Asbestos Policy. Version 2

Transcription

1 SH NCP 41 Summary: Keywords (minimum of 5): (To assist policy search engine) The sets out how Southern Health NHS Foundation Trust will comply with all relevant Health and Safety legislation regarding the management of Asbestos. Asbestos, Health, Safety, Register, Control Target Audience: All Trust Staff All Health and Safety Committee Representatives All Infection Prevention and Control Committee Representatives All Trust Estates and Facilities Management Staff All Trust Project Leads Next Review Date: December 2019 Approved by: Health & Safety Forum Date of meeting: December 2014 Date issued: Author: Sponsor: Head of Estate Services 1

2 Version Control Change Record Date Author Version Page Reason for Change 23/12/2016 Keith Alexander Review of Policy minor amendments only. Review date extended for further 3 years Reviewers/contributors Name Position Version Reviewed & Date Keith Alexander 17/07/2012 Alison Edmundson Compliance Assurance Manager 17/07/2012 Ivor Watson Senior Estates Capital Projects Manager 17/07/2012 Paul Johnson Head of Estate services 17/07/2012 Teresa Lewis Infection Control Nurse 17/07/2012 Karl Beanland Senior FM Operational Manager 17/07/2012 Louise Hartland LEAD 17/07/2012 Sharon Gomez LEAD 17/07/2012 David Batchelor Governance 17/07/2012 Carole Moor Compliance Administration Manager 17/07/2012 Tiffany Hallett Legal Team 17/07/2012 Keith Tutt Support Systems Manager 17/07/2012 Tracy England Senior Contracts and PFI/LIFT Manager 17/07/2012 Annette Chalmers Compliance Group Attendee 17/07/2012 Kim Pullen Health and Safety Manager 17/07/2012 Karl Allen Capital and Maintenance Delivery Manager 17/07/2012 2

3 Contents Page 1. Introduction 4 2. Scope 4 3. Definitions 5 4. Duties/ responsibilities 5 5. Main policy content 8 6. Training requirements 9 7. Monitoring compliance Policy review Associated documents Supporting references 10 A1 Training Needs Analysis (TNA) 11 A2 Equality Impact Assessment (EqIA) 12 3

4 1. Introduction This sets out how Southern Health NHS Foundation Trust (the Trust) will comply with 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 (ACM s) 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 Policy requires 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. This policy is not applicable to social care supporting living services. Any concerns should be raised with the relevant Housing Provider and the Locality Manager. 2. Scope The Trust recognises its duties under the Health and Safety at Work Act, 1974 and the Control of Asbestos Regulations 2012 and all associated Approved Codes of Practice and is committed to the effective management of asbestos. The Trust recognises its responsibilities 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 Where the term employees and regular building users has been used it should be taken to refer to all direct employees, agency staff, long term contracted suppliers and those employed by Trust Directorates. Where the term contractors has been used in this policy document it should be taken to refer to all parties who undertake work for the Trust on a short term, limited contract basis. This would include tradespersons brought in for a specific task or time period, but not those who have an on-going supply agreement with the Trust. Where Estates and FM Services are managed on our behalf by another organisation they will abide by the same policy. 4

5 3. Definitions The Control of Asbestos Regulations 2012 came into force on 6 April 2012, updating previous asbestos regulations to take account of the European Commission's view that the UK had not fully implemented the EU Directive on exposure to asbestos (Directive 2009/148/EC). Asbestos fibres are present in the environment in Great Britain so people are exposed to very low levels of fibres. However, a key factor in the risk of developing an asbestos-related disease is the total number of fibres breathed in. Working on or near damaged asbestos-containing materials or breathing in high levels of asbestos fibres, which may be many hundreds of times that of environmental levels can increase your chances of getting an asbestos-related disease. The control limit for asbestos is 0.1 asbestos fibres per cubic centimetre of air (0.1f/cm3). The control limit is not a 'safe' level and exposure from work activities involving asbestos must be reduced to as far below the control limit as possible. 4. Duties / Responsibilities 4.1 Chief Executive The Chief Executive has the overall responsibility for health, safety and welfare of staff and others affected by the work activities of the Trust and for the effective implementation of asbestos management policies and procedures. 4.2 Director of Finance and Corporate Services The Chief Executive has nominated the Director of Information and performance to carry the specific responsibility for the effective implementation of asbestos management policies and procedures. 4.3 Head of Estates Service The Head of Estates Service has delegated responsibility for the operational implementation and monitoring of asbestos management policies and procedures. 4.4 Senior Estates Capital Projects Manager The Senior Estates Capital Projects Manager has delegated responsibilities for the operational implementation and monitoring of asbestos management policies and procedures. 4.5 Service Leads or Site Managers 1. To ensure that the Asbestos Coordinator is informed immediately when asbestos is identified or suspected so that assessments can be made and the appropriate action taker. 2. To ensure that their department implements any procedures deemed necessary by the Asbestos Coordinator. 5

