Review Date 01/09/2015 Director of Estates and Facilities Expiry Date 11/09/2016 Withdrawn Date

Transcription

1 Policy No: RM78 Version: 1.0 Name of Policy: Corporate Asbestos Management Policy, Organisational Arrangements and Procedures Policy Effective From: 24/10/2013 Date Ratified 12/09/2013 Ratified Health and Safety Committee Review Date 01/09/2015 Sponsor Director of Estates and Facilities Expiry Date 11/09/2016 Withdrawn Date This policy supersedes all previous issues. Corporate Asbestos Management Policy, Organisational Arrangements and Procedures Policy v1

2 Version Control Version Release Author/Reviewer Ratified by/authorised by /10/2013 K Smeaton Health and Safety Committee Date 12/09/2013 Changes (Please identify page no.) Corporate Asbestos Management Policy, Organisational Arrangements and Procedures Policy v1 2

3 Section Contents Page 1 Introduction Policy scope Aim of policy Duties (Roles and responsibilities) Definitions Asbestos policy Commitment to comply with Legislation, Approved Codes of Practice and Health and Safety Executive Guidance Commitment to reduce all exposures to asbestos to the lowest levels reasonably practicable Identifying the presence of asbestos in buildings Provision of information and labelling of asbestos in buildings Risk Assessments for Asbestos in Buildings Budget provision for remediation works Change of use of buildings Building alteration, refurbishment, routine maintenance or demolition Work with asbestos insulation, asbestos coatings and asbestos insulating board Work with asbestos cement Provision of Personal Protective Equipment and Respiratory Protective Equipment Provision and Use of Control Measures Provision of Washing and Changing Facilities Emergency Procedures Health Surveillance Disposal of Asbestos Waste Procedures for maintenance works general guidance Incident response and emergency procedures Training Equality and diversity Monitoring compliance with the policy Consultation and review Implementation of policy (including raising awareness) References Appendices Appendix Corporate Asbestos Management Policy, Organisational Arrangements and Procedures Policy v1 3

4 Corporate Asbestos Management Policy, Organisational Arrangements and Procedures Policy 1 Introduction This document sets out the approach of Gateshead Health NHS Foundation Trust to ensure the safe management of asbestos present in all the buildings owned, occupied and used by the Trust and in particular in which people work. The document has been produced under the framework of the Trust s Health and Safety Policy in order to provide specific detail in relation the Trust s commitments to ensure the safe management of asbestos, to set out the arrangements necessary to achieve this safe management, and to provide detailed procedures for the conduct of particular activities which may involve contact or work either with or in the vicinity of asbestos containing materials (ACMs). 2 Policy scope Asbestos is a generic term used to describe a group of mineral silicates that occur naturally as seams or veins as long thin crystalline fibres and fibre bundles. The fibres have been used in building materials and other manufacturing products as a consequence of their physical and chemical properties that make them ideal for a wide variety of uses. The fibres have high tensile strength, are flexible, have good resistance to chemical attack, high thermal stability, low thermal conductivity, and do not conduct electricity. These properties have lead to the widespread uses of asbestos for thermal and acoustic insulation and fireproofing products. Other products in which asbestos is commonly found include electrical components, friction linings, flooring products such as vinyl floor tiles, structural sheets and boards including asbestos cement sheets and asbestos insulating board ceiling tiles, asbestos cement pipes and flues, roofing products including asbestos cement slates and asbestos containing roofing felts, and asbestos textile products including fire blankets and heat protective suits and oven gloves. Provided that asbestos products in buildings are in good condition and sealed or otherwise protected and not in a position so as to be not vulnerable to damage, then they are unlikely to release fibre and as such are safe to leave in place. This is an issue which is recognised by the Trust and which represents a major consideration and influence in the formulation of this document. The Trust also recognises that the unnecessary removal of asbestos that is in good condition is a misuse of financial resources and is a practice that could in fact lead to an increased risk of exposure in the short term. 3 Aim of policy The Trust are committed to comply with all Legislation, Approved Codes of Practice and all Health and Safety Executive Guidance Notes relevant to the safe management of asbestos across the whole range of its services. Corporate Asbestos Management Policy, Organisational Arrangements and Procedures Policy v1 4

