The information can be used to undertake an assessment on whether planned works will be affected by known or presumed asbestos prior to commencing works. The results of this assessment will then be passed on to the relevant personnel. Where third party contractors are brought in to do works the necessary checks should be made by whoever is managing the works against the database. FM Service providers have been provided with access to MICAD. All those who plan and manage project / refurbishment works within the Trust have been provided with access to MICAD. It is the responsibility of all users of the MICAD database to ensure that they understand how to interrogate the database and make an assessment of their planned works. Any persons who are unsure as to how to proceed or use the database should contact the Asbestos Coordinator before commencing works. Section 7 SAFE SYSTEMS OF WORK A safe system of work is a procedure or adopted policy which should always be followed to ensure that the relevant precautions are taken and that no-one is exposed to asbestos during the course of their work. Prior to any work being undertaken which may be affected by the presence of asbestos in any UCLH NHS Foundation Trust owned or occupied building, an assessment and an appropriate safe system of work should be documented and put in place. In this section three main processes are described; 1. MAINTENANCE & MINOR WORKS: A Safe System of Work procedure for general maintenance and minor works (including data cabling, utilities). 2. CONSTRUCTION / REFURBISHMENT PROJECTS: A Safe System of Work procedure for all construction projects. 3. ASBESTOS REMOVAL WORKS: A Safe System of Work procedure for all asbestos removal works. Maintenance and Minor Works The reactive maintenance needs of the Trust are met by Trust appointed Facilities Management Service providers. For every-day maintenance works, once a task assessment has been carried out and a safe system of work defined, then provided the environment remains the same, it will be valid for all such activities. Some guidance may be needed to assess certain maintenance activities, but essentially every task should be checked to ensure that no-one is accidentally disturbing known or Asbestos Management Plan Page 20 of 47

21 suspected asbestos containing materials whilst carrying out a task. If it is found that planned works will be affected by the presence of known or suspected ACMs then further guidance should be sought from the Asbestos Coordinator. It is just as important to inform all concerned if no asbestos is present but safe systems of work should always be followed. Should any ACMs be discovered during the course of the works or if it is suspected that asbestos may have been disturbed then the Asbestos Coordinator should be notified immediately. It is the responsibility of those managing third party contracted works to ensure that they ensure that the contractor is provided with all relevant asbestos information and/or access to the MICAD database prior to works commencing. All contractors are required to provide copies of their policies in relation to the general provisions of the Health and Safety at Work Act 1974 and asbestos management. They will in turn be given access to all relevant Asbestos Records. All contractors should also provide evidence of competency (for example, an appropriate examination certificate, licenses, training, etc.) in working with identified asbestos; to a standard equal to or greater than that required by the UCLH NHS Foundation Trust. They should also demonstrate general competence and an understanding of the relevant codes and standards which will be required to carry out work in accordance with regulatory requirements and codes of practice for asbestos work. All persons must cooperate with the process of identification, assessment and control of asbestos and participate in training programmes. Employees of Facilities Management companies should be made aware by their employer that areas listed as No Access on any Asbestos Register must be presumed to contain asbestos unless there is strong evidence to the contrary. Procedures for those working near known asbestos, including emergency procedures, should also be clearly communicated. MAINTENANCE / MINOR WORKS: This flow chart summarises steps which should be taken to ensure that day to day maintenance tasks and minor works are carried out in a safe manner. Asbestos Management Plan Page 21 of 47