6 3. To ensure departmental staff, patients or visitors are not at risk of exposure to hazardous asbestos materials. 4. To ensure any work likely to affect asbestos materials is carried out after consultation with, and in agreement with, the Asbestos Coordinator. 5. To ensure new equipment or apparatus erected, installed, purchased or gifted on behalf of the divisional/directorate is free of asbestos material. 6. To receive and be aware of asbestos in their area of influence and ensure others in their control are aware of the location of the and the location of asbestos containing materials. 4.6 Asbestos Coordinator The nominated Asbestos Coordinator for the Trust is: Name: Number: Location: Estates and Facilities Management, Tom Rudd Unit, Moorgreen Hospital. Helpdesk: The above named person should be available if any help is needed to understand this document; if any asbestos information is required; if any works are planned which may affect known or suspected asbestos containing materials (ACMs); or if accidental disturbance of ACMs is suspected. The Asbestos Coordinator will: 1. Compile and maintain a record (Asbestos Register) of all known or suspected Asbestos Containing Materials (ACMs) within of all premises owned or controlled by the Trust. 2. Ensure that an Asbestos Management Plan is kept up to date and reviewed on a regular basis as in accordance with Regulation 4 of the Control of Asbestos Regulations Be responsible for actively working with Estates to maintain services that could compromise the service provision, ensuring safe accesses to suspected areas when needed. 4. Involve the operational estates manager responsible for the building. 5. Actively lead and advise on the removal of any contaminants that could compromise access to areas, plant and or equipment within any of the Trust buildings. 6. Ensure that prior to any project works (refurbishment, demolition, etc) ensure a specific asbestos assessment and take steps to mitigate the risk posed by any potential asbestos present in areas affected by the planned works. 6

7 7. Ensure all contractors working within Trust premises, before they start work, of the nature and extend of any known or suspected ACMs which may affect their work; where all asbestos information is kept; the name and contact details of the nominated Asbestos Coordinator and what to do should they suspect asbestos has been disturbed. 8. Oversee the removal of any high-risk asbestos items identified throughout Trust premises and actively manage any remaining asbestos to ensure the continued, safe running of all Trust premises. 9. Implement and regularly review suitable control measures to ensure that the risk from ACMs is adequately managed. 10. The Asbestos Coordinator will ensure that all relevant personnel will undertake initial training and then annual refresher training to ensure they are kept updated on new developments in the management and control of asbestos to ensure competent performance of their specific duties. Attendance will be recorded and maintained ready for inspection if required. 11. Ensure all asbestos information is made available upon request. 12. Be actively involved in monitoring of any asbestos or consultancy works completed by a third party (such as an asbestos consultant, laboratory, principle contractor or a licensed contractor). Where records or documents are prepared or maintained by a third party, this will be clearly stated, and centrally controlled by the Trust. 13. Ensure that labelling is undertaken in non-public areas and/or areas where labelling is deemed necessary to ensure the safety of building users. (Labelling to be carried out at the Trust s discretion). 14. Only used Trust approved, licensed asbestos removal contractors to carry out any planned, necessary works on asbestos containing materials. A list of used and approved contractors is maintained for this purpose. 4.7 All Employees 1. Actively cooperate with the Trust in all matters of Health and Safety and proactively identify potential hazards to the Trust that may affect themselves or other building users. 2. When working with asbestos, comply with all relevant legislation, Trust policies and all Health and Safety procedures. 3. Refrain from any activities which may disturb known or suspected asbestos containing materials; access any previously inaccessible areas; undertake any refurbishment or demolition works prior to consultation with the Asbestos Coordinator. 4. Work together with the Trust to prevent the spread or exposure to asbestos. 5. To report any incidents of exposure to asbestos or risk of harm due to failing to follow this policy onto the Trust s incident reporting system (Ulysses) 7