5 To facilitate a co ordinated approach to the safe management of asbestos the Trust report to the Authority s Health and Safety Committee established under the provisions of Section 2 of the Health and Safety at Work etc. Act 1974 and Regulation 9 of the Safety Representatives and Safety Committee Regulations The Trust are committed to take all measures which are necessary to ensure that all possible exposures to asbestos are reduced to the lowest levels reasonably practicable. The Trust will commission appropriate surveys to identify the presence of asbestos in all the buildings under its ownership, including commercial or industrial buildings.if the tenant has responsibility for the maintenance of either the internal or external fabric of the building the Trust will subsequently require the leaseholder to undertake the Duty Holder responsibilities as prescribed by Regulation 4 of the Control of Asbestos Regulations 2012 and to keep the Trust informed of any change in the condition of the asbestos materials identified by the initial surveys. The Trust will establish procedures to ensure that information in relation to the occurrence of asbestos in its buildings is provided to all persons who have any possibility of disturbing the materials and in this respect will label ACMs in all circumstances considered appropriate according to an agreed labelling strategy. The Trust will ensure that wherever asbestos is identified as being present in a building, assessments will be undertaken to define the risks posed by the asbestos. Where the ACMs are found to be in good condition and without risk to any building or room occupiers or users, the general presumption will be leave the material in place and to manage it for the future in accordance with a defined management plan. Where asbestos materials are found to be in a condition where removal or other remedial works measure are considered to be necessary the Trust will ensure that budgetary provisions are made to conduct these works. The Trust will ensure that when ever any building alteration, refurbishment, demolition or routine maintenance works are to be undertaken, no design processes or works will commence until the presence of any ACMs in the buildings concerned is fully understood and all associated costs are included in the project or maintenance costs. Whenever any works result in the removal or change in condition of any identified ACMs, the Trust will ensure that procedures are put in place to ensure that these changes are recorded in the Trust s Asbestos Management database. The Trust will ensure that no change of use of any room or building will be implemented until such time that the full implications of any ACMs present are considered and the assessments of risk amended to take account of these changes in circumstances. The Trust will ensure that all works with asbestos insulation, asbestos coatings or asbestos insulating board will only be undertaken by Contactors holding an appropriate License under the provisions of the Control of Asbestos Regulations 2012 the only exception being approved minor works provided that those undertaking the works are appropriately trained and have the necessary equipment to undertake the works safely. Corporate Asbestos Management Policy, Organisational Arrangements and Procedures Policy v1 5

6 The Trust will ensure that all works with asbestos cement products is undertaken in strict accordance with all relevant Legislation, Approved Codes of Practice and relevant HSE Guidance Notes and that those undertaking the works have received appropriate training and have all equipment required to undertake the works in a safe manner. The Trust will put in place procedures to ensure that all employees, who have involvement with any works involving ACMs, even of a very minor nature or any management responsibilities relating to ACMs, will receive training appropriate to their level of involvement in these functions. The Trust will ensure that where any works are to be undertaken in premises, information will be provided to any persons who may be in the vicinity, or other wise affected by the works, as part of the overall strategy to ensure that they are not exposed to any risk. The Trust will ensure that whenever a risk assessment identifies a need for the provision of Personal Protective Equipment, Respiratory Protective Equipment or any other measure to prevent or control exposure to asbestos, the Trust will ensure that these provisions are made, as these needs affect the direct employees of the Trust. The Trust will put in place procedures to be followed in the event of any inadvertent disturbance of ACMs in any of the buildings under their control. The Trust will put in place appropriate Health Surveillance Procedures to be activated in respect to any situations where risk assessments or other exposure evaluations show that employees may be or have been exposed to the Levels as detailed in the CONTROL OF ASBESTOS REGULATIONS The Trust will ensure that appropriate procedures are put in place to ensure that all asbestos wastes are disposed of in accordance with the Hazardous Waste Regulations 2005 and are transported to appropriately Licensed Waste Management sites by Registered Waste Carriers. 4 Duties (Roles and Responsibilities) The Officer Structure for the Trust is presented in Appendix 1 to this document. These organisational arrangements detail how the Asbestos Management Policy is complied with and how the responsibilities for asbestos management are allocated within the Authority. As detailed later in these Organisational Arrangements, Heads of Service together with their respective Executive Directors will be responsible to ensure that any necessary further organisational arrangements and detailed procedures are put in place to ensure compliance with the Trust s Asbestos Management Policy. 4.1 Trust Board The Trust Board will ensure that a declared statement of policy which is effective in achieving, so far as reasonably practicable, the safe management of asbestos Corporate Asbestos Management Policy, Organisational Arrangements and Procedures Policy v1 6

7 present in all buildings owned, occupied or otherwise under the control of the Trust is adopted by the Authority. Matters relating to the safe management of asbestos are brought before them as required for appropriate attention. Sufficient resources are identified and made available to ensure the safe management of asbestos across the whole of the Trust s undertakings. 4.2 Technical Manager In line with the Authority s Corporate Health and Safety Policy the ultimate responsibility for ensuring compliance with the Trust s Asbestos Management Policy rests with the Technical Manager Having ensured that all necessary resources have been provided the Technical Manager will ensure that Building Managers ensure the safe management of asbestos within the Trust and will hold them accountable to do so. The Technical Manager will on an ongoing basis promote the safe management of asbestos across the whole of the Authority s undertakings and will ensure that the necessary measures are integrated into the Trust s Management Systems. The Technical Manager will ensure that the Health And Safety Committee of the Trust are on an ongoing basis kept appraised as necessary in relation to the Legislative requirements and associated HSE Guidance which relates to asbestos and with which the Trust is obliged comply. The Technical Manager will identify appropriate persons within their areas of responsibility to whom the functions of the Duty Holder as prescribed by Regulation 4 of CONTROL OF ASBESTOS REGULATIONS 2012, and as detailed in Section above, can be delegated to ensure that the required duties can be complied with on a day to day basis. For the most part the person to whom the Duty Holder functions should be delegated will be the person in day to day control of the building under consideration i.e. the Technical Department / Building Department. The responsibility for ensuring that the Duty Holder functions are delegated to appropriate persons within each Service Area of the Trust s activities rests firmly with the Technical Manager The Technical Manager will ensure that the persons to whom the Duty Holder functions are delegated are provided with relevant training to acquire the necessary skills to undertake these duties, and are provided with the requisite resources and authority to ensure that they can effectively discharge these duties. The Technical Manager will further put in place detailed procedures for their respective Service Areas to ensure that the asbestos management requirements of Corporate Asbestos Management Policy, Organisational Arrangements and Procedures Policy v1 7

