Asbestos Management Plan. Policy, Organisation and Arrangements V2.2

Transcription

1 Asbestos Management Plan Policy, Organisation and Arrangements V2.2 December 2015

2 Summary / Policy Statement The Royal Cornwall Hospitals NHS Trust is committed to meeting all the duties placed upon it under the Control of Asbestos Regulations 2012 and specifically will: Protect, so far as reasonably practicable, all staff, contractors and users of the Trusts properties from any exposure to asbestos fibres; Provide adequate resources to effectively deliver this Asbestos Management Plan; Identify, so far as reasonably practicable, all ACMs in the Trusts buildings; Maintain an asbestos register of ACMs identified and make it accessible to staff, contractors and any other party that undertakes work on Trust properties; Implement and maintain an effective Asbestos Management Plan (AMP) to ensure that all ACMs identified are maintained in a safe condition or alternatively are isolated or removed; Raise the understanding of the risks of ACMs, the Trusts AMP and the process and procedures for dealing with ACMs through training and ongoing awareness for relevant staff, contractors and any other interested party; Remove all asbestos from areas where major refurbishment is taking place; Appoint a competent and suitably qualified person to undertake the role of Asbestos Co-ordinator; Ensure that only appropriately trained, qualified and competent persons undertake work with ACMs; Review the Asbestos Management Plan on an annual basis or more frequently if required. Page 2 of 23

3 Table of Contents Summary / Policy Statement Introduction Purpose of this Policy/Procedure Scope Policy Statement Ownership and Responsibilities Chief Executive is responsible for: Director of Estates is responsible for: Head of Estate Operations (Appointed Person) is responsible for: Other Directors and Managers are responsible for: Asbestos Coordinator is responsible for: Business Manager Estates Department is responsible for: Maintenance Team Manager Estates Department is responsible for: Maintenance Staff are responsible for: All other staff are responsible for: Contractors are responsible for: Health and Safety Manager is responsible for: Project Managers, Contract Managers and Contract Administrators are responsible for: Standards and Practice Asbestos Management Plan Identification and recording of asbestos containing materials Role and responsibilities Types of Survey undertaken Intrusive works The Asbestos Register Assessing and managing risk Dissemination and Implementation Monitoring compliance and effectiveness Updating and Review Appendix 1. Governance Information Appendix 2. Initial Equality Impact Assessment Form Page 3 of 23

4 1. Introduction 1.1. This document, the Asbestos Management Plan (AMP), sets out the Royal Cornwall Hospitals NHS Trusts policy organisation and arrangements for managing the risks from Asbestos Containing Materials (ACMs) in all of its premises This version supersedes any previous versions of this document. 2. Purpose of this Policy/Procedure 2.1. This document details the steps that will be taken by the Trust to ensure that the risk from known or suspected Asbestos Containing Materials (ACMs) within Trust owned or controlled buildings is managed in accordance with the Control of Asbestos Regulations (2012), and that so far as reasonably practicable no one can come to any harm from asbestos Some buildings owned or occupied by the Trust were built or refurbished at a time when the use of ACMs in construction was common. This Plan is designed to effectively manage and minimise asbestos health risks to staff and other persons working in or using the Trusts premises. 3. Scope 3.1. The Policy and Plan apply to all Trust employees and contractors across all Trust properties. 4. Policy Statement The Royal Cornwall Hospitals NHS Trust is committed to meeting all the duties placed upon it under the Control of Asbestos Regulations 2012 and specifically will: 4.1. Protect, so far as reasonably practicable, all staff, contractors and users of the Trusts properties from any exposure to asbestos fibres; 4.2. Provide adequate resources to effectively deliver this Asbestos Management Plan; 4.3. Identify, so far as reasonably practicable, all ACMs in the Trusts buildings; 4.4. Maintain an asbestos register of ACMs identified and make it accessible to staff, contractors and any other party that undertakes work on Trust properties; Page 4 of 23

