SCHOOL OF MEDICINE OCCUPATIONAL SAFETY, HEALTH AND ENVIRONMENT POLICY ( )

Transcription

1 SCHOOL OF MEDICINE OCCUPATIONAL SAFETY, HEALTH AND ENVIRONMENT POLICY ( ) Author(s) Karl Hanzel Policy v.1.1 Prof. B. Paul Morgan Date 19 th June 2011 Approved by (archived) Area Applicable School of Medicine Review date November 2011 Policy v.1.2 Approved by Prof. B. Paul Morgan Date 21 st Nov 2011 Area Applicable School of Medicine Review date December 2011 Page 1 of 48

2 Table of Contents 1. COMMITMENT TO SAFETY, HEALTH AND THE ENVIRONMENT MANAGEMENT OUTLINE 6 2. ORGANISATION THE HEAD OF SCHOOL RESPONSIBILITIES: INSTITUTE DIRECTORS (FORMERLY HEAD OF DEPARTMENT) RESPONSIBILITIES: TEACHING STAFF RESPONSIBILITIES: RESEARCH STAFF (PRINCIPAL INVESTIGATORS) RESPONSIBILITIES: ALL SCHOOL PERSONNEL RESPONSIBILITIES: ARRANGEMENTS WITHIN THE SCHOOL OF MEDICINE SAFETY, HEALTH AND ENVIRONMENT COMMITTEE SAFETY, HEALTH AND ENVIRONMENTAL TRAINING RISK ASSESSMENT CODES OF PRACTICE AND APPROVED PROCEDURES FIRE SAFETY MANAGEMENT FIRE RISK ASSESSMENTS SAFETY, HEALTH AND ENVIRONMENT PANELS SAFETY REPRESENTATIVES INSTITUTE SAFETY OFFICER ECO CHAMPIONS RADIATION PROTECTION SUPERVISORS (RPS) 14 Page 2 of 48

3 3.12 BIOLOGICAL SAFETY OFFICER (BSO) FIRE WARDENS DISPLAY SCREEN EQUIPMENT ASSESSORS (DSE) FIRST AIDERS OCCUPATIONAL HYGIENE CARDIFF UNIVERSITY ESTATE WATER HYGIENE TRANSPORT REDUCTION IN ENERGY AND NATURAL RESOURCE USE CONTROL OF WASTES EXPLOSIVE / FLAMMABLE ATMOSPHERES SAFETY PROCEDURE - PERMITS TO WORK PROCUREMENT OCCUPATIONAL HEALTH ACCIDENT PROCEDURES INCIDENT INVESTIGATION OUT-OF-HOURS WORKING 20 SCHOOL OF MEDICINE, CARDIFF UNIVERSITY 22 TERMS OF OCCUPANCY (SCHOOL OF MEDICINE BUILDINGS) 22 APPENDIX 2 25 SCHOOL OF MEDICINE 25 SAFETY, HEALTH AND ENVIRONMENT COMMITTEE (SOMSHEC) 25 MEMBERSHIP 25 Page 3 of 48

4 APPENDIX 3 26 THE ROLE OF THE BIOLOGICAL SAFETY OFFICER 26 APPENDIX 4 28 ARRANGEMENTS WITHIN THE SCHOOL OF MEDICINE FOR PROVISION OF 28 INSTITUTE/BUILDING SAFETY OFFICERS (ISOS) 28 APPENDIX 5 30 THE ROLE OF THE ECO-CHAMPION 30 APPENDIX 6 31 THE ROLE OF THE FIRE WARDEN 31 APPENDIX 7 32 THE ROLE OF THE FIRST AIDER 32 APPENDIX 8 33 SECURITY AND PORTERING SERVICES 33 APPENDIX 9 35 BRIEFING DOCUMENTS 35 APPENDIX HEALTH AND SAFETY RESPONSIBILITIES OF SUPERVISORS TOWARDS UNDERGRADUATE AND POST GRADUATE STUDENTS 37 SCHOOL OF MEDICINE: HEALTH, SAFETY AND ENVIRONMENT MANAGEMENT STRUCTURE 39 SCHOOL OF MEDICINE: ADMINISTRATIVE DEPARTMENTAL, INSTITUTIONAL STRUCTURE 40 MEDIC HEAD OF SCHOOL ACTION PLAN OCTOBER SCHOOL SHE OBJECTIVES (ADDENDUM TO MEDIC HOS ACTION PLAN) 46 Page 4 of 48