8 Regulation 4 of CONTROL OF ASBESTOS REGULATIONS 2012 and the Trust s Asbestos Management Policy can be complied with in all respects. The Technical Manager will ensure that whenever any remedial or preventative building maintenance works, or any building alteration, refurbishment, or demolition works are undertaken on premises under their control and responsibility as Duty Holder, procedures are in place to ensure that the contracting company or organisation procured to undertake the works: Are provided with information in relation to the occurrence, location, extent and condition of any ACMs or suspected ACMs in the building in question Are provided with the results of the additional refurbishment / demolition surveys which must be commissioned prior to the implementation of any major refurbishment or demolition works Have ensured the preparation of the necessary risk assessment for the works by a competent person Have in place detailed method statements that fully addresses all requirements for the safe conduct of the work Puts in place all measures necessary to protect the Health Safety and Welfare of all the persons who may be affected by the said works Have all necessary equipment to undertake the works in a safe manner Where necessary, for work involving asbestos insulation, asbestos coatings and asbestos insulating board, holds the appropriate Licence for conducting the works under the provisions of the control of Asbestos 2012 and has provided the necessary Notification for the works to the Health and Safety Executive All works undertaken on their premises is undertaken in accordance with all legislative requirements and specific guidance issued by the Health and Safety Executive by virtue of Approved Codes of Practice and Guidance Notes. All Operatives, Supervisors and Managers involved in the conduct of the works have received appropriate training necessary to ensure the conduct of the works All waste generated during the course of the works is disposed of in accordance with all Legislative Requirements and the copies of all Waste Transfer or Consignment notes are provided to the Trust to ensure that Duty of Care responsibilities are fulfilled. That information relating to any removal of any asbestos recorded on the database utilised by the Trust, or any alteration, repair or change in Corporate Asbestos Management Policy, Organisational Arrangements and Procedures Policy v1 8

9 condition of any ACMs or suspected ACMs occurring as a consequence of the works are informed to the Head of Property and Technical Services to ensure that the records of the occurrence, condition and risks associated with the ACMs across the whole of the Trust s estate are kept up to date. Where any works are undertaken and controlled by the Technical Manager the duties detailed in above will be fulfilled as part of the service provided. It will however be for the respective Heads of Service to ensure that this is the case for all work undertaken if the works are procured through other routes. The Technical Manager will on a periodic basis, not to exceed six monthly intervals, review the performance and compliance of the areas of activity for which they are responsible against the requirements of the Trust s Corporate Asbestos Management Policy and the detailed procedures established in the relevant Service Area. Where any deficiencies in procedures are identified the Engineering Manager will ensure that appropriate corrective actions are taken within a reasonable time so as to ensure that no one is put at risk. The Technical Manager will on an ongoing basis keep their Respective Executive Directors informed in relation to the continued progress relating to the safe management of asbestos within their respective areas of responsibility. In addition to the general duties of Technical Manager to ensure the safe management of asbestos for the Trust the following duties are allocated to specific service areas: The Technical Manager will be responsible for: Commissioning and controlling the surveys of all buildings owned by the Trust. Transferring the asbestos information from the survey reports received from the appointer Surveying Consultants to the electronic database chosen by the Trust for the ongoing recording of asbestos occurrence and condition across its property portfolio. Establishing systems for the access to the asbestos survey information to all persons who are authorised and have a need to be in possession of the information for the conduct of their duties. This includes both authorised electronic access and the distribution of hard copy reports and plans to all buildings surveyed. Preparing the Corporate Asbestos Management Policy documentation in conjunction with the appointed external consultants and ensuring together with the Head of Human Resources that this documentation and the associated Asbestos Management Plan is regularly reviewed and if necessary updated on a six monthly basis in accordance with the appropriate Health and Safety Executive Guidance. Corporate Asbestos Management Policy, Organisational Arrangements and Procedures Policy v1 9

