Radon Management Policy V2.0

Size: px
Start display at page:

Download "Radon Management Policy V2.0"

Transcription

1 V2.0 September 2015

2 Summary. Start Scope All premises for which the organisation has maintenance responsibility will have radon measurements taken and, where identified as radon affected, control measures will be put in place. In addition, the organisation will ensure that we receive information regarding radon monitoring undertaken by other organisations / landlords in buildings where our employees work to be assured that the risks have been adequately assessed/managed. Radon Gas Monitoring Programme - Estates Service (or landlords, where applicable) A planned programme of radon gas monitoring at all sites will take into account an appropriate time scale for each property as determined by HSE/PHE guidance and previous radon monitoring results in conjunction with advice from the Radiation Protection Adviser (RPA). Risk Assessments and Remedial Actions - Estates Service (or landlords, where applicable) Following radon monitoring, risk assessments will be undertaken in areas which have an estimated winter maximum level in excess of 400 Becquerel per cubic metre. The assessment should outline controls and actions for the safe use of the building until remedial works can be undertaken. Radon Records Estates will maintain a record of monitoring, results and supporting risk assessment documentation and remedial actions. This documentation will be held in perpetuity for radon affected premises. Monitoring Compliance & Effectiveness Monitoring Programme / Actions in respect of radon affected premises - annually. Head of Estates is accountable. The RPA will monitor progress, reporting to Radiation Protection Committee End Page 2 of 12

3 Table of Contents Summary Table of Contents Introduction Purpose of this Policy/Procedure Scope Definitions / Glossary Ownership and Responsibilities Employer: Radiation Protection Adviser: Occupational Health Department: Estates Service (or landlords, where applicable): Role of the Managers Role of the Radiation Protection Advisory Committee Monitoring and Assessment of Radon Monitoring compliance and effectiveness Updating and Review Equality and Diversity... 8 Appendix 1. Governance Information... 9 Appendix 2. Initial Equality Impact Assessment Form Page 3 of 12

4 1. Introduction 1.1. This policy describes the measures taken by the Trust to assess the potential risks posed by radon gas to employees in premises in which the organisation s staff work and the measures to manage radon affected premises This version supersedes any previous versions of this document. 2. Purpose of this Policy/Procedure 2.1. Radon is a colourless, odourless radioactive gas. It comes from the radioactive decay of radium, which in turn comes from the radioactive decay of uranium. Uranium acts as a permanent source of radon and is found in small quantities in all soils and rocks, although the amount varies from place to place. Radon in the soil and rocks mixes with air and rises to the surface where it is quickly diluted in the atmosphere. Concentrations in the open air are very low. However radon that enters enclosed spaces, such as buildings, can reach relatively high concentrations in some circumstances. It is particularly prevalent in granite areas but not exclusively so. Radon levels vary not only between different parts of the country but even between neighbouring buildings The UK has been extensively surveyed by the former Health Protection Agency (HPA) and British Geological Survey and the Indicative Atlas of Radon in England and Wales shows that Cornwall is a Radon Affected Area. The Health Protection Agency defines Radon Affected Areas as those with 1% probability or more of a home having radon above the Action Level Radon poses a health risk to employees; cumulative exposure increases an individual s risk of lung cancer The Health and Safety at Work Et Cetera Act 1974/Ionising Radiations Regulations 1999/Management of Health and Safety at Work Regulations 1999 establish a legal requirement to assess the risks from radon and prescribe an action level. 3. Scope 3.1. All premises for which the organisation has maintenance responsibility: will have radon measurements taken and, where identified as radon affected, appropriate control measures will be put in place In addition, this policy will demonstrate how the organisation will ensure that we receive appropriate information regarding radon monitoring undertaken by other organisations / landlords in buildings where our employees are working in order to be assured that the risks have been adequately assessed/managed. 4. Definitions / Glossary 4.1. The Employer is Royal Cornwall Hospitals NHS Trust; for legal purposes the Chief Executive is identified as the accountable officer Radiation Protection Adviser (RPA) is defined by the Ionising Radiation Page 4 of 12