5 4.5. Implement and maintain an effective Asbestos Management Plan (AMP) to ensure that all ACMs identified are maintained in a safe condition or alternatively are isolated or removed; 4.6. Raise the understanding of the risks of ACMs, the Trusts AMP and the process and procedures for dealing with ACMs through training and ongoing awareness for relevant staff, contractors and any other interested party; 4.7. Remove all asbestos from areas where major refurbishment is taking place; 4.8. Appoint a competent and suitably qualified person to undertake the role of Asbestos Co-ordinator; 4.9. Ensure that only appropriately trained, qualified and competent persons undertake work with ACMs; Review the Asbestos Management Plan on an annual basis or more frequently if required. Page 5 of 23

6 5. Ownership and Responsibilities 5.1. The successful delivery of the Asbestos Management Plan (AMP) is dependent on clear accountability for delivering key tasks. Figure 1, sets out they key roles and responsibilities for delivering the AMP within the Trust. Chief Executive Officer Director of Estates Head of Estates Health & Safety Manager Responsible Staff Project Managers Maintentance Team Manager Craftspersons Asbestos Co-ordinator Figure 1- AMP Organisation Chart 5.2. Chief Executive is responsible for: The health, safety and welfare of staff and others effected by the work activities of the Trust; The effective implementation of health and safety management policies and arrangements; As Duty Holder, ensuring that the Trusts responsibility under CAR 2012 is effectively resourced, delivered and monitored. Delegating the delivery of the Trusts responsibility under CAR 2012 to an Appointed Person. See Paragraph 3.6.1, Levels of training and competency for Trust staff and contractors for training requirements. Ensure sufficient resources are made available to safely manage, repair or remove the asbestos on site to meeting CAR Page 6 of 23

7 5.3. Director of Estates is responsible for: The Director of Estates will retain ownership and accountability for all works involving any amendments to any aspect of the physical estates or infrastructure, including external areas, utilities and services. Keeping the Trust Board informed of any risks to compliance, concerns or incidents in relation to the management of asbestos. Ensuring that sufficient resources are made available for the completion of work related to the management of asbestos in a timely manner Head of Estate Operations (Appointed Person) is responsible for: Compiling and maintaining an effective Asbestos Management Plan and ensuring Trust compliance with the Plan; Management of Capital and Revenue budgets for the effective delivery of the AMP; Appointing an Asbestos Co-ordinator; See Paragraph 3.6.1, Levels of training and competency for Trust staff and contractors for training requirements Other Directors and Managers are responsible for: Complying with this AMP; Ensure that staff and contractors that work under their control are aware of and deliver works in compliance with the AMP and are adequately trained and competent to undertake works where ACMs may be present; See Paragraph 3.6.1, Levels of training and competency for Trust staff and contractors for training requirements Asbestos Coordinator is responsible for: Providing competent and professional advice on the management of ACMs to those with a responsibility under this Plan; Compiling and maintaining the Asbestos Register for all Trust premises; Ensuring that regular inspections of ACMs are undertaken and updating the Asbestos Register to reflect the current condition; Programming surveys in Trust premises to identify any ACMs that may be present and updating the Asbestos Register; Ensuring that the Asbestos Register is updated to record any removal or changes in conditions of ACMs. Ensuring that all records of ACMs include a Material Risk Assessment in accordance with HSG 227 A Comprehensive Guide to Managing Asbestos in Premises ; Regularly reviewing the risks from all known ACMs and making recommendations to the Appointed Person; Page 7 of 23