10 Developing an emergency procedure which can be implemented in the event of a very significant disturbance of asbestos such as in a major building fire which may have the potential to affect a community in general. Consulting with all other Service Areas as necessary to establish the Authority s priorities for asbestos management and in particular to ensure a coordinated approach to ensure that the management and control actions as detailed in the asbestos survey reports prepared by external consultants are completed in the time scales identified. 4.3 The Health and Safety Committee Together with the Technical Manager continue the development of the Corporate Asbestos Management Policy documentation and to ensure that this is reviewed on a six monthly basis as required by the advice contained within the HSE Guidance HSG 227, A Comprehensive Guide to Managing Asbestos in premises. To ensure that detailed Procedures for compliance with the Corporate Asbestos Management Policy are developed for each Service Area of the Trust s Activities Assist the Duty Holder in assessing the training requirements necessary to ensure compliance with the Corporate Asbestos Management Policy, to organise the provision of this training, and to maintain the ongoing records of this. Establish with the Duty Holder detailed procedures for any necessary health surveillance requirements arising from contact with and exposure to airborne asbestos fibre and to maintain the resultant health surveillance records Investigate all accidental exposures to airborne asbestos fibre and all related incidents and to ensure that any necessary corrective actions are put in place to ensure that the possibility of similar recurrences are prevented as far as is reasonable practicable. Consider all reported incidents and establish whether the circumstances are such that these are Dangerous Occurrences requiring reporting under the terms of the Reporting of Injuries, Diseases, and Dangerous Occurrences Regulations In the event of incidents falling into the Category of Dangerous Occurrences to submit the required reports to the HSE Incident Contact Centre Undertake compliance auditing for each Service Area against the Trust s Corporate Asbestos Management Policy and the Service Area Detailed Procedures. Corporate Asbestos Management Policy, Organisational Arrangements and Procedures Policy v1 10

11 4.4 Director of Estates Assist Duty Holder in preparing budgetary provisions for compliance with all issues of asbestos management and remediation. 4.5 The Information Technology Officer Prepare a detailed procedure to ensure that ACMs are not disturbed during the installation of any IT or any voice or data communications networks in any of the Trust s buildings To ensure prior to the commissioning of any design works for IT, voice or data communications networks that the asbestos database is consulted and that this information is taken into account in order to avoid, so far as is reasonably practicable, routing data cabling through ACMs or areas which may be contaminated with dusts containing free asbestos fibre. Consider together with The Technical Manager the necessity for any asbestos remediation works prior to the commencement of data installation projects involving contact with asbestos. Will ensure that all operatives employed by the Contractors on the Approved Lists for data installation contracts receive the Asbestos Awareness training as required under the provisions of CONTROL OF ASBESTOS REGULATIONS Premises Managers Responsibilities All Premises Managers across the full range of the Trust s Services to whom Duty Holder functions have been delegated will ensure so far as is reasonably practicable that: A suitable and sufficient assessment has been carried out as to whether asbestos is present in the building for which they are responsible and that an inspection has been carried out of all reasonably accessible areas to confirm the location and condition of the ACMs. A plan has been prepared which clearly illustrates the location of these materials. A copy of the plan and the associated survey report is held in the Estates Department in the Premises Asbestos Management File and that this can be accessed at all times required and by all persons who may need access to the information. Information relating to the presence of ACMs in the building has been conveyed to all persons who may have a need to know. This in addition to other relevant persons may include caretaking and cleaning Staff. Corporate Asbestos Management Policy, Organisational Arrangements and Procedures Policy v1 11

12 That the risk arising as a consequence of the presence of the ACMs has been undertaken and that where appropriate the management or control actions recommended in the survey report have in fact been completed within the timescales recommended. Where this is not the case the Premises Manager will convey this information to the Building Services Manager with a request that the required actions or works are completed forthwith. The condition of the identified ACMs is regularly inspected as part of the normal day to day management of the premises. The Premises Manager will ensure that such inspections are formally undertaken in the normally occupied areas of the building and recorded in a format to be agreed at periods not exceeding six months as part of the general inspections of the premises for the purposes of the Management of Health and Safety at Work Regulations Persons who have been specifically trained for the task will inspect the ACMs in other areas. The Premises Manager will ensure that whenever there is a change in the condition of any ACM in an occupied area that the relevant information is conveyed to the Head of Property and Technical Services in a format to be agreed with a request for the necessary remedial works to be implemented within a reasonable period of time such that no one is put at risk. Where a Premises Manager considers that any particular ACM has been damaged to an extent that persons utilising the area of concern may be exposed to elevated levels of airborne asbestos fibre then the Premises Manager will ensure that the area is vacated until such time that the level of risk can be fully evaluated by persons with the required level knowledge and expertise and that any necessary decontamination works have been undertaken in accordance with the Emergency Procedures detailed later in this document. The area of concern will not be reoccupied until such time that appropriate reassurance air monitoring has been carried out to confirm satisfactory air quality in the area. Whenever there is a proposed change of use for any particular building or part of building the Premises Manager will ensure that a reassessment of the risk arising from the presence of any ACM has been undertaken to ensure that no one is put at risk. Persons with the appropriate level of training and knowledge should undertake this risk assessment. The Engineering Manager will ensure that whenever any remedial or preventative maintenance works are to be undertaken in the building that the contracting company procured to undertake the works: - have been provided with information relating to the presence of ACMs in the building and are specifically given access to the copy of the asbestos survey report and plans available in the premises. - have prepared adequate risk assessments and method statements for the works and have these with them for reference Corporate Asbestos Management Policy, Organisational Arrangements and Procedures Policy v1 12