22 Asbestos Management Plan Page 22 of 47

23 Construction / Refurbishment Projects This group consists of all project driven tasks (including asbestos removal works) and any tasks which are not carried out by the Trust s FM Service provider / minor works contractors. Within the Trust all large project or refurbishment works are implemented by the Capital, Estates & FacilitiesDepartment who in turn are responsible for ensuring that asbestos information is relayed to the project teams. Project Managers are able to commission surveys (such as Refurbishment and Demolition surveys) prior to any demolition or refurbishment works and remedial works following consultation with the Asbestos Coordinator. For these works a project-specific assessment should be undertaken once the scope of works has been established. In consultation with the Asbestos Coordinator, all asbestos records must be checked and an assessment made of how any known or presumed asbestos may affect the planned works. For all projects that fall under the CDM Regulations 2015 (Construction, Design & Management) the Trust will ensure that the CDM Co-ordinator is provided with all asbestos information in the Trust s possession relating to the project, for inclusion in the Health and Safety file as in accordance with Regulation 4(9) (C) of the Control of Asbestos Regulations Contractors will also be informed that should they discover any unrecorded suspected ACMs during the course of their work, that they must notify the Asbestos Coordinator IMMEDIATELY. All persons must cooperate with the process of identification, assessment and control of asbestos and participate in training programmes. Employees and contractors should be made aware that areas listed as No Access on any Asbestos Register must be presumed to contain asbestos unless there is strong evidence to the contrary. Procedures for those working near known asbestos, including emergency procedures, should also be clearly communicated. Asbestos Management Plan Page 23 of 47

24 CONSTRUCTION / REFURBISHMENT PROJECTS: This flow chart summarises steps which should be taken to ensure that project/capital works within the Trust are carried out in a safe manner. Asbestos Management Plan Page 24 of 47

25 Asbestos Management Plan Page 25 of 47

26 Only the Capital, Estates & Facilities Department can commission asbestos remedial / removal works. This procedure is designed to ensure that there is a consistent approach for all asbestos removal works. It should be noted that only Capital, Estates & Facilitiesapproved removal contractors and analytical companies will be employed to undertake asbestos removal and analytical works on any Trust owned or controlled property. Prior to any asbestos removal works the Trust will identify the scope of works. The Asbestos Coordinator will ensure that full asbestos information is available for the planned works following consultation with the Trust. In the case of refurbishment / demolition works a Refurbishment / Demolition survey as described in HSG 264 will be undertaken. Tendering companies for asbestos works should demonstrate knowledge of relevant current legislation pertaining to the safe removal of asbestos and awareness of other Health & Safety legislation and hazards that may be encountered on site. Information provided to tendering companies will include an asbestos survey report with fully annotated plans, full scope of works, information regarding any non-asbestos hazards relevant to the work area and any working practices required for working on the site. Prior to the commencement of any removal works the licensed asbestos removal contractor appointed will be expected to: Provide risk assessments as to how the asbestos is going to be removed; Attend a pre-contract site meeting if requested. The Asbestos Coordinator will be expected to prepare, review and comment on asbestos removal works specifications and prior to commencement of the works the contractors method statement on behalf of the Trust. Where works are undertaken by other analytical companies the Asbestos Coordinator will review the planned works and method statements. Within the Trust only UKAS accredited companies on the Trust s approved list will be commissioned to undertake survey works or analytical work. For survey works the company should be accredited to ISO and for analytical works to ISO Air monitoring during any removal works will be undertaken by an independent UKAS accredited laboratory. Unless commissioned through a Principal Contractor the Trust will engage the services of an analytical company directly. Under no circumstances should the asbestos removal contractor engage the services of the analysts on behalf of the Trust. An approved analytical company will be employed by the Trust to oversee the smoke testing, provide air monitoring (including leak testing where appropriate), conduct the Four Stage Clearance procedure and oversee the contractor at all stages of the works. The analytical company will also be expected to attend any pre-start meetings, progress meetings and a handover meeting Asbestos Management Plan Page 26 of 47