8 Reviewing and updating this AMP in consultation with the Appointed Person; Promoting awareness of the hazards of ACMs and the AMP throughout the Trust by advising on and facilitating the provision of appropriate training and induction to Trust staff as required and in particular to those whose work might bring them into contact with ACMs; Managing the Trusts asbestos communications strategy including asbestos labelling strategy for the Trust; Reporting any incidents of alleged asbestos exposure to the Health and Safety Manager and assisting with any investigation; Assisting the Health and Safety Manager in liaising with the Health and Safety Executive; Attending is in accordance with the Emergency Action Plan Accidental Release of Asbestos (paragraph 3.4.4); Maintaining their professional competence and awareness of changes in relevant regulatory controls, codes of practices and guidance on good practice; See Paragraph 3.6.1, Levels of training and competency for Trust staff and contractors for training requirements Business Manager Estates Department is responsible for: Maintenance and development of the electronic asbestos management system (Micad); Management of and adherence to the asbestos data management protocol; See Paragraph 3.6.1, Levels of training and competency for Trust staff and contractors for training requirements Maintenance Team Manager Estates Department is responsible for: Responsible for ensuring that all direct employed labour has suitable awareness of asbestos. Ensure that all direct improved labour checks the asbestos register prior to commencing works Ensure compliance with this policy by the direct employed labour Maintenance Staff are responsible for: Checking the Asbestos Register before undertaking any work in Trust properties; Notifying the Authorised Person immediately and stopping work if they encounter damaged or disturbed known or suspected ACMs; See Paragraph 3.6.1, Levels of training and competency for Trust staff and contractors for training requirements. Page 8 of 23

9 5.10. All other staff are responsible for: Being aware of the risk of asbestos within the Trusts properties and taking all necessary steps to safeguard their health and the health of others; See Paragraph 3.6.1, Levels of training and competency for Trust staff and contractors for training requirements Contractors are responsible for: Ensuring that any employee or sub-contractor that undertakes work on Trust property has received asbestos training to a level that is commensurate with the works being undertaken and the environment in which that works is taking place (as a minimum all employees or sub-contractor employees to receive Asbestos Awareness training); Checking the Asbestos Register before undertaking any work in Trust properties; Not undertaking any work which may disturb known or suspected ACMs; Notifying the Authorised Person immediately and stopping work if they encounter damaged or disturbed known or suspected ACMs; Complying with this AMP; See Paragraph 3.6.1, Levels of training and competency for Trust staff and contractors for training requirements Health and Safety Manager is responsible for: Periodically auditing compliance with this AMP; In conjunction with the Authorised Person investigating and reporting on any alleged incident or accidental asbestos exposure and for ensuring the reporting under RIDDOR, where appropriate. See Paragraph 3.6.1, Levels of training and competency for Trust staff and contractors for training requirements Project Managers, Contract Managers and Contract Administrators are responsible for: Ensuring that the risk of asbestos on the site is brought to the attention of the contractors formally, and that the contractors abide by this policy and statutory requirements relating to asbestos. Ensure that contractors are suitably competent to carry out the works in relation to asbestos. Ensure that method statement, risk assessments are supplied which are both suitable and appropriate for the works to be undertaken. Ensure there is sufficient information available for the works being undertaken including Demolition & Refurbishment survey when necessary. Page 9 of 23

10 Ensure the contractors are following the agreed method statement and risk assessments, and are remaining within the area for which the extent of the asbestos has been established via a Demolition & Refurbishment survey. Ensure that only licensed contractors are used for work on asbestos materials. 6. Standards and Practice 6.1. Asbestos Management Plan This Plan sets out the organisation and arrangements by which ACMs are to be managed. It details how the Trust will protect staff, contractors who work on Trust properties as well as users of our services and visitors from exposure to asbestos Legal Framework The Control of Asbestos Regulations (CAR) 2012 places a specific duty to manage asbestos on the owners and/or those responsible for maintenance in non-domestic premises. The Regulations place minimum standards for the protection of employees from risks related to exposure to asbestos. In addition, it places a duty on employers to take account of people not directly employed by them, but who could be affected by the work being done on asbestos, (including employees of other employers, people occupying buildings, members of the public etc) This Plan is intended to enable compliance with all aspects of the requirements of CAR 2012 and other relevant legislation; the following duties within CAR 2012 are highlighted as being fundamental to the effective delivery of the asbestos management system: Regulation 4 - requires Duty Holders to: Find ACMs and check their condition; Presume that materials contain asbestos unless there is strong evidence to suppose they do not; Keep an up-to-date written record of the location and condition of ACMs Assess the risk of anyone being exposed to these materials Prepare and put into effect a management plan to manage the risk and keep ACMs in a good state of repair, or ensure that it is repaired or if necessary removed Provide information on the location and condition of the material to anyone potentially at risk Regulation 5 - Identification of the presence of asbestos states: An employer shall not undertake work in demolition, maintenance, or any other work which exposes or is liable to expose his employees to asbestos unless either: He has carried out a suitable and sufficient assessment as to whether asbestos is liable to be present Page 10 of 23