13 - takes all measures necessary to protect the Health Safety and Welfare of any persons who may be in the vicinity of the works or who may other wise be affected. - have all necessary equipment, personal protective and respiratory protective equipment with them in order to conduct the works in a safe manner. - that all operatives involved in the works with or in the vicinity of ACMs have received appropriate training and are able to provide certification for this training if so required. - removes all waste from the site in accordance with legislative requirements and leaves the site in a safe condition on completion. - informs any changes to ACMs in the building as a consequence of the works via the Premises Manager to the Technical Manager The Premises Manager shall ensure that they have received all training necessary to ensure that they can effectively undertake their duties. 4.7 Duty Holder In relation to asbestos management the Duty Holder will be responsible for the safe management of asbestos, in full compliance with all relevant Legislation, Approved Codes of Practice, Health and Safety Executive Guidance Notes, relevant Governmental advice and the Trust Asbestos Management Policy, for all the Authority buildings and undertakings under their Control. The Duty Holder will hold the responsibilities for the purposes of compliance with Regulation 4 of CONTROL OF ASBESTOS REGULATIONS 2012 and for all the Trusts properties responsibility and accordingly will ensure that: A suitable and sufficient assessment has been carried out as to whether asbestos is present in any buildings under their control In conducting this assessment account has been taken of the available building plans or other relevant information and of the age of the building An inspection has been made of all areas of the buildings which are reasonably accessible The assessment is periodically reviewed at periods not exceeding 12 months and forthwith if there are significant changes including a change of use of the premises to which the assessment relates The risk arising from the asbestos identified in any building has been determined Corporate Asbestos Management Policy, Organisational Arrangements and Procedures Policy v1 13

14 A written plan has been prepared showing the areas of the building inspected and the location of the ACM is identified. The measures which are to be taken to manage the asbestos are specified in a written plan including: The arrangements for monitoring the condition of the ACMs or materials suspected of containing the asbestos The arrangements for ensuring that these or any such substance are properly maintained or where necessary safely removed The arrangements to ensure that information about the location and condition of any asbestos or any such substance is provided to every person who is likely to disturb it Information relating to the presence of ACMs in the buildings under their controlled is made available to the Emergency Services as specifically required in CONTROL OF ASBESTOS REGULATIONS All Staff Duties of all Employees In respect to the Asbestos Management Policy Documentation, and associated changes Organisational Arrangements and Procedures every Employee of the Trust will: Take reasonable care for the health safety and welfare of themselves and that of others who may be affected by their activities in relation to any contact or involvement with ACMs in buildings. Not interfere with or misuse any equipment which is provided to ensure that any exposure to airborne asbestos fibre is kept to a lowest level reasonable practicable. Immediately report to their Line Manger any damage to or disturbance of ACMs that they may become aware of. Co operate in the implementation of the Trust s Asbestos Management Policy, Organisational Arrangements and Procedures. Comply with any working procedure so as to ensure that their own exposure to airborne asbestos fibre, and that of others, who may be affected by their activities, is kept to a level, which is low as reasonably practicable. Use all control measure equipment, PPE and RPE that is provided for the safe conduct of the works. Corporate Asbestos Management Policy, Organisational Arrangements and Procedures Policy v1 14

15 Co operate in any investigations in relation to any uncontrolled release of asbestos fibre into the working environment. 4.9 Duties of Contractors employed by the Trust Contractors employed by the Trust will: Comply with the requirements of the Asbestos Management Policy, Organisational Arrangements and Procedures documentation. Comply with all relevant Health and Safety Legislation, Approved Codes of Practice and Health and Safety Executive Guidance Notes. Be registered on Construction Line as a pre requisite for inclusion on the contractors register Not carry out any work involving ACMs unless specifically trained to do so. Not commence any work unless a competent person has prepared an appropriate risk assessment and method statement and that this documentation is supplied to site staff for their reference and use. Remain vigilant throughout their work and take care as to the possibility of uncovering ACMs concealed within the structure of buildings during the course of works. Stop work immediately in the event of any inadvertent damage being caused to any ACM that results in an uncontrolled release of asbestos fibre into the working environment. Report any inadvertent disturbance of any ACM to the Premises Manager or other Officer of the Trust in charge of the Contract. Co operate in any investigation in relation to any uncontrolled release of airborne asbestos fibre arising from the works in which the Contractor is involved. Provide all necessary asbestos related information, instruction and training to their Employees as required by Regulation 10 of CAR2006 and the associated advice in the Approved Code of Practice, L143 work with materials containing Asbestos and control of asbestos regulations 2012 Provide specific evidence to the Trust in relation to the provision of the training as referred to in paragraph above for each of its Employees engaged in work for the Trust. Corporate Asbestos Management Policy, Organisational Arrangements and Procedures Policy v1 15