5 Regulations (IRR99) as an individual who is accredited as meeting the criteria of competence specified by the Health and Safety Executive (HSE) 4.3. Becquerel per cubic metre (Bq/m3) is the unit in which radon concentrations, more colloquially referred to as radon levels, are measured Controlled Area: is an area designated under IRR99, access is restricted or the work activity is limited and/or supervised Ionising Radiations Regulations 1999 (IRR99): regulations which govern work with radiation Action level: Action level is the radon concentration at which the Ionising Radiations Regulations 1999 become applicable, requiring the Employer to take action. The action level is a concentration of 400 Bq/m 3 (averaged over 24 hours). 5. Ownership and Responsibilities 5.1. Employer: The Employer has a legal duty to ensure the health, safety and welfare of employees and others who have access to that working environment The Employer must ensure the risks to staff and the public arising from radon exposure during work in premises are assessed and, for premises in excess of the defined action level, measures are taken to control radon exposure (usually by remedial work to reduce radon levels) For any premises identified as being in excess of the action level, the Employer is required to notify the Health and Safety Executive (HSE), outlining actions to be taken (this is undertaken in consultation with the Radiation Protection Adviser) 5.2. Radiation Protection Adviser: Provide specialist advice on radiation protection to assist the employer in compliance with the requirements of the IRR Assist with the planning and implementation of a programme of radon monitoring and will report and liaise with relevant Landlords / the organisation on remedial action Interpret radon measurements to determine workplace exposure to radon Occupational Health Department: Will provide information, support and guidance to employees working in areas that have radon concentrations that exceed the recognised action levels Estates Service (or landlords, where applicable): Will undertake a programme of radon monitoring in premises occupied by the organisation s staff Will arrange to implement any necessary remedial work where radon levels have been identified as above the action level Will undertake planned maintenance of remediation systems and Page 5 of 12

6 ensure re-monitoring is undertaken following remedial work to ensure systems installed are and remain effective Will liaise with the RPA following receipt of results to ensure the safety of employees Will liaise with Landlords to ensure that there is adequate assurance that radon monitoring/risk assessment has been carried out on non-rcht premises where Trust staff work Will assist with risk assessments where necessary. Will maintain a database of sites affected by radon and a record of remediation systems installed Will liaise with Landlords when remonitoring dates are approaching to ensure required actions are carried out Will liaise with Landlords regarding the progression of any remedial works to premises Will maintain records of radon monitoring of premises in perpetuity Role of the Managers Line managers will facilitate access to areas for the placement and recovery of radon monitors and other such site visits as may be appropriate For radon affected premises, line managers will be supplied with information by the Radiation Protection Adviser and, in the first instance, speak with any staff expressing concerns Line managers will ensure that, where remediation systems are installed, any failure of these systems (e.g. indicated by audio/visual alarm) is promptly reported to the estates department Role of the Radiation Protection Advisory Committee The Radiation Protection Advisory Committee will receive reports from the Radiation Protection Adviser, and Head of Estates as may be required, regarding the level of the Trust s compliance with the law and this policy with regard to management of radon gas The Radiation Protection Advisory Committee will advise Trust Management Committee of any concerns which, in the view of the committee, require escalation. 6. Monitoring and Assessment of Radon 6.1. Surveying and Sampling Indoor radon levels can fluctuate from season to season, from day to day and by the hour and it is recommended that monitoring radon levels should be over a prolonged period of time to establish accurate readings. This can be achieved very simply and cost effectively by using passive detectors for a period of three months Radon Gas Monitoring Programme A planned programme of radon gas monitoring at all sites is to be implemented. This programme will take into account an appropriate time scale for each property as determined by HSE/PHE guidance and previous Page 6 of 12