8 4.8 Health and Safety The Health and Safety representative for the Trust is: Name: Head of Health, Safety and Security Number: Main Policy Content In order to ensure compliance with all relevant Health and Safety legislation regarding asbestos, on behalf of the Trust, the Associate Director of Estates and Facilities Management will be given the resources (time, staff and funds) to discharge the following duties. If not, details will be logged in the Trust Corporate Risk Register. 5.1 Provide all resources deemed necessary to manage the risk posed by asbestos, including the appointment of an Asbestos Co-ordinator. See Item Take reasonable steps to undertake an assessment of all its owned/controlled buildings, (and work together with any other nominated Duty Holder(s) with regard to asbestos, taking all relevant information into account. 5.3 Expect the cooperation of all employees, regular building users and contracted third parties in undertaking this assessment. 5.4 Implement systematic surveys to find and record the location and condition of known or suspected ACMs. 5.5 Undertake an assessment of the risk of all known or suspected ACMs on all its owned/controlled buildings, or co-operate with those undertaking such an assessment where the building is shared, let or rented. 5.6 Hold all conclusions and findings of all asbestos assessments, all surveys commissioned and all other relevant information in a central and accessible location. This information will be updated regularly and all updates recorded. 5.7 Undertake all necessary steps to ensure asbestos information is made available to all parties who may be affected by the presence of ACMs. 5.8 Ensure, as far as reasonably practicable, that anyone who may come into contact with known or suspected asbestos within any of its owned or controlled premises is made aware of all current information held regarding asbestos which may affect their activities. 5.9 Undertake the development of an Asbestos Management Plan which will be monitored, reviewed and revised regularly, and which will state what steps will be taken to manage the risk from known or suspected ACMs Undertake regular training of relevant managers and staff and inform third party contractors where necessary to ensure that information is effectively disseminated Develop, implement and monitor safe systems of work to protect the safety, health and welfare of employees, building users and third party contractors. 8

9 5.12 Provide appropriate precautionary health screening for relevant staff who may have come into contact with ACMs during the course of their work The following procedure should be followed whenever suspected ACMs are identified: Stop work immediately. Isolate the area, i.e. shut doors and windows etc. Post warning notices and inform people in the immediate area and request that everyone move away. Make contact with the Estates Helpdesk and Asbestos Coordinator for guidance and instruction. Appropriate risk assessments and control procedures shall be agreed following consultation with the Asbestos Coordinator and implemented to avoid exposure of ACMs to building users. Encapsulation, treatment or removal of the disturbed ACMs shall be carried out in accordance with current legislation before areas are re-occupied. In circumstances where a site is under control of a Principal Contractor and ACMs are discovered the procedures contained in the Health and Safety Plan should be followed and the Project Manager and Planning Supervisor informed as soon as practical. The following points should be noted: Do not allow works to continue on any materials which are suspected of containing asbestos If suspected ACMs have been damaged or disturbed during works in progress the materials should be left in-situ, the works suspended and the area isolated pending further investigation Do not attempt to take an unauthorised sample. This could expose the sampler to dangerous levels of fibres samples should only be taken under the supervision of the Principal Estates Manager and Specialist Advisor 6. Training Requirements 6.1 Any worker liable to disturb asbestos while performing their normal everyday work is required to be trained. Every employer must ensure that adequate information, instruction and training is given to those employees who are liable to be exposed to asbestos during the course of their work. There are three types of asbestos training: Awareness training Training for work with asbestos that does not require a licence from HSE Training for asbestos work that does require a licence from HSE. 6.2 The Asbestos Coordinator will ensure that all relevant personnel will undertake initial training and then annual refresher training to ensure they are kept updated on new developments in the management and control of asbestos to ensure competent performance of their specific duties. Attendance will be recorded and maintained ready for inspection if required. 9