5 SCHOOL OF MEDICINE OCCUPATIONAL SAFETY, HEALTH AND ENVIRONMENT POLICY 1. Commitment to Safety, Health and the Environment The School of Medicine (hereafter referred to as the School ) recognises that the health and safety of its students and staff, which it considers to be its most valued and valuable resource, and protection of the environment, are of primary importance. Furthermore the School recognises that it must aim to ensure that its work does not adversely affect the health and safety of patients, visitors and the general public. Therefore, the School has established detailed mechanisms to achieve its commitment to: (i) Maintenance and continual improvement, as far as is reasonably practicable, of a safe and healthy working environment for all staff, students and visitors and to strive for continual improvement in environmental performance in all its operations through meeting or exceeding common and statutory safety, health and environmental requirements. (ii) Maintenance and continual improvement of a safety, health and environmental culture in which safety, health and environmental objectives are regarded by staff and students at all levels as aligned with its goal of being a world leading university. To achieve its goals the School has established detailed mechanisms for providing information, training and advice about the various potential hazards which are likely to be encountered for monitoring and the maintenance of its high safety, health and environmental standards and for regular consultation between the School and representatives of its staff and students on health, safety and environmental matters. Furthermore, the School will provide appropriate safety, health and environmental information for interested parties, contractors and others, who work within it, handle its products or operate its technologies. In addition, through these mechanisms, the School will remind staff and students at all levels that they have an individual duty to take reasonable care for their own health and safety and for that of other persons who might be affected by their actions (or lack of them); they must co-operate with the School in meeting its statutory and other requirements and; cooperate with those persons who are responsible for health, safety and the environment so as to enable them to carry out their duties. Page 5 of 48

6 1.1 Management Outline The School recognises that the reduction and elimination of the causes of accidents and incidents and the reduction of the School environmental impact requires effective management and competent staff at all levels, which will ensure that hazards are identified, effective control measures are implemented and environmental matters are addressed. The development and implementation of health and safety policies can only be effected through delegated lines of authority, therefore, the management of safety, health and environment will be based on a safety, health and environmental policy, the responsibility for which rests with the Head of School (HoS) who must ensure compliance with the University s obligations to provide a healthy and safe environment for staff and other persons in, or affected by, the School. Operational responsibility for health and safety matters has been delegated in the newly formulated School structure to the Institute Directors. The School will monitor its safety, health and environmental performance through a process of audit and inspection and will seek to promote continual improvement through appropriate training of staff at all levels, consideration of new, safer and more environmentally sustainable technologies and setting of challenging safety, health and environmental objectives. This statement of intent, and the organisation and arrangements as described within the remainder of this document constitute the formal safety, health and environmental policy of the School, with which all staff and visitors are expected to comply. Professor B. Paul Morgan Dean and Head of School of Medicine Date Page 6 of 48

7 SCHOOL OF MEDICINE OCCUPATIONAL SAFETY, HEALTH AND ENVIRONMENT MANAGEMENT ARRANGEMENTS 1. OCCUPATIONAL SAFETY, HEALTH AND MANAGEMENT OBJECTIVES Cardiff University School of Medicine will strive to: (i) (ii) Maintain and continually improve, as far as is reasonably practicable, of a safe and healthy working environment for all staff, students and visitors and to strive for continual improvement in environmental performance in all its operations through meeting or exceeding common and statutory safety, health and environmental requirements. Maintain and continually improve a safety, health and environmental culture in which safety, health and environmental objectives are regarded by staff and students at all levels as aligned with its goal of being a World leading university. 2. ORGANISATION 2.1 As the employing body, the University Council bears ultimate responsibility for the health and safety of persons at the University and for those who might be affected by the activities of the University. In practice, Council has delegated the authority for ensuring compliance with its obligations to the Vice-Chancellor. The Vice-Chancellor has further delegated authority to the Heads of Schools (HoS) and to the administrative Directors and this is consistent with the delegation of other responsibilities within the University. The lines of responsibility for Occupational Safety, Health and Environment are, therefore, as follows: The Head of School responsibilities: The School's Occupational Safety, Health and Environment Policy Protecting the safety and health of personnel within their School Promoting the importance of safety, health and environment amongst their students and staff Page 7 of 48

8 Ensuring that the organisational structure within the School is appropriate to manage safety, health and environment Ensuring that adequate resources are provided to meet safety, health and environment requirements Ensuring that adequate communication and consultation channels are present so that all managers are made aware of changes which may affect them and of any other relevant safety, health and environmental requirements Ensuring that adequate communication channels are present so that relevant safety, health and environmental issues are brought to the attention of senior management Ensuring the suitable training, instruction and supervision 1 for all students and staff so that they can competently carry out their safety, health and environmental responsibilities Ensuring that relevant University Policies are implemented Developing School safety, health and environmental objectives Ensuring that effective contingency arrangements are in place to control potentially serious hazards or imminent danger Ensuring that the same management standard is applied to safety, health and environment as to other management functions Ensuring that accidents and ill-health due to work which involve School students and staff are investigated and any rectifying action that is identified is taken Ensuring that suitable and sufficient control measures are in place to mitigate any foreseeable hazards Reviewing School safety, health and environmental performance Ensuring that health, safety and environmental monitoring is carried out at recommended frequencies Ensuring that a safe means of access and egress to the place of work is provided Ensuring the prompt return of the annual Health and Safety Reports Ensuring that there is provision of emergency procedures within the School and ensuring that personnel comply with the procedures 1 See Appendix 10 Page 8 of 48