27 so that the Trust is kept fully informed at all times. On completion of any asbestos remedial works the Project Manager should ensure that the Asbestos Coordinator is provided with a completion document. This document should be retained with the project file in a central stored location. The completion document should include the following: Air monitoring certificates; Waste consignment notes; Removal contractors method statement; Updated plans illustrating all asbestos items that have been removed and all asbestos that has been retained. The Asbestos Coordinator is responsible for ensuring the asbestos records are updated following any survey or remedial works. The Project Managers should ensure that the Asbestos Coordinator is provided with up to date asbestos information following any works. Section 8 MONITORING AND REVIEW OF THIS PLAN The key objective of the Asbestos Management Plan is to reduce the risk of exposure. If it can be demonstrated that the risk from asbestos containing materials throughout the Trust is under control, this Asbestos Management Plan will be fulfilling its intended purpose. This Asbestos Management Plan will be reviewed at six monthly intervals by the Asbestos Coordinator to ensure that it remains effective. This may not mean that any changes are necessary, but rather that all current provisions are appraised, checked and audited and that any changes which may make them more efficient are discussed and implemented where necessary. The procedure in the following flow chart will be undertaken to ensure this remains a valid document and that the risks from asbestos are being adequately assessed: Asbestos Management Plan Page 27 of 47

28 MONITOR AND REVIEW PLAN: This flow chart summarises steps which will be undertaken by the Asbestos Coordinator in association with the Capital, Estates & FacilitiesDepartment to ensure the management plan is reviewed and remains a valid document. Asbestos Management Plan Page 28 of 47

29 Asbestos Management Plan Page 29 of 47

30 Section 9 ROLES AND RESPONSIBILITIES Overview of Roles and Responsibilities Where duties have been outlined, this should be used as an initial guide for discussion / definition of roles within the Trust. All responsibilities can be delegated, unless otherwise stated, but it should remain the responsibility of the designated person to ensure they are completed satisfactorily. The following organogram outlines the organisation within the Trust for asbestos management: Asbestos Management Plan Page 30 of 47

31 ASBESTOS COORDINATOR: 1. Oversee asbestos management provision across the Trust. Asbestos Management Plan Page 31 of 47

32 2. Oversee the implementation of all procedures and safe systems of work regarding asbestos throughout the Trust. 3. Review agreed roles and nominate as appropriate. 4. Attend monthly review meetings with the Trust. 5. Advice on asbestos policy and management plans and undertake reviews at defined timescales. 6. Verification of third party information. 7. Vetting of contractors. 8. Advice on LARC costs. 9. Evaluation of asbestos removal tenders. 10. Attend monthly asbestos management meetings. 11. Undertake an assessment of any new acquisitions and ensure they have full asbestos records (including Management asbestos surveys). 12. Ensure reinspections surveys are undertaken at least annually. 13. Ensure the MICAD database is updated following any asbestos works. 14. Ascertain that all work carried out on asbestos containing materials complies with current regulations and best practice. 15. Ensure an assessment of the hazards and risks from asbestos containing materials is undertaken and recommended, appropriate control measures defined. 16. Coordinate the monitoring of the environment during asbestos works. Where works are undertaken by other analytical companies act in an advisory capacity to the Trust and oversee asbestos works undertaken. 17. Ensure appropriate management of asbestos remedial works and/or further surveys etc. where day to day maintenance activities are affected by the presence of asbestos i.e. task-driven remedial works. 18. Facilitate asbestos training for appropriate Trust staff via a UKATA approved training company. 19. Undertake regular reviews of the Safe Systems of Work procedures. 20. Maintain all records in accordance with the regulatory requirements and codes of practice for asbestos work. Asbestos Management Plan Page 32 of 47