10 7. Monitoring Compliance There are three essential steps to monitoring compliance of Asbestos: 7.1 Find out whether the premise contains asbestos, and, if so, where it is and what condition it is in. If in doubt, materials must be presumed to contain asbestos; Assess the risk; and make a plan to manage that risk and act on it. The below table details which elements require monitoring. Element to be monitored Lead Tool Frequency Reporting arrangements Asbestos Annual Risk Assessment Estates Compliance Officer External agency Assessors and Internal software programme Annually Reports from external company and software action plan Asbestos Register Estates Compliance Officer External agency Assessors and Internal software programme Annually Reports from external company and software action plan 8. Policy Review 8.1 This policy will be reviewed in 3 years 8.2 This policy will be reviewed by the Estates and Facilities Departmental Management Team meeting prior to presentation for ratification at the Health & Safety Forum 9. Associated Documents Trust Health and Safety Policy Health and Safety at Work Act, 1974 and the Control of Asbestos Regulations 2012 and all associated Approved Codes of Practice and is committed to the effective management of asbestos. 10. Supporting References Trust Health and Safety Policy Health and Safety at Work Act, 1974 Control of Asbestos Regulations 2012 and all associated Approved Codes of Practice 10

11 Appendix 1: LEaD (Leadership, Education & Development) Training Needs Analysis If there are any training implications in your policy, please complete the form below and make an appointment with the LEAD department (Deputy Head of LEAD or LEAD Strategic Education Lead) before the policy goes through the relevant Expert Committee. Directorate Division Target Audience Adult Mental Health MH/LD ICS Corporate Services Learning Disabilities Older Persons Mental Health Specialised Services TQtwentyone Adults Children s & Wellbeing Dental All (HR, Finance, Governance, Estates etc.) Asbestos awareness for all estates maintenance operatives and project officers followed by a bi annual refresher. Arranged in house by the. Non licensable work training course for emergency estates maintenance operatives selected. 11

12 Appendix 2: Equality Impact Analysis Screening Tool. Equality Impact Assessment (or Equality Analysis ) is a process of systematically analysing a new or existing policy/practice or service to identify what impact or likely impact it will have on protected groups. It involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of your functions, policies or decisions. The form is a written record that demonstrates that you have shown due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations with respect to the characteristics protected by equality law. For guidance and support in completing this form please contact a member of the Equality and Diversity team. Name of policy/service/project/plan: Policy Number: SH NCP 41 Department: Estate Services Lead officer for assessment: Date Assessment Carried Out: 31 st October Identify the aims of the policy and how it is implemented. Key questions Briefly describe purpose of the policy including: How the policy is delivered and by whom Intended outcomes Answers / Notes This sets out how Southern Health NHS Foundation Trust (the Trust) will comply with 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 (ACM s) 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 Policy requires 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. This policy is not applicable to social care supporting living services. Any concerns should be raised with the relevant Housing Provider and the Locality Manager. 12

13 2. Consideration of available data, research and information Monitoring data and other information involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of your functions, policies or decisions. It can help you to identify practical steps to tackle any negative effects or discrimination, to advance equality and to foster good relations. Please consider the availability of the following as potential sources: Demographic data and other statistics, including census findings Recent research findings (local and national) Results from consultation or engagement you have undertaken Service user monitoring data Information from relevant groups or agencies, for example trade unions and voluntary/community organisations Analysis of records of enquiries about your service, or complaints or compliments about them Recommendations of external inspections or audit reports Key questions Data, research and information that you can refer to 2.1 What is the equalities profile of the team delivering the N/a service/policy? 2.2 What equalities training have staff received? N/a 2.3 What is the equalities profile of service users? N/a 2.4 What other data do you have in terms of service users or staff? (e.g results of customer satisfaction surveys, consultation findings). Are there any gaps? N/a 2.5 What internal engagement or consultation has been undertaken as part of this EIA and with whom? N/a What were the results? Service users/carers/staff 2.6 What external engagement or consultation has been undertaken as part of this EIA and with whom? N/a What were the results? General Public/Commissioners/Local Authority/Voluntary Organisations In the table below, please describe how the proposals will have a positive impact on service users or staff. Please also record any potential negative impact on equality of opportunity for the target: In the case of negative impact, please indicate any measures planned to mitigate against this: 13

14 Positive impact (including examples of what the policy/service has done to promote equality) N/a Negative Impact Action Plan to address negative impact Actions to overcome problem/barrier Resources required Responsibility Target date Age Disability Gender Reassignment Marriage and Civil Partnership Pregnancy and Maternity Race Religion or Belief Sex Sexual Orientation 14