9 2.1.2 Institute Directors 2 (formerly Head of Department) responsibilities: Ensuring suitable and sufficient risk assessments are undertaken, reviewed and communicated to all interested parties Ensuring that personnel in their Institute have adequate instruction, training and supervision Ensuring that relevant University rules, policies and procedures are adhered to Demonstrating their personal commitment to safety, health and environment through adoption of best practice and encouraging those whom they manage to do the same The preparation of safe systems of work Ensuring adherence to the School of Medicine Terms of Occupancy (see Appendix 1) Teaching Staff responsibilities: Ensuring that students are evacuated promptly from teaching areas in the case of emergency evacuations using the appropriate routes Ensuring suitable and sufficient risk assessments are undertaken, reviewed and communicated to all interested parties Demonstrating their personal commitment to safety, health and environment through adoption of best practice and encouraging those whom they supervise to do the same (see Appendix 10) Research Staff (Principal Investigators) responsibilities: Ensuring that students and junior colleagues are evacuated promptly from research areas in the case of emergency evacuations using the appropriate routes The preparation of safe systems of work Ensuring suitable and sufficient risk assessments are undertaken, reviewed and communicated to all interested parties Ensuring that students and staff under their supervision have adequate instruction, training and supervision (see Appendix 10) Demonstrating their personal commitment to safety, health and environment through adoption of best practice and encouraging those whom they supervise to do the same 2 The Head of Department role will be superseded by the establishment of the New Institute Directors (June 2011). The Institute Director will have overall Safety, Health and Environmental responsibility for their respective Institute Page 9 of 48

10 2.1.5 All School personnel responsibilities: Complying and co-operating with safety, health and environmental rules, policies and procedures Ensuring that they do not interfere, change or compromise anything put in place for safety, health and environment Their own safety and health and those who may be affected by their actions / inaction Promptly informing management of any work situation that may compromise safety, health and environment Ensuring that their day-to-day work processes have as little environmental impact as possible Fully appreciating the hazards encountered within their work processes through understanding of the associated risk assessments 3. ARRANGEMENTS WITHIN THE SCHOOL OF MEDICINE 3.1 Safety, Health and Environment Committee The School has a recognised committee that is dedicated to the strategic management of safety, health and environment across the School. The size and composition of the committee is appropriate to the School and it is chaired by the Head of School (or nominee). Through the committee structure, management of safety, health and environmental issues is reviewed; dissemination of relevant safety, health and environmental information is conducted; and broad safety, health and environmental aims and objectives are formulated and monitored Delegation of responsibility for Operational Safety, Health and Environment matters The Head of School has delegated responsibility for operational health and safety matters to the Institute Directors within the School. Institute Directors are responsible for appointing relevant staff to undertake various duties in respect of the full range of safety, health and environmental matters. By way of example, these may include: Institute/Building Safety Officer Biological Safety Officer 3 To be reinstated following establishment of new Institutes within the School of Medicine (currently, operational Safety Issues throughout the School are discussed and minuted through School of Medicine Operations team and School of Medicine Executive) Page 10 of 48

11 Radiation Protection Supervisor Fire Wardens Display Screen Equipment Assessors First Aiders Institute Directors must ensure that staff understand their responsibilities, are competent to undertake their tasks and are allocated sufficient time, support and resources. 3.2 Safety, Health and Environmental Training Each member of staff shall receive safety, health and environmental induction on joining the School. The induction shall include: The University and School s safety, health and environmental responsibilities Their own personal safety, health and environmental responsibilities Emergency procedures Accident and incident reporting Staff and students shall receive specific safety, health and environmental training which will identify the local rules and relevant personnel with safety, health and environmental duties Cardiff University s Safety, Health and Environment Training Policy can be found at: Risk Assessment The School recognises that suitable and sufficient risk assessments are fundamental to effective risk management and that all risk assessments must consider all factors relevant to the activity including environmental impact and the disposal routes of any waste or effluent Risk assessments should be treated as dynamic living documents that should be readily available for reference, communicated to and agreed by the interested parties, and reviewed in-line with accidents/incidents relating to the activity, relevant changes in legislation and the assigned review date For general hazards, Cardiff University operates a risk assessment process through a generic risk assessment form: Page 11 of 48

12 3.4 Codes of Practice and Approved Procedures In addition to the University formulated and adopted Policies and Codes of Practice; each Department/Institute within the School has developed specific policies to deal with specific risks and circumstances. It is the duty of all members of staff, students and visitors, where appropriate, to be familiar with the provisions of the Policies and Codes of Practice and to comply with them at all times. It is the duty of Institute Directors to ensure such compliance. The University's Policies and Codes of Practice can be downloaded from: See Appendix 7 to this Policy for the codes currently in force in Cardiff University. 3.5 Fire Safety Management All Cardiff University Schools based on hospital sites will be subject to the Fire Safety Policy and procedures of the relevant Cardiff and Vale University Local Health Board (C&V UHB) formerly NHS Trust. This policy can be accessed at: AUG%202006%20VERSION%203.pdf Responsibility for the implementation of the relevant C&V ULHB Safety Policy has been delegated to Institute Directors within the School of Medicine For School premises that are not based on hospital sites, the University's Fire Safety Policy applies. This can be accessed at: 20Hospital%20Based%20Sites%20Policy.doc 3.6 Fire Risk Assessments The School shall assist Cardiff University with fire risk assessments in the appropriate buildings these are: Wales Heart Research Institute, Heath Park Tenovus Research Building, Heath Park Henry Wellcome Building, Heath Park Cancer and Genetics Building Neuadd Meirionydd Glamorgan House Monmouth House Page 12 of 48