33 FACILITIES MANAGEMENT SERVICE PROVIDERS: 1. Ensure all operatives who are employed to work on Trust properties have had appropriate asbestos awareness training. 2. Ensure that a suitable assessment is undertaken to determine whether planned works will affect or be affected by asbestos PRIOR to commencing works. 3. Inform the Asbestos Coordinator if they find any damaged asbestos or if they know that the condition of any ACM has changed in any way. 4. Undertake works with due care and attention and follow safe working practices. 5. Direct any questions or queries regarding asbestos to their supervisor or the Asbestos Coordinator. THOSE WHO PLAN AND MANAGE WORK: (For example, Capital, Estates & FacilitiesManagers, ICT Infrastructure Managers etc) 1. Receive training on ACMs. 2. Prior to any demolition works, check the asbestos register and ensure a Refurbishment/Demolition asbestos survey is undertaken if required. 3. Ensure compliance with the asbestos requirements as detailed within the CDM Regulations 2015 where required. 4. Responsibility for the undertaking and assessment of scope of project works against asbestos records prior to engaging third party contractors to undertake works. Typically, this would be coordinated by the Project Manager. 5. Responsibility for ensuring that all relevant asbestos information is provided to those conducting the works. Typically, this would be coordinated by the Project Manager. 6. Inform the Asbestos Coordinator if they find any damaged asbestos or if they know that the condition of any ACM has changed in any way. 7. Fully cooperate with the Asbestos Coordinator in order to maintain compliance with asbestos legislation and achieve the goal of effective asbestos management. 8. Ensure satisfied with asbestos records held, how to use them and understand the information held within them. If unsure or Asbestos Management Plan Page 33 of 47

34 have any queries then these must be raised with the Asbestos Coordinator. 9. Direct any questions or queries regarding asbestos to the Asbestos Coordinator. CONSTRUCTION CONTRACTORS: 1. Act as the main point of contact for any third party contracted works commissioned. 2. Responsibility for undertaking a task assessment prior to engaging third party contractors to undertake works. 3. Responsibility for ensuring that all relevant asbestos information is provided to all third party contractors upon arrival to site. 4. Check and ascertain that asbestos safe working practices are followed by third party contractors as far as practicable i.e. through spot checks, walk around etc. 5. Provide the Asbestos Coordinator with any relevant asbestos information so that the Asbestos Registers can be kept up to date. 6. Inform the Asbestos Coordinator if they find any damaged asbestos or if they know that the condition of any ACM has changed in any way. 7. Fully cooperate with the Asbestos Coordinator in order to maintain compliance with asbestos legislation and achieve the goal of effective asbestos management. 8. Ensure satisfied with asbestos records held, how to use them and understand the information held within them. If unsure or have any queries then these must be raised with the Asbestos Coordinator. 9. Direct any questions or queries regarding asbestos to the Asbestos Coordinator. Asbestos Management Plan Page 34 of 47

35 Section 10 ACTION PLAN Action Plan This section details which steps should be undertaken to achieve the goal of effective asbestos management. The detail given here is further to the comments and recommendations given within the Asbestos Registers held. Action Timescale Responsibility Status 1. Review of Asbestos Management Plan June 2016 Asbestos Coordinator / Trust Ongoing (6 monthly) 2. Programme of Management surveys where As and when Asbestos Ongoing required required Coordinator 3. Reinspections Annual Asbestos Coordinator Ongoing 4. Identify areas for which no asbestos Within 3 months Asbestos Ongoing information is available and programme Coordinator surveys as required 5. Identify all asbestos items requiring Within three Asbestos Ongoing remediation and prioritise remedial works or months Coordinator / Trust implement management options 6. Ensure asbestos training is available for November 2011 Asbestos Ongoing relevant Trust staff Coordinator 7. Refresher asbestos management training Annual Asbestos Coordinator Ongoing 8. Update the MICAD database when new As and when Asbestos Ongoing records become available required Coordinator 9. Inform all parties of their responsibilities with November 2011 Capital, Estates & Complete regards to asbestos management (asbestos Facilities policy and management plan to be made available on Trust intranet) Asbestos Management Plan Page 35 of 47

36 10. Label all back of house items known to contain Within 6-12 Asbestos Ongoing asbestos as part of reinspections where months Coordinator / Trust appropriate or as part of removal works Asbestos Management Plan Page 36 of 47

37 Section 11 EMERGENCY PROCEDURES The following procedure should be followed in the event of accidental disturbance of known or presumed asbestos: Asbestos Management Plan Page 37 of 47