11 If there is doubt, assumes that asbestos is present Regulation 10 - requires employers to: Ensure that adequate information, instruction and training is given to employees who are liable to disturb asbestos while carrying out their normal everyday work, or who may influence how work is carried out Identification and recording of asbestos containing materials In order to manage the risk from asbestos the Trust will ensure that a suitable and sufficient assessment is carried out as to whether asbestos is present within the Trusts buildings. This requirement is valid for any property built before the end of Role and responsibilities The Asbestos Coordinator is responsible for coordinating the commissioning of all surveys. All surveys undertaken will be undertaken in line with HSG 264 Asbestos The Survey Guide The Asbestos Coordinator is responsible for ensuring that information from all surveys undertaken is held on the Asbestos Register. Original copies of the surveys will be held by the Asbestos Coordinator. The Business Manager (Estates Department) is responsible for updating the electronic Asbestos Register (managed through Micad) 6.4. Types of Survey undertaken Management Survey its purpose is to locate, as far as reasonably practical, the presence and extent of any ACMs in a building which could be damaged or disturbed during normal occupancy and to assess their condition. The survey will only involve minor intrusive work but this will involve inspection of false ceilings and inside risers, service ducts, lift shafts etc. Where an area is inaccessible, it may involve presuming the presence of ACMs. A Management Survey has been completed and forms the base information for the Asbestos Register. Re-inspections are undertaken every twelve months; the purpose of the re-inspection is to assess the condition of the ACMs and amend the risk register accordingly Refurbishment and Demolition Survey will be undertaken prior to any refurbishment or demolition work being carried out. This type of survey is intrusive and is used to locate and describe, as far as reasonably practicable, all ACMs in the area where the work is being carried out or in the whole building if demolition is planned Intrusive works Where the Trust is undertaking intrusive works including demolition or breaking out, forming openings (of any size) in walls, floors and ceilings, opening up of ducts, boxing or voids, lifting of covers etc, it will undertake a suitable and sufficient assessment as to whether asbestos is likely to be present. A Management Survey is unlikely to provide sufficient information to satisfy this requirement, particularly where intrusive works are planned. Page 11 of 23

12 Where any intrusive work is planned in a building constructed before the year 2000, the Asbestos Co-ordinator must be consulted. The Asbestos Co-ordinator will assess the quality and the extent of the information available and decide whether it is suitable and sufficient to permit the proposed work to proceed. Where the Asbestos Co-ordinator deems it is not sufficient further survey work must be commissioned The Asbestos Register The Asbestos Register records known and suspected ACMs in the Trusts buildings. Where ACMs are recorded, as a minimum it will record the following information: Location; Material type; Asbestos type; Extent of damage; Surface treatment; Management status; Date of inspection; Name of the person inspecting; Date of next inspection Updating the Register Any updating of the Register will be authorised by the Asbestos Coordinator. Updates will be made following: Re-inspection of the ACM; Removal, repair or encapsulation of the ACM; Identification of further ACMs or following sampling of non ACMs; New management surveys; New refurbishment and demolition surveys; Changes in building layout or area use Storage and availability of the Asbestos Register The Asbestos Register is stored on the Trusts Micad system. Read-only access is available to all authorised Trust staff through the Asbestos Portal. Access is available to authorised external contractors and consultants through the Trust s Micad Information Portal Assessing and managing risk Management Strategy Where ACMs are in a safe condition and unlikely to be disturbed they will be left in situ. They will be inspected regularly at intervals determined by the Asbestos Coordinator. This will typically be every twelve months but may be less or more based upon risk assessment Assessment and action priorities Page 12 of 23