13 Barri Building The Fire Safety risk assessments for School of Medicine occupied areas within the main tower block buildings will be coordinated through the UHB Fire Safety Officer. 3.7 Safety, Health and Environment Panels The main agency for the monitoring of the School's Safety, Health and Environment Policy is the School's Safety, Health and Environment Committee. The Committee will monitor the conduct of audits and inspections at a Institute/Building level, and make recommendations in writing to the Head of School who is responsible for any necessary action that needs to be taken. Reports on the audit / inspection are submitted to the Director of OSHEU, who will arrange for them to be considered by the OSHEU Committee. This ensures that where the School's policies and procedures impact upon the University Safety Policy this can be appropriately taken into account Workplace Inspections It is the responsibility of the Head of each School and Institute to ensure that the workplace under their control is inspected regularly and in accordance with the University s Monitoring Policy and guidance. In practice it is the responsibility of health and Safety managers (ISO s) and supervisors to ensure the workplace under their control is inspected and that issues raised as a result of the inspections are addressed within a timescale proportionate to the risk. Records of the workplace inspections should be retained within each School and Institute. guidance%20final%20she.doc 3.8 Safety Representatives The School recognises that Safety Representatives are entitled to inspect the workplace as laid down in the guidance Safety representatives and safety committees Further information is available at: Institute Safety Officer The Institute Director(s) will identify a suitable individual(s) to take on the role of Institute Safety Officer to be concerned with the oversight of health and safety matters within the Institute. This is a staff member with sufficient experience and background knowledge to deputise if necessary for the 4 Institute Safety Officer to supersede the role of Departmental Safety Officer Page 13 of 48

14 Institute Director on health and safety matters. (See Appendix 4 for Arrangements for provision and duties of ISO s) The duties of the Institute Safety Officers are detailed in Appendix ECO Champions The School must identify a suitable individual(s) to take on the role of Ecochampion to promote and encourage the reduction in unnecessary energy and water consumption, minimise waste production and ensure efficient recycling of unwanted resources. The duties of the Eco-champion are detailed in Appendix The current School of Medicine Eco-champion is Dr Clive Gregory. Contact details: Tel: +44 (0) Fax: +44 (0) gregoryc1@cardiff.ac.uk 3.11 Radiation Protection Supervisors 5 (RPS) The role of a radiation protection supervisor is to supervise the arrangements set out in the local rules. It may not always be necessary for the RPS to be present in the department when work with ionising radiation is in progress. This will depend on the competency and experience of the workers, the work in progress and alternative arrangements that have been made for action in the event of an emergency University Radiation Protection Adviser (RPA) In accordance with the Ionising Radiation Regulations the University will ensure the appointment of a person to act as RPA for the University. The departmental RPS should liaise directly with the RPA for up to date guidance, information and instruction. The current RPA is based in OSHEU and their responsibilities can be accessed at: P1.doc 3.12 Biological Safety Officer (BSO) Institute Directors, where applicable, must identify a suitable individual(s) to take on the role of BSO to advise and assist in the control of hazards associated with the work. The duties of the Biological Safety Officer are detailed in Appendix 3. 5 RPS role currently organised Departmentally: this will require review following establishment of new Institutes Page 14 of 48

15 3.13 Fire Wardens Institute Directors must identify a suitable individual(s) to take on the role of Fire Wardens to ensure that emergency evacuation is rapid and complete. Details of the role of the Fire Wardens are detailed in Appendix Display Screen Equipment Assessors (DSE) Institute Directors must identify suitable and sufficient numbers of individual(s) to take on the role of Display Screen Equipment Assessors to ensure that issues associated with workstation ergonomics are addressed. Training of DSE assessors is coordinated through OSHEU (Contact: safety@cardiff.ac.uk) Cardiff University s DSE Policy can be found at: %20Policy.doc 3.15 First Aiders Institute Directors must identify a suitable and sufficient numbers of individual(s) to take on the role of First Aider to ensure that prompt and competent first aid assistance is given in the event of instance of ill health. Schools engaged in fieldwork must have a first aider accompanying the work. The roles of the First Aiders are detailed in Appendix Occupational Hygiene The School will undertake proactive and reactive monitoring, through OSHEU, of the local environment of staff and students for: Noise Certain chemicals Dusts Light levels Temperature Humidity The findings and recommendations from this monitoring will be disseminated to relevant parties to enable any corrective action to be undertaken Cardiff University Estate Cardiff University Estates Division is responsible for meeting statutory requirements concerning the maintenance of the University estate and new Page 15 of 48