16 5 Definitions There are no specific definitions required within this policy. 6 Asbestos policy This document relates to the complete property portfolio of the Trust which comprises: Property Detail Hospital Hospital Hospital Address Bensham Hospital Saltwell Road Gateshead Tyne & Wear NE8 4YL Dunston Hill Hospital Whickham Highway Dunston Tyne & Wear NE11 5QT Queen Elizabeth Hospital Sheriff Hill Gateshead Tyne & Wear NE9 6SX This document replaces all previous asbestos management policy and procedure documents previously adopted by the Trust 6.1 Commitment to comply with Legislation, Approved Codes of Practice and Health and Safety Executive Guidance. In accordance with its Corporate Health and Safety Policy the Trust acknowledges and accepts its responsibilities under the Health and Safety at Work etc. Act 1974, the Management of Health and Safety at Work Regulations 1999, the Control of Asbestos Regulations 2012, The Asbestos (Prohibitions) Regulations 1992 (as amended) and all related and relevant Approved Codes of Practice and Health and Safety Executive Guidance Notes. In relation to management of Asbestos in nondomestic premises the Trust is particularly mindful of Regulation 4 of CONTROL OF ASBESTOS REGULATIONS 2012, The Approved Code of Practice The Management of Asbestos in non domestic premises, and the HSE Guidance Notes HSG 227 A Comprehensive Guide to Managing Asbestos in Premises. Corporate Asbestos Management Policy, Organisational Arrangements and Procedures Policy v1 16

17 6.2 Commitment to reduce all exposures to asbestos to the lowest levels reasonably practicable. The over riding policy for the Trust is to ensure so far as is reasonably practicable that no persons are exposed to risks to their health due to exposure to asbestos while they are in premises controlled by the Trust or are otherwise engaged in any of the Trust undertakings. A further over riding consideration for the Trust is to ensure so far as is reasonably practicable that no one works on or in the vicinity of ACMs unless they are fully aware of the nature of the materials with which they may be in contact, are fully aware of the measures which they need to take to protect their own health and safety and that of anyone else who may be affected by their activities, they have received all necessary training to enable them to undertake the work safely and they have all the equipment necessary for the safe conduct of the work. This includes contractors employed by the Trust. The objective of Policy as above is to ensure that where it is not reasonably practicable to prevent exposure to asbestos, the Trust will ensure that such exposures are reduced to a level, which is as low as reasonably practicable. 6.3 Identifying the presence of asbestos in buildings In recognition of the dates of construction of many of the buildings in the control or ownership of the Trust and in recognition of the risks that may arise as a consequence of the likely presence of these materials, the Trust will ensure that building surveys are undertaken of all non domestic premises. These surveys will be undertaken in strict accordance with the HSG 264 Asbestos the survey guide In commercial or industrial buildings, which may be subject to leases of various formats the Trust will undertake the initial surveys and subsequently bring to the attention of the lessees the requirements to comply with the asbestos management provisions of CONTROL OF ASBESTOS REGULATIONS 2012 for all cases where the tenant has any duty whatsoever for the maintenance of the fabric of the building concerned. The Trust recognises its duty to survey and produce an asbestos management plan for the common areas of any commercial or industrial buildings, which may not be subject to any tenancy agreement or contract. Accordingly the Trust will ensure that these duties are fulfilled. For the very small number of residential accommodation premises owned by the Trust, it recognises that its duties to survey and produce an asbestos management plan applies only to the common areas of the premises not subject to any tenancy lease. In recognition of its role in protecting the health safety and welfare of those who carry out maintenance work in these residential premises and that of others who may be affected by these works, namely the tenants, and in recognition of the duties imposed on the Trust by virtue of the Defective Premises Act 1972 and the Corporate Asbestos Management Policy, Organisational Arrangements and Procedures Policy v1 17

18 Statutory Nuisance Provisions of the Environmental Protection Act 1990, the Trust will carry appropriate Management Surveys for the properties concerned. The commission for surveys will be for a management survey Standard sampling, identification and assessment survey as detailed in HSG264. The Trust recognises that where refurbishment or demolition works are to be undertaken it is probable that further surveys as described in the HSE Guidance Note HSG264, Refurbishment and Demolition survey. Following the implementation of the surveys, the Trust will ensure that the survey information is precisely recorded on a suitable electronic data base which has the facility for up dating as necessary following re inspections, asbestos removal or remediation works, or changes in the risks associated with any change in use of the buildings concerned. The Trust will further ensure that following the implementation of the surveys that appropriate risk assessments are undertaken for the ACMs located, the information from which shall be used to form the basis of the Trust s Asbestos Management Plan. These risk assessments shall be undertaken in accordance with HSG264 and HSG 227, A comprehensive guide for Managing Asbestos in premises namely Material Risk Assessments which take into account the type of product, the type of asbestos present, the extent of damage, and surface treatment and Priority Risk Assessments which takes into account a range of human risk factors such as maintenance activities and occupant activities. The Trust will ensure that in addition to the production of the risk assessments, a plan will be produced for each building surveyed which will clearly show the location of the ACMs identified during the course of the survey. The plan will also show the location of other samples which, following analysis, were subsequently found not to contain asbestos, this being useful information for subsequent building maintenance work. The Trust will ensure that a hard copy report is available at the Estates Department and that procedures will be put in place to ensure that no maintenance work is undertaken unless this information is consulted before commencing. The Trust will eventually ensure that the relevant information is issued to building maintenance contractors along with each works requisition instruction or job note. 6.4 Provision of information and labelling of asbestos in buildings The Trust will, in recognition of its duties under Regulation 4 of CONTROL OF ASBESTOS REGULATIONS 2012, ensure that the information in relation to the location of ACMs is provided to any person who is likely to disturb them. This in addition to building maintenance contractors may well include room users, caretakers and cleaning employees. Corporate Asbestos Management Policy, Organisational Arrangements and Procedures Policy v1 18