7 radon monitoring results in conjunction with advice from the Radiation Protection Adviser All sites will be routinely measured every 10 years. For sites where high radon levels have previously been measured (greater than 300 Bq/m 3 estimated winter maximum level), or where remedial work has taken place, measurements should be performed every three years Planned periodic monitoring should be conducted in winter (November February) when radon concentrations are highest. Periodic monitoring in summer is to be avoided as this involves the use of correction factors to estimate worst case winter levels, which increases the uncertainty in the results obtained Risk Assessments and Remedial Actions Following radon monitoring, risk assessments will be undertaken in areas which have an estimated winter maximum level in excess of 400 Becquerel per cubic metre (the action level set for workplaces by the Ionising Radiations Regulations 1999). The assessment should outline controls and actions for the safe use of the building until remedial works can be undertaken Although not enforced in law, for domestic premises an action level of 200 Becquerel per cubic metre annual average level exists. For comparison with workplace measurements, which are conventionally given as winter maximum level rather than annual average level, it is more useful to express this as an equivalent estimated winter maximum level. Through calculation using published seasonal correction factors (and assuming the building has a typical summer/winter variation), the 200 Bq/m 3 annual average level corresponds to a 294 Bq/m 3 estimated winter maximum level. When reviewing monitoring data, areas in excess of 294 Bq/m 3 estimated winter level should be reviewed to determine if they are areas of protracted public occupancy (e.g. occupancy >> 3 months), if so then a formal risk assessment may be required Radon Records Estates will maintain a record of monitoring, results and supporting risk assessment documentation and remedial actions. This documentation will be held in perpetuity for radon affected premises. 7. Monitoring compliance and effectiveness Element to be monitored Lead Tool Monitoring Programme / Actions in respect of radon affected premises. Head of Estates / Radiation Protection Adviser Monitoring of premises in accordance with schedule Page 7 of 12

8 Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Annually Reporting to Radiation Protection Committee Head of Estates is accountable. The RPA will monitor progress. The Radiation Protection Adviser will monitor the effectiveness of the implementation of this policy and any regulatory changes on an on-going basis. 8. Updating and Review 8.1. This policy will be updated 3 yearly or earlier (e.g. as may be requested by the Radiation Protection Committee, Head of Estates, Radiation Protection Adviser) The Document approval route will be via the Radiation Protection Committee. 9. Equality and Diversity 9.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 8 of 12

9 Appendix 1. Governance Information Document Title Date Issued/Approved: September 2015 Date Valid From: September 2015 Date Valid To: September 2018 Directorate / Department responsible (author/owner): Contact details: Brief summary of contents Suggested Keywords: Target Audience Executive Director responsible for Policy: Head of Estates Jim Tinsdeall Radiation Protection Adviser Trevelyan Foy Jim Tinsdeall Trevelyan Foy This policy describes the measures taken by the Trust to assess the potential risks posed by radon gas to employees in premises in which the organisation s staff work and the measures to manage radon affected premises Radon, Radiation RCHT PCH CFT KCCG Medical Director Date revised: May 2015 This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Radon Policy Radiation Protection Advisory Committee CSSC Governance DMB ( ) Divisional Manager confirming approval processes Name and Post Title of additional signatories Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Sally Kennedy, Divisional Director CSSC Trevelyan Foy Radiation Protection Adviser Garth Weaver - Acting Director of Estates {Original Copy Signed} Name: Janet Gardner, Governance Lead CSSC {Original Copy Signed} Internet & Intranet Intranet Only Clinical / Medical Physics Page 9 of 12

10 Links to key external standards Ionising Radiations Regulations CQC Outcome 10. Related Documents: Ionising Radiations Regulations Training Need Identified? Version Control Table No Date Version No March 12 V1.0 Initial Issue Summary of Changes 20 May 15 V2.0 Updating of policy to current template format. Changes Made by (Name and Job Title) Richard Cranage Radiation Protection Adviser Trevelyan Foy Radiation Protection Adviser All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 10 of 12

11 Appendix 2. Initial Equality Impact Assessment Form Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description): Directorate and service area: Is this a new or existing Policy? Existing CSSC, Medical Physics Name of individual completing Telephone: assessment: Trevelyan Foy 1. Policy Aim* Refer to policy section 1 Who is the strategy / policy / proposal / service function aimed at? 2. Policy Objectives* Refer to policy section 2 3. Policy intended Outcomes* 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure. Refer to policy sections 1 and 2 Refer to policy sections 6 and 7 All persons occupying premises where Trust staff work Radiation Protection Advisory Committee Yes Radiation Protection Advisory Committee 7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence Age Sex (male, female, transgender / gender reassignment) Page 11 of 12

12 Race / Ethnic communities /groups Disability - Learning disability, physical disability, sensory impairment and mental health problems Religion / other beliefs Marriage and civil partnership Pregnancy and maternity Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please explain why. Policy could not have impact on any identified areas. No potential differential impact identified Signature of policy developer / lead manager / director Trevelyan Foy Date of completion and submission 29/05/2015 Names and signatures of members carrying out the Screening Assessment 1. Trevelyan Foy 2. Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust s web site. Signed Date Page 12 of 12