16 builds. The School of Medicine is responsible for ensuring that the equipment they own meets statutory requirements. The Estates Division will provide advice and direct assistance where appropriate. Where Estates has been delegated by the University to meet the requirements of any statutory regulation on behalf of and for the University, all University Directorates, Schools and members of their staff will be expected to co-operate with Estates to assist in discharging those duties as identified by the regulation. C&V ULHB Estates Ext (Facilities Contact Centre) Cardiff University Estates (01798) (Maintenance Hot-Line) 3.18 Water Hygiene Water can harbour bacteria and other harmful agents. In order to minimise the risk to personnel health, an on-going water hygiene programme has been established; the responsibility for which rests with the Estates department. Cardiff University s Legionella Policy can be found at: It is mandatory for Staff within School Institutes to have a water usage evaluation programme in place to assess the frequency of water systems usage and, if applicable, implement a flushing programme or arrange disconnection via C&V UHB Estates. Information can be obtained from: Karl Hanzel, School Health and Safety Coordinator: Ext John Nettleton, Capital and Asset Management UHB Estates Department: Ext Transport The University is working towards reducing its impact on the local environment by encouraging the use of bicycles, walking and the greater use of public transport and a reduction in single occupancy car journeys. Further information can be found at: Reduction in energy and natural resource use It is the responsibility of all personnel to continually strive to reduce the University s environmental impact by using energy and natural resource efficient working practices. Guidance on and monitoring of these practices is achieved through the School s Eco-champion(s). Page 16 of 48

17 3.21 Control of Wastes The School acknowledges its responsibility in protecting the environment and as such will, wherever possible, reduce its environmental impact by continually striving to minimise the production of wastes and effluents and ensuring hazardous wastes and effluents are disposed of in compliance with current legislation. As such the School is responsible for ensuring the correct disposal of all wastes Guidance on Waste streams can be found at: CU Guidance on the Disposal of Hazardous Waste NHS Waste Management policy CU WEEE disposal Guidelines Chemical Waste Pro-forma Cardiff University Energy Water and Waste Management Policy Explosive / flammable atmospheres Areas where explosive / flammable atmospheres are known to exist or areas where there is a potential for such a hazard to occur must be identified and highlighted in accordance with current legislation. Further information can be found at: Safety Procedure - Permits to work The School recognises that the effective management of specific hazardous activities is of paramount importance. In accordance with the University's Policy, the School operates a permit to work system under which certain high risk activities may only be carried out if the appropriate control measures, identified by the risk assessment, are in place and with the specific permission of an Authorised Person. Permits-to-Work are required to be used for the following: Hot work (welding etc.) Building Service Isolation Roof access Entry into designated hazardous areas 6 UHB waste policy currently under review. (April 2011) Page 17 of 48

18 Asbestos repair or removal Building or other construction works to, or causing disruption to, common areas or access routes Working in designated Red areas 3.24 Procurement Purchasers of any new equipment must ensure that the items and their installation comply with relevant legislation, conform to or better relevant recognised standards, conform to local rules, and are sourced, wherever practicable, from parties whose safety, health and environmental principles are compatible with School of Medicine and Cardiff University. Information on Procurement issues can be found at Occupational Health The University operates a Health Centre with equipped sick bay facility located in the University s Occupational Safety, Health and Environment Unit. The Centre provides health services for University staff, students and visitors. It is responsible for: advising the University and individual members of it on matters of public health providing an appointment and drop-in service for students seeking advice, or treatment for illness, injury or to discuss any work related health problems providing, when possible within the Health Centre s resources, an accident and emergency service for all persons on University premises the delivery of and the assessment of candidates on first aid at work training courses providing statutory and non-statutory health surveillance Contact details: University Health Centre, Tel Fax N.B. Acute/emergency cases e.g. needle stick injury will be dealt with by C&V UHB Occupational Health located at Denbigh House, UHW when accompanied by relevant incident report form. Page 18 of 48

19 3.26 Accident Procedures The University accident reporting procedure complies with the requirements of the Reporting of Injuries, Disease and Dangerous Occurrences Regulations Whenever an accident occurs to any person on University premises, an Accident Report Form must be completed as soon as possible. If the accident or incident is potentially serious, where an injury may necessitate absence from work, the Head of School must be notified immediately, together with the Director of OSHEU (OSHEU Contact Number: ) Although it is not necessary to obtain the signature of any of the School safety staff prior to distributing the Accident form, the incident must be brought to their attention. This may be followed by an investigation by OSHEU staff if circumstances dictate. The objective of the investigation will be to establish the circumstances of the accident, not to apportion blame. This may include seeking statements from witnesses to the accident and preparing reports All accidents resulting in lost time of three or more days will be reported by the Director of OSHEU (or nominee) to the Health and Safety Executive, and to the University Insurers by the Insurance Officer in Cardiff University Finance Division Incident forms are available from the OSHE Unit or via the OSHEU web: These forms should be completed as soon as possible after the accident giving all relevant detail and, where applicable, a written risk assessment for the activity being undertaken when the accident occurred. One copy should be sent to OSHEU and a copy retained by the School and ed to School of Medicine Health and Safety Coordinator, Karl Hanzel (hanzelkw@cardiff.ac.uk) OSHEU is responsible for circulating copies of the accident forms to the relevant persons All correspondence received by a School arising from a claim for compensation after an accident has occurred must be forwarded to the Finance Insurance Officer without delay or acknowledgement. It is imperative that liability is not admitted at any time. 7 Page 19 of 48

