Asbestos Policy. Policy. The whole of the Trust. Intranet

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1 Document name: Document type: What does this policy replace? Staff group to whom it applies: Distribution: Asbestos Policy Policy Update of previous Procedure for the Safe Management of Asbestos guidance document and (NHS Barnsley) Asbestos Policy January 2011 All staff within the Trust The whole of the Trust How to access: Intranet Issue date: December 2013 Next review: December 2016 Approved by: The Trust Board/Executive Management Team Developed by: Derrick Kelly, Estates Manager Corporate Services Director leads: Alan Davis, Director of Human Resources & Workforce Development Contact for advice: Derrick Kelly, Estates Manager Corporate Services, Note - This document should be read in conjunction with the Trust s Asbestos Management Plan.

2 ESTATES DEPARTMENT - ASBESTOS POLICY ASBESTOS STATEMENT The Control of Asbestos Regulations 2012 apply to all sites owned, occupied or operated by South West Yorkshire Partnership NHS Foundation Trust where there is a risk of any person being exposed to asbestos containing material. The Trust attaches the greatest importance to the Health, Safety and Welfare of its staff and considers it essential that management, staff and contractors should work together positively to achieve an environment compatible with the proper provision of services to patients and where hazards to health of staff, patients and visitors are reduced to a reasonably practicable minimum. It is accepted that it is for management to do all that it is reasonably practicable to reduce risks related to asbestos in the field of construction, operation and maintenance of buildings, plant, equipment and facilities. Where appropriate, training and information will be provided to appropriate persons by the Trust together with the necessary safety and protective clothing It is the intention of the Trust to ensure effective implementation of the aforementioned statements and to keep them under consideration in all aspects of Health Practice and decision making. Signed Head of Estates and Facilities (Senior Responsible Officer) Date Signed Estates Manager Corporate Services (Responsible Officer) Date Signed.. Health and Safety Manager Date Note:- This document is to be read in conjunction with, A Comprehensive Guide to Managing Asbestos (HSG 227). The Control of Asbestos Regulations 2012 Approved Code of Practice The Management of Asbestos in non-domestic premises and the Approved Code of Practice (ACOP) L143 2

3 POLICY & PROCEDURE FOR THE SAFE MANAGEMENT OF ASBESTOS CONTENTS Section Title 1. Introduction 2. Delegated Responsibilities 3. Introduction and Requirements of Guidance and Statutory Regulations 4. Emergency Repair/Work 5. Contamination 6. References Appendix 1 Appendix 2 Appendix 3 Principle Legislation and Guidance Notes on Sampling of Asbestos Materials and For Airborne Contamination Equality and Impact Assessment Appendix 4 Checklist for the Review and Approval of Procedural Document Appendix 5 Version Control Sheet 3

4 1. INTRODUCTION Asbestos Procedure and Code of Practice The Estates Department, in conjunction with the Health and Safety Manager, is concerned to take appropriate precautions to ensure the health and safety of staff and others who may be affected by risks associated with asbestos present in some building structures and plant or other machinery upon the Trust s estate. Consequently a system of survey, encapsulation and removal has been put in place and covered the Asbestos Management Plan. Strict safety protocols have been laid out, which must be adhered to, by those working with or likely to disturb asbestos products, be they Trust staff or Contractors. These systems and safety protocols form part of this policy and code of practice thus ensuring that any risk to the health of employees working within buildings that contain asbestos building products or plant components, or working directly with such asbestos products or components, is reduced to the lowest level reasonably practicable. This Procedure and the attendant Codes of Practice have been drawn up in accordance with the latest Regulations, Approved Codes of Practice and Guidance, on asbestos, from the Health and Safety Executive and will be reviewed and updated in the light of any future changes to these Regulations, Approved Codes of Practice or Guidance. A register of surveys carried out to identify asbestos will be maintained and updated annually by the Estates Department and in accordance with the Asbestos Management Surveys requirements each property will have a detailed Asbestos Report and supporting Risk Assessment. Current Guidance advises that immediate removal of all asbestos containing material is not necessarily the best option. Where asbestos is in good condition, not likely to release fibres into the air and not in a position where it is likely to be damaged by normal building use, it is best sealed or covered and its presence noted by labelling and/or entry on a register. This Trust intends to follow such Guidance by removal, at the earliest opportunity, any asbestos building materials or components that are identified as being in poor condition whereby fibres may be released into the air or where the normal work practices of the building users are likely to damage such asbestos materials, whereby fibres may be released into the air. Where asbestos materials are in good condition and fibres are not likely to be released into the air such asbestos materials will be sealed and /or encapsulated and labelled as asbestos materials save when such labelling may cause undue concern to other building users e.g. members of the public. Contractors/in-house maintenance staff will be fully informed of any known or suspected asbestos material in the vicinity prior to carrying out any work which may result in damage/fibre release. If there is any doubt as to the composition of materials uncovered during building works, or prior to works commencing, a sample will be removed only by an approved/competent person and sent to a suitably accredited laboratory for analysis before work proceeds, It is the intention of the Trust to ensure effective implementation of the aforementioned statements and to keep them under consideration in all aspects of health practice and decision making. 4