19 The Trust accept the value of labelling confirmed areas of asbestos in buildings as an effective measure to warn building maintenance workers of its presence and thereby to form part of the Trusts strategy to ensure that any exposures to ACMs are kept to as low as reasonably practicable. The Trust will ensure in accordance with Regulation 4 of CONTROL OF ASBESTOS REGULATIONS 2012 that the Emergency Services are provided with all information relating to the presence of ACMs present in the Trust s buildings as they may require. 6.5 Risk Assessments for Asbestos in Buildings The Trust recognises that following the implementation of appropriate surveys to identify the presence of ACMs, the undertaking of appropriate risk assessments as referred to in this Policy, and the dissemination of information to all those who may disturb the ACMs, there is a duty to formulate an effective Management Plan to which they commit to in accordance with CONTROL OF ASBESTOS REGULATIONS 2012 and by virtue of this Policy Document. Where the risk assessment indicates that the ACM is in a condition such that the likelihood of fibre release is minimal and the material is therefore in a condition whereby it can be safely left in place, the Trust commits to introducing appropriate management actions to ensure that the ACM is not inadvertently disturbed and that its condition is periodically monitored. The introduction of measures to ensure that the identified ACMs are regularly reinspected and the updating of management actions will be subject to detailed procedures. Where the risk assessments indicates a high risk of fibre release arising from the condition of the ACM, the Trust will ensure that appropriate Control Actions as detailed in the HSE Guidance Note HSG 227 are carried out. Where in the circumstance that the Control Action is not that of removal the Authority will ensure that the ACM which has been subject to the repair, encapsulation or enclosure works is subsequently managed in accordance with the duties prescribed by Regulation 4 of CONTROL OF ASBESTOS REGULATIONS 2012 and this Policy. 6.6 Budget provision for remediation works The Trust commit to making budget provisions on an ongoing basis to allow any necessary asbestos remediation works to proceed as necessary. The appropriate budget sums will be evaluated from the available survey information. 6.7 Change of use of buildings Where there is any proposed change of use of any building or any part of any building, which may affect the risk associated with any ACMs present, the overall project cost will take into account any necessary asbestos remediation works. Corporate Asbestos Management Policy, Organisational Arrangements and Procedures Policy v1 19

20 6.8 Building alteration, refurbishment, routine maintenance or demolition Where any building alteration, refurbishment or demolition works are to be undertaken it is the policy of the Trust that no works are to commence until such time that the Asbestos demolition survey has taken place relevant asbestos information for the building is available. This will enable the full consideration of the risks associated with the asbestos in accordance with the requirements of CONTROL OF ASBESTOS REGULATIONS 2012 and the Construction (Design and Management) Regulations 1994 (as amended). In addition such early consideration of the asbestos implications is likely to result in substantial financial savings to the Trust. Where any routine maintenance, alteration or refurbishment works are undertaken in any building under the control of the Trust, and in which ACMs have been identified, the Trust will put in place the necessary organisational arrangements and where necessary detailed procedures to ensure that any changes to the condition of the asbestos or other issues which affect the risk assessment for the material as originally prepared, are informed back to the Trust Officer in control of the Corporate Asbestos Management Database. On receipt of this information the nominated Officer will make the appropriate amendments to the risk assessments for the ACMs affected by the works. 6.9 Work with asbestos insulation, asbestos coatings and asbestos insulating board It is the Policy of the Trust that where any work is implemented on asbestos insulation, asbestos insulating board or asbestos coatings, other than for minor works as prescribed by the Control of Asbestos Regulations 2012, that only Contractors who hold an appropriate License under Licensing Regulations shall be appointed to undertake the works. For such works as described in the paragraph above it is the Policy of the Trust to give consideration to the engagement of the services of specialist consultants to fully supervise the conduct of the works to ensure compliance with all appropriate Legislation, the Approved Code of Practice, Work with materials containing asbestos and Control of Asbestos Regulations 2012 L143 and all appropriate HSE Guidance Notes. If appointed the consultants will further undertake all necessary inspections and airborne fibre monitoring analysis necessary for the safe conduct of the works. The consultants will have in place all necessary quality control and assurance measures so as to ensure compliance with ISO This is demonstrated in the United Kingdom by achieving accreditation through the United Kingdom Accreditation Service (UKAS). These Consultants will further hold a Supervisory License issued by the HSE under the provisions of the Control of Asbestos Regulations The Trust will maintain an approved list of Contractors and Consultants licensed under the provisions of the Control of Asbestos Regulations Corporate Asbestos Management Policy, Organisational Arrangements and Procedures Policy v1 20