13 All ACMs are subject to a material risk assessment in accordance with HSG264. This is the primary guide in assessing priority action. The algorithm within the risk assessment assesses the likelihood of an ACM releasing fibres if it is disturbed. Scores and associated risks are set out in Table 1 below. Material Score Implications A high risk with a significant potential to release fibres 7 9 Medium risk 5-6 Low risk < 4 Very low risk Table1 ACM risk assessment Taking action Remedial action will be taken is based on two criteria: 1. Essential actions to stop exposure; and 2. The agreed management, remediation and removal programme which has been developed in line with this Policy and Plan Areas of minor damage will be repaired and sealed. Where effective repair cannot be achieved, ACMs will be removed. The decision to instigate remedial action is at the direction of the Head of Estates Removing and remediating asbestos Work involving the repair, encapsulation or removal of asbestos will only be carried out by the Trusts approved HSE Licensed Asbestos Contractors (LARC). The appointment of the LARC will generally be made directly but may be made through a principal contractor when agreed by the Asbestos Coordinator. Where scaffold is required, only organisations who are registered on the HSE Register of Asbestos Licensed Scaffolders will be used Air monitoring and four stage clearance certification Where air monitoring and four stage clearance certification is required, this may only be carried out by one of the Trusts approved asbestos consultants. The consultant must be accredited to BS The consultant will be appointed by the Trust without exception. (Annex B Procedure for Assessing and Managing Suspect ACM) Emergency Action Accidental release of asbestos Following the discovery of significant damage of suspected or known ACMs or where accidental damage has been caused in the course of a work activity, the following actions will be undertaken: The senior Site Manager will take control of the situation. Work must cease immediately. No effort should be made to clean up; The Site Manager should immediately notify the Asbestos Co-ordinator; Page 13 of 23

14 The Site Manager should arrange to clear the immediate area of all staff and contractors, taking names and contact details. Staff and contractors who have been exposed to asbestos fibres should be held in a designated area in order to allow an assessment of potential contamination; As soon as practical the Site Manager should inform the relevant Trust staff; The designated asbestos consultant will access the area in appropriate PPE/RPE and assess the situation. Where the Asbestos Co-ordinator is unable to confirm or dismiss the presence of asbestos, samples will be taken for analysis; The material shall be presumed to be asbestos and the area will be adequately sealed until such time as results to the contrary have been received. Air tests will be run; If ACMs are confirmed the Asbestos Co-ordinator will instigate remedial action in accordance with this AMP and Trust procedures; The Asbestos Co-ordinator will investigate the matter with the Health and Safety Manager. The report will include recommendations on whether the incident should be classed as a dangerous occurrence. If this is the case it will be notified to the Health and safety Executive under the Reporting of Injuries, Disease and Dangerous Occurrences Regulations (RIDDOR) 1995; The Appointed Person will make arrangements to inform all persons who might have been exposed to the uncontrolled release of asbestos of their potential exposure. (Annex A Emergency Action Procedure) Page 14 of 23