20 3.27 Dangerous Occurrence Procedures A dangerous occurrence can be defined as a "near miss" or more correctly a "near hit" where the incident has the potential to cause serious personal injury, has caused property damage or has the potential to cause property damage. It is important that equipment or objects relating to the incident should be left in situ at the time of the incident unless it would be unsafe to do so The investigative and reporting procedure is exactly the same as for accidents. OSHEU will inform the Health and Safety Executive, and the Finance Insurance Officer will inform the University Insurers Incident Investigation All incidents must be reported within the School and also to Occupational Safety Health and Environment Unit (OSHEU) indicating all the relevant information and detailing the exact location of the incident using the correct School / Directorate address Incidents must be investigated by the School and the findings and recommendations disseminated to all relevant parties Where an incident that requires attendance at the Health Centre, then the School must ensure that the casualty is accompanied at all times Out-of-hours working Any member of staff working out-of-hours must follow the lone working procedures below and be fully trained in all procedures that are to be carried out. All work to be undertaken must be approved by the line manager (supervisor) beforehand. Out of hours is classed as any work carried out between and weekdays, all day Saturday and Sunday and any statutory University leave days Lone Worker When working out of hours all members of staff MUST report their presence in the Building/laboratory to the UHW switchboard by following the Out of Hours Procedure. This procedure is: a) Dial the "Out-of-Hours" extension number as soon as you arrive. Henry Wellcome Building, Cancer and Genetics Building ( ) Main Building/Tenovus and WHRI Ext b) Provide the following information i) Full name ii) iii) Location Extension number of the main area that you will be working in (or mobile if you will be moving about) Page 20 of 48

21 iv) Estimated time that you intend staying on site v) Home/mobile telephone number c) When you have finished working you must dial the extension number ( ) or Ext and inform UHW Switchboard that you are leaving the area If you fail to notify switchboard, 30 minutes after your estimated leaving time, switchboard will telephone the extension number you provided. If they are unsuccessful in contacting you, UHW Security staff will be notified and they will despatch a patrol officer to look for you in the laboratory area. If they do not find you, switchboard will contact you at home or on your mobile. The Head of Institute and Institute Safety Officer will be notified if you fail to comply with the University s disciplinary policy If you are working late and on your own, you can request a Patrol Officer to escort you to your vehicle, as long as it is parked on site. The availability of this service is subject to Security staff being available to undertake these duties 9. 8 Cardiff University disciplinary policy 9 See appendix for Security Functions and Contact details- outlining C&V UHB and Cardiff University Security Roles and Responsibilities Procedures document Page 21 of 48

22 SoM Ops/Terms of Occupancy (School of Medicine Buildings)/November 2011 Version 2.1 Preamble: School of Medicine, Cardiff University Terms of Occupancy (School of Medicine Buildings) In April 2009 the School Executive approved the formation of the Space Management Advisory Group (SMG) to provide advice and guidance to the School Executive and School Board on space management issues within the School 10. In June 2009 SMG undertook an extensive Space Survey of all space occupied by the School of Medicine at the Heath Park and Llandough Hospital campuses. This Space Survey process is now repeated on a continuous basis by the School of Medicine Operations Team (now part of the Institute of Translation, Innovation, Methodologies and Engagement (TIME). It has been agreed by School of Medicine Executive that the allocation of all space will be subject to Terms of Occupancy agreements with Institute Directors. This will ensure clear lines of responsibility for Institutes, Sections, and/or Individual Research Groups (as represented by the Institute Director) in occupying School of Medicine space and in receiving central School support. It will likewise formalise procedures and allow the co-ordination and streamlining of all aspects of Building Management in the School 11. Timescales: Terms of Occupancy agreements will run for a period of 12 months (August 1 st to July 31 st ) and will be subject to annual review by School Executive in consultation with the TIME Institute. Terms of Occupancy: Allocation of space will involve consultation between the School (represented by the Dean of Medicine and/or his nominated representatives) and Institute Directors and Research Group Leads (PIs). All decisions made will be the ratified by the School Executive and will be final. Decisions will be made based on the School Strategy 12 that is designed to support the School s Research, Teaching and I&E Missions. A number of criteria will be considered including, but not restricted to: School strategic objectives and need, support for research strategy, trajectory of research group(s), funding streams, research impact, provision of essential support and teaching needs. The process will include consultation with key stakeholders (Institute Directors, School of Medicine Manager, Institute Managers, Cardiff 10 Space Management Group (SMG)- Terms of Reference (approved by School Board May 2009) 11 MEMO; Building Management Arrangements in the School of Medicine (to be distributed to HoDs in April 2009). 1 See Appendix School of Medicine Strategy Document ( ) (to be distributed in May 2010). Page 22 of 48