21 6.10 Work with asbestos cement In relation to major works with asbestos cement, and in particular in relation to demolition works, the Trust recognises the potential for significant exposures to airborne asbestos fibre to occur and the substantial physical risks associated with the works. Accordingly the Trust are committed to ensuring a high level of competency for the contractors engaged to undertake such works. In particular the Trust will ensure a high degree of supervision both prior to the commencement in the overseeing of the risk assessments and method statements for the works and in the site demolition works to ensure that the highest possible standards are in place to reduce the exposure of the operatives and all others who may be affected by the works to airborne asbestos fibres. The Trust will further ensure that the demolished asbestos materials are adequately contained and eventually disposed of in accordance with the Hazardous Waste Regulations 2005 at a site holding an appropriate Waste Management License under the provisions of the Environmental Protection Act Provision of Personal Protective Equipment and Respiratory Protective Equipment Where risks assessments for work with ACMs completed under the requirements of Regulation 6 of CONTROL OF ASBESTOS REGULATIONS 2012 identifies the need for the provision of any Personal Protective Equipment, Respiratory Protective Equipment, the Trust will do all that is possible to ensure that this equipment is provided by the Contracting Employers concerned and used by their respective employees. The Trust will endeavour to ensure that the suitability and compatibility of this equipment is fully assessed in accordance with the requirements of the Personal Protective Equipment Regulations Provision and Use of Control Measures Where risk assessments prepared under Regulation 6 of CONTROL OF ASBESTOS REGULATIONS 2012 identify the need for the use of appropriate control measures such as high efficiency Type H vacuum cleaners complying with BS 5415, the Trust will do all that is possible to ensure that such equipment is provided by the contracting employers and used and maintained in accordance with manufacturers instructions and all legislative requirements Provision of Washing and Changing Facilities The Trust are committed to ensure that where any works with ACMs are undertaken the contracting employers will provide adequate washing and other personal hygiene facilities appropriate to the risks identified Emergency Procedures Despite the substantial commitments made by virtue of this Policy Document and the associated Organisational Arrangements and Detailed Procedures, the Trust recognise that due to the widespread occurrence of asbestos in buildings, circumstances could arise whereby exposures to airborne asbestos fibre may occur Corporate Asbestos Management Policy, Organisational Arrangements and Procedures Policy v1 21

22 as a consequence of accidental damage to buildings, storm, fire, flood, or inadvertent disturbance of ACMs due to occasional failure of procedures. While the Trust will do everything possible to reduce such risks so far as is reasonably practicable, the further commitment is to put in place Emergency Procedures in accordance with Regulation 14 of CONTROL OF ASBESTOS REGULATIONS 2012 which shall be followed in the event of such incidents or emergencies occurring Health Surveillance Where any employees of the Trust may be directly involved with work on or in the vicinity of ACMs the Trust will ensure that they have in place measures, through the preparation of thorough risk assessments, to evaluate the cumulative exposure to air borne asbestos fibre. Where assessments show that individual employees or groups of employees are exposed at levels approaching or in excess of the Action Levels prescribed in CONTROL OF ASBESTOS REGULATIONS 2012, the Authority will consider the requirement for the implementation of Health Surveillance examinations. Where an inadvertent exposure to airborne asbestos fibre occurs as a consequence of occurrences as referred to above, the Trust will ensure that the potential exposures of those who may have been affected by the occurrence will be evaluated. Where such exposures are found to be near to or in excess of the appropriate Action Level, the Authority will ensure that the record of the exposure is formally recorded on the employee s personnel records. Further the occurrence of the exposure will be reported to the HSE in accordance with the requirements of the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations In such circumstances consideration will be given to the need for medical surveillance particularly if the employee is involved with building maintenance work involving future contact with ACMs Disposal of Asbestos Waste The Trust will ensure that where ever asbestos waste is generated as a consequence of any of the Trust s undertakings via its contractors, that waste is contained and handled in waste containers which are adequate to ensure that there is no escape of asbestos fibre. The contained waste will be further kept secure in lockable skips or other suitable containers and at a site which is itself considered to be secure. The Trust will ensure that all asbestos, contained as above, will only be removed from site by a Carrier who is registered under the Provisions of the Controlled Waste (Registration of Carriers and Seizure of Vehicles) Regulations The Trust will do all that is reasonable to ensure that the Carrier complies in all respects with the Carriage of Dangerous of Goods by Road Regulations It is the Trust s Policy that all asbestos waste is disposed of as Special Waste in accordance with the Hazardous Waste Regulations 2005 utilising the appropriate consignment note system and at Waste Management sites holding an appropriate Waste Management License under the provisions of the Environmental Protection Act Corporate Asbestos Management Policy, Organisational Arrangements and Procedures Policy v1 22