15 7. Dissemination and Implementation 7.1. Good communication about where ACMs are within Trust properties and the AMP and systems and procedures for managing them correctly is central to the safety of staff, contractors and users of our services. The key communication tools are: The Asbestos Management Plan (AMP) The AMP is made widely available to staff, representatives, contractors and the emergency services The Asbestos Register and the Micad System The core communications tool is the Asbestos Register. The Trust has developed an electronic version of this which is available to Maintenance Staff. The Asbestos Register (either in hard copy form or through Micad) is available to all staff and contractors who work in or on the Trust properties. The register must be reviewed prior to any work being undertaken Labelling ACMs Labelling is an important communications tool, if managed sensitively and constructively, it can form an important part of a broad communication and education programme Asbestos labels or appropriate signage are used to signify where ACMs are considered to be a significant risk where the Asbestos Coordinator deems it to be: A help in preventing accidental damage, and It will not cause undue concern Areas where ACMs will be labelled include: Areas only likely to be accessed by maintenance operatives and contractors such as boiler and plant rooms, loft space, ceiling voids and ducts etc; Areas where it is considered that there is a higher than usual risk of the ACM releasing fibres if disturbed e.g. sprayed materials; Areas where it is considered that there is a higher than usual risk of ACMs being disturbed such as a lining of a column in a high traffic area Lower risk materials such as floor tiles, textured coatings and cement materials will not be routinely labelled but adequate steps will be taken to raise awareness of their presence. Page 15 of 23

16 Information, instruction and training The Trust recognises that adequate information, instruction and training for staff and contractors working in the Trusts properties is essential for the safe management of asbestos. The Trust specifies the levels of training and competence for specific tasks and provides training directly to its own staff and specifies levels of competency related to tasks for contractors and other service providers Levels of training and competency for Trust staff and contractors Training is delivered in accordance with need. All training is to be recorded Directors and Managers All Directors and Managers who have a responsibility for staff who undertake work that is likely impact on ACMs will attend an annual Asbestos Awareness course Asbestos Coordinator As the competent person, the Asbestos Coordinator will be qualified to P405 (Management of Asbestos in Buildings) and will attend further courses as required to remain up to date with current legislation, best practice and any other matter that will maintain his competence Maintenance staff and project managers Asbestos training is mandatory for all staff who may come into contact with asbestos in the course of their work. In particular, it will be given to all workers involved in demolition, refurbishment, maintenance, IT and related trades where it is foreseeable that their work will disturb the fabric of the building because ACMs may become exposed during their work. Exemption from this requirement will only apply when the Trust can demonstrate that work will only be carried out in or on buildings that are free from ACMs. Training will be given annually and reflect the AMP requirements and management system employed by the Trust Staff who administer asbestos related works Staff who are involved in the administration of works that is likely to involved work on ACMs will be given annual asbestos refresher training. The training will reflect their role in delivering AMP requirements and the management system as it relates specifically to their responsibilities. Training will be given annually or when significant changes are made to the relevant duties under the AMP. Page 16 of 23

17 All other staff All Trust staff will receive an asbestos awareness module as part of their core Induction training Levels of training and competence for consultants and contractors The Trust will not allow any contractor or consultant to work on its properties unless they can demonstrate a level of asbestos competence and training that is commensurate with the work task being undertaken. An assessment of staff competence is a pre-requisite of being approved as a contractor to deliver services to the Trust. As a minimum, contractors and consultants working in Trust properties built before 2000 must have received asbestos awareness training as specified in the CAR 2012 Approved Code of Practice and guidance (Managing and Working with Asbestos) Site Induction Ongoing Maintenance Tasks All contractors personnel delivering ongoing maintenance tasks must undertake a full Maintenance Induction which will include details of the AMP requirements and management system employed by the Trust and information as to how to access the asbestos register. All contractors staff will receive refresher training on an annual basis Site Induction Project Work Contractors and consultants personnel working on project work, must receive a site specific induction (delivered by the Contractor or the Asbestos Co-ordinator, this is subject to the agreement of the Asbestos Co-ordinator prior to the project commencing). Page 17 of 23