23 SoM Ops/Terms of Occupancy (School of Medicine Buildings)/November 2011 Version 2.1 University Estates and PIs) and will be used to inform decisions on space allocation by the School Executive. Acceptance criteria: In accepting these terms of occupancy, Institute Directors agree to ensure compliance with and support the School in the following areas: Ensuring that Cardiff University policies and procedures for the employment of staff are implemented fully and consistently. Ensuring appropriate communication with staff about School objectives and key decisions. Contributing to and supporting the collection of Space Survey (Updates). Contributing to and supporting the collecting of Equipment Inventory data. Collecting and regularly updating Staff Occupancy Data about the location and areas occupied by Institutes, Sections, Research Groups but also supports the wider School need to maintain accurate records for School HR and MEDIC Web Project databases of staff locations, designations and tenure. Working closely with the nominated Institute Safety Officer to ensure staff compliance with Cardiff University and School of Medicine, Health & Safety policies 1 (including; Induction of all Staff, Fire Safety, COSHH Incident Reporting and annual compliance safety audit). Ensuring compliance of staff using Human Tissues with appropriate regulations governing the storage, archiving and movement of human tissues 13. Ensuring that staff who are involved in the Conduct of Clinical Trials comply with current European Clinical Trial Regulations 14. Ensuring appropriate consultation with the School when planning staff recruitment that impact on space allocation and expansion (liaison with School HR, Operations Team and SOMRES). Liaising with the Operations Team to ensure that any equipment purchases align with need, avoid duplication where possible and increase efficiency. Liaising with the Operations Team to make maximal use of centralised facilities (e.g. -80 C Freezers and Liquid N 2 medium and long-term storage). Maximising the use of Offsite storage of records (e.g. The Maltings) to release available space on campus and comply with Cardiff Universities Record Keeping policies 15. Encouraging efficient use of resources and thereby compliance with Cardiff Universities Energy Policy and 14 European Clinical Trial Regulations: 15 Cardiff University Record Management Policy: 16 Cardiff University Energy Policy: Page 23 of 48

24 SoM Ops/Terms of Occupancy (School of Medicine Buildings)/November 2011 Version 2.1 Liaising with the Operations Team and/or its nominated officers in all issues related to building management and maintenance (via the Reactive Maintenance Hotline 17 ). Liaising with the Operations Team to discuss ongoing refurbishments that maintain and continuously improve the research environment. Documents to be appended to the individual Terms of Occupancy documents: Annotated Cardiff University ESTAT CAD of all occupied areas. Office/Laboratory list (CU designation as per CAD) Staff Occupancy List that includes Office/Room/Laboratory location (to include names; status; tenure period; funding source, FTE and Line manager/supervisor) 18. This information will be collected and collated by the SoM Operations Team on a 6 monthly basis (and in the H&S induction processes) but the onus will be on Institute Director s to ensure that this information is regularly updated as new staff are recruited and come into post. Declaration: I, the Head of the Institute of...(insert Institute)... agree to the above "Terms of Occupancy" and to a review of these terms in 12 months time. Name:... (Insert Name)... Signature:... (Insert signature) Cardiff University Reactive Maintenance Hotline will be rolled out to Schools in May SoM Operations Staff Occupancy proforma and floorplans will be available from (May 2010). Page 24 of 48

25 Appendix 2 School of Medicine Safety, Health and Environment Committee (SoMSHEC) Membership Representation and Terms of Reference of Committee to be actioned following establishment of New Institutes ISO s December 2011 Page 25 of 48