18 8. Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Compliance with the policy Asbestos Co-Ordinator for Estates MiCAD asbestos module and permits to penetrate. Quarterly Reported to the Estates Board, with exception reports to the H&S Committee through the Estates Directorate 6 monthly report. Head of Estates Operations will be responsible for ensuring all actions are completed, and will report to the Estates Board as required. Changes to practice will be made based on findings and recommendations in relation to the Control of Asbestos Regulations This will be implemented using formal training sessions within one month of the changes where practicable. 9. Updating and Review 9.1. The Trust will review the AMP at regular intervals in order to ensure that the Plan remains relevant and effective. The review will be undertaken by the Asbestos Coordinator in consultation with Head of Estates Services and the Health and Safety Manager. The review is to assess the effectiveness of the AMP in the following key areas: Organisational Responsibilities; Identification and recording of asbestos containing materials; Assessing and managing risk; Communication; Risk assessment and method statements; Information, instruction and training The review will be carried out annually or sooner if in response to: A significant incident involving an uncontrolled release of asbestos fibres; A change in the Control of Asbestos Regulations; If the AMP is no longer considered adequate Monitoring The Health and Safety Manager will periodically audit compliance with this AMP across the Trust Departments. The audit programme will be agreed on an annual basis but will be flexible in order to react to areas of concern as they arise. Page 18 of 23

19 10. Equality and Diversity 10.1.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 Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 19 of 23

20 Appendix 1. Governance Information Document Title Asbestos Management Policy and Plan Date Issued/Approved: December 2016 Date Valid From: 1 st January 2016 Date Valid To: 1 st December 2018 Directorate / Department responsible (author/owner): Anthony Ayers, Estates Officer Contact details: Brief summary of contents Suggested Keywords: Target Audience Executive Director responsible for Policy: Date revised: This document replaces (exact title of previous version): Approval route (names of committees)/consultation: This document details the steps that will be taken by the Trust to ensure that the risk from known or suspected Asbestos Containing Materials (ACMs) within Trust owned or controlled buildings is managed in accordance with the Control of Asbestos Regulations (2012), and that so far as reasonably practicable no one can come to any harm from asbestos. Asbestos, Health & Safety, Estates, Occupational Health, Project Management, Contractors, COSHH RCHT PCH CFT KCCG Director of Estates Asbestos Policy Health & Safety Committee 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 Head of Estate Operations Not Required {Original Copy Signed} Name: Phil Bond {Original Copy Signed} Page 20 of 23

21 Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Links to key external standards Related Documents: Training Need Identified? Internet & Intranet Intranet Only Estates / Health & Safety Control of Asbestos Regulations 2012 HSE Asbestos Guidance Health & Safety General Policy Management of Contractors Policy Site Rules Yes Version Control Table Date Version No. Summary of Changes April 2011 V1.0 First Draft May 2011 V1.0 Consultation with HSC members 1 June June March 2013 V2.0 Revised policy in accordance with implementation of the Control of Asbestos Regulations V2.0 Consultation with HSC Members V2.1 Minor revisions, consultation with HSC Changes Made by (Name and Job Title) J Robin Gatenby Health and Safety Advisor (Interim) J Robin Gatenby Health and Safety Advisor (Interim) J Robin Gatenby Health and Safety Manager J Robin Gatenby Health and Safety Manager J Robin Gatenby Health and Safety Manager Dec 2015 V2.2 Rewritten and updated Anthony Ayers, Estates Officer 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 21 of 23

22 Appendix 2. Initial Equality Impact Assessment Form Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description): Asbestos Policy Directorate and service area: Is this a new or existing Policy? Existing Estates Name of individual completing Telephone: assessment: Phil Bond 1. Policy Aim* All Staff Who is the strategy / policy / proposal / service function aimed at? 2. Policy Objectives* To manage asbestos across the Trust 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? Ensure that there is no unintended exposure to Asbestos Containing Materials Reported incidents All Staff, visitors, patients and contractors No b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure. 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 X Sex (male, female, transgender / gender reassignment) X Page 22 of 23

23 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 X X X X X Sexual Orientation, X 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 X 9. If you are not recommending a Full Impact assessment please explain why. Signature of policy developer / lead manager / director Anthony Ayers Date of completion and submission 26 th January 2016 Names and signatures of members carrying out the Screening Assessment 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 23 of 23