26 APPENDIX 3 THE ROLE OF THE BIOLOGICAL SAFETY OFFICER To ensure that the local rules 20 are followed. To ensure that containment equipment is maintained and tested at appropriate intervals. Where necessary, monitor for the presence of viable GMOs outside of the containment area. Before agreeing to a new entrant in a containment laboratory, to be satisfied that the individual concerned is familiar with the local rules and the correct use of the laboratory equipment. The training must be commensurate with the level of risk. To maintain a list of all people who are working in the laboratories for which he/she is responsible. To ensure that the work of all new entrants are supervised by a responsible member of the laboratory staff. To ensure that no-one may enter the containment area (other than in an emergency) for cleaning, servicing of equipment, repairs or other activities outside the normal work of the laboratory unless the persons responsible for work in that area have previously been informed, have assessed the risks to the visitor, and have decontaminated laboratory surfaces and equipment when necessary. To ensure the safe storage of GMOs, harmful or potentially harmful material and ensuring that records of these are kept. To ensure the appropriate transport of all GMOs (transfer of organisms constructed at containment level 2 and above should be recorded). To ensure that laboratories are appropriately disinfected prior to the start of a new experiment or the entry of maintenance personnel. Appropriate disinfection could range from swabbing down work surfaces to complete fumigation and will be dependent on the Risk Assessment. To ensure appropriate waste disposal procedures are used. To formulate and implement emergency plan and procedures. To organise regular departmental investigations to assist them in meeting the other duties and monitor local standards of safety. To advise the head of the establishment or Institute in all matters relating to the containment of biological hazards and the safety of staff, except for those in which he/she is involved as principal investigator, when appropriate deputising arrangements should be made. To investigate all accidents, spillages etc. in the laboratory and taking what action he/she considers necessary. Each incident and the action taken must be recorded, together with the names of the personnel involved. All accidents and any incidents in a containment level 2 20 Special safety conditions relating to specific areas e.g. Containment level 3 laboratories will be managed and coordinated centrally by the School and the respective Institute Director Page 26 of 48

27 laboratory must be reported to the Occupational Safety, Health and Environment Unit (OSHEU) OSHEU Central Campus - 47 Park Place Tel Fax Safety@cardiff.ac.uk The responsible member of staff in charge of an experiment is: (i) Answerable at all times to the Biological Safety Adviser for the safe execution of the work in progress and (ii) Responsible for ensuring the day-to-day cleanliness of the laboratory. (iii) Responsible for all aspects of training in appropriate microbiological practice. Page 27 of 48

28 APPENDIX 4 Arrangements within the School of Medicine for provision of Institute/Building Safety Officers (ISOs) The following information is taken from the Cardiff University Safety, Health and Environment Policy and should be considered as the "benchmark" against ensuring compliance with University Policy within your Institute. In addition, given the School of Medicine s location on the University Hospital of Wales (UHW) site then, where appropriate, there will be a need for ISO to liaise with UHB on matters of Fire Safety, Security and Waste Disposal provision. Contents: 1.0 Institute Safety Officers (ISOs) 2.0 The Role of the Institute Safety Officer 1.0 Institute Safety Officers Each Institute Director (or, where a building is shared between Institutes, the nominated lead Institute Director 21 ) must identify a suitable individual to take on the role of Institute Safety Officer. This individual will take responsibility for the oversight of all Health and Safety (H&S) matters within the Institute/Building. This will be a senior member of tenured staff with sufficient experience and knowledge 22 to deputise if necessary for the Institute Director on H&S matters. Where appropriate, there will need to be a Institute/Building Safety Officer appointed (where more than one Institute occupies the space) to oversee the dayto-day safety matters arising in "out-lying" buildings in order for there to be consistency of communication between staff and ISOs to reduce local rule confusion. ISOs will normally devote only part of their time to H&S matters but, to enable them to fulfil this role, it is likely they will need to be relieved of some of their other duties. They will also be required to attend formal training organised by OSHEU to enable them to fulfil this role. 2.0 The Role of the Institute Safety Officer (ISO) To act as liaison between the School/Directorate and the OSHE Unit (OSHEU). To be an ex-officio member of the School Safety Committee (SoMSHEC). To retain familiarity with University and School/Directorate Health and Safety policies. To maintain a general knowledge of safety, health and environmental legislation in relation to the activities of the School/Directorate. 23 That individual who signs the "Terms of Occupancy" agreement with the School of Medicine as per the newly introduced Building Management Arrangements. 22 Qualifications required e.g. Managing Safely in Higher Education (Cardiff University course), IOSH Managing Safely, NEBOSH Certificate Page 28 of 48

29 To follow an appropriate programme of development so that an appropriate standard of safety, health and environmental knowledge is sustained. To provide general health and safety advice or, where appropriate, to refer members of the School/Directorate to the OSHE Unit (OSHEU). To disseminate health and safety information and reports to appropriate members of School/Directorate staff and students. Where appropriate, to liaise with the School/Directorate Eco-Champion on matters relating to the safe disposal of hazardous waste. Where appropriate, to liaise with the School Biological Safety Adviser and School Radiation Protection Supervisor on matters relating to biological and radiation safety. Liaise with the School/Directorate Safety Committee to review health and safety procedures within the School/Directorate. Liaise with the School/Directorate Safety Committee to assist with the coordination of systematic health and safety inspections of the workplace. Liaise with School/Directorate Safety Committee to assist with the co-ordination of the reporting and investigation of accidents/incidents. The School of Medicine Operations Team will commence a systematic and rigorous action plan to ensure compliance and adherence to the current Safety, Health and Environment Policy and strategically align itself to Cardiff University through commitment to Health and Safety with the objectives of: Maintaining and continually improving, as far as is reasonably practicable, a safe and healthy working environment for all staff, students and visitors. Striving for continual improvement in safety, health and environmental performance, demonstrable by achieving and maintaining internationally recognised standards in safety, health and environmental management through strong, active and visible leadership from senior management. Page 29 of 48