5 2. DELEGATED RESPONSIBILITIES The Chief Executive shall be responsible for ensuring that all Health and Safety Regulations and Approved Guidance Documents are complied with. In practice the responsibility for ensuring that regulations and guidance relating to asbestos are complied with will be delegated to The Director of Human Resources. The Head of Estates & Facilities will be responsible for monitoring records, policy documentation, etc. Chief Executive The Chief Executive has overall responsibility for the health, safety and welfare of all trust staff, patients, visitors, etc. This will include compliance with all Statutory Instruments and Approved Codes of Practice relating to the safe handling and disposal of asbestos products. Director of Human Resources The Director of Human Resources has the delegated responsibility for the health and safety of all personnel who may come into contact with asbestos products. He shall ensure that appropriate policies and strategies for the handling and disposal of asbestos related products are in place and maintained. Head of Estates & Facilities The Head of Estates and Facilities as Senior Duty Holder shall ensure the execution of all policies and strategies relating to asbestos. He shall ensure the identification and prioritisation of asbestos removal schemes, ensure application for adequate funding, the provision of Personal Protective Equipment and appoint and audit the Responsible Officers and ensure they are adequately trained. Estates Manager - Corporate Services The Estates Manager-Corporate Services as Duty Holder shall ensure the departments Asbestos Management Plan is fully executed and work closely with the Estates Manager- Operations and ensure that all capital work containing an asbestos removal content are carried out with due compliance to all current asbestos, guidance and regulations. Estates Manager - Operations Estates Manager Operations as Responsible officer/competent Person for the Disposal of Asbestos shall work in concert with the Estates Manager-Corporate Services and the Estates & Facilities Co-ordinators to ensure that asbestos is consigned and disposed with due compliance to all current asbestos guidance and regulations. Estates & Facilities Co-ordinator(s)/Estates Officer(s) Competent Officers The Competent Officers are responsible for: Ensuring up-to-date knowledge of current regulations and ensuring policies are kept up-todate Maintaining all records, relating to asbestos 5

6 Ensuring existing asbestos materials are protected, adequately marked and identified Maintaining a record of the location of asbestos on Trust properties Liaison with building occupiers and administrators to keep those persons informed of impending asbestos related work and to keep the occupier informed of progress and completion Identifying and prioritising removal schemes Arranging regular inspection of the condition of asbestos at the identified location Training competent persons The up-keep of the Health and Safety Manuals identifying Personal Protective Equipment needs Ensuring all facilities staff are trained to obey notices identifying restricted areas Ensure all facilities staff are trained to obey instruction, relative to sealed asbestos products Supervising sampling of Asbestos Arranging and supervising for air sampling when necessary Writing Specifications/Tenders Keeping a register of approved local contractors Monitoring contracts Information officer Designated Officer The Designated Officers are responsible for: The Designated Person shall arrange for (non invasive), surveys to be carried out as defined in the Control of Asbestos Regulations 2012 and in accordance with HSG 264; The Survey Guide. Asbestos products identified will be recorded in the Asbestos Register held in the Estates Office (s) Estates shared folders and in the Estates Planet FM Enterprise Computer Network, and shall be accessible by all Estates/Projects Officers. The Contract Controller / Supervising Officer for each project or task shall have sufficient access to allow identification of areas and materials, which will require to be considered. Sufficient detail shall be provided to each Contractor to ensure he is aware of the extent of any asbestos within the proposed working area(s). Capital Projects (Team) The Capital Projects Team shall ensure that all responsible and designated lead Project Managers undertaking any works associated with any asbestos survey or abatement work adheres to the upkeep and maintenance of the electronic asbestos register. The lead Project Manager shall ensure that all asbestos surveys are undertaken by the Trusts nominated and approved asbestos consultant and that the electronic register is immediately updated with any changes. The Project Manager shall ensure that the Designated Officer is formally informed of any changes made to the electronic asbestos register to ensure that the Designated Officer can allow for any administrational changes to be made to the electronic register and associated asbestos management systems. Leased/Rented Buildings The Project Officer shall ensure that each Trust managed, shared, leased or rented property is surveyed and the information held in the Trusts Asbestos Database Register. Asbestos Management Surveys/Inpections & Register The Designated Officer will ensure that the Asbestos Register is updated as required. The register, maintained by the Estates Information Services Officer, shall be held electronically, given details of the materials, assessments, locations and shall be augmented by CAD & PDF drawings/plans showing the room locations of identified or suspected materials. 6

7 Drawings shall be updated by the Information Officer (CAD) as and when changes occur. All persons who supervised any work with asbestos are responsible for complying with relevant procedures and if in doubt for seeking advice and assistance from the Repsonsible Officer (s), and shall have access to the Electronic Asbestos Register for all Trust premises as required. Monitoring The Designated Officer shall ensure that a system of inspection to monitor known areas containing asbestos is maintained. Employees and Contractors MUST be instructed to report any damage that occurs to material containing asbestos immediately, (verbally), to the Designated Estates and/or Projects Officer Competent Persons:- (South West Yorkshire Partnership NHS Foundation Trust Employees) Competent persons are Management or Supervisory staff who are aware of the necessary precautions and procedures relating to asbestos and who are authorised to monitor approved contractors working on site. Note: It is not the policy of South West Yorkshire Partnership NHS Foundation Trust to work with or handle asbestos related products on our own site. (Except for sampling and some emergency work) Competent Persons (Approved and Registered Contractor) Competent persons (approved and registered contractors) are contractors approved by the Trust and licensed by the Health and Safety Executive (H.S.E). They will be contracted to carry out the work: sealing and/or removing and disposing of asbestos materials to a pre-arranged Statement of Method. These contractors will conduct the work after appropriate notification to the Health and Safety Executive and having received due approval by the H.S.E. All relevant documentation associated with the safe disposal of asbestos shall be provided by the Registered Contractor. Health and Safety Manager The Health & Safety Manager for South West Yorkshire Partnership NHS Foundation Trust will be notified prior to the commencement of any work involving asbestos materials and his advice sought as and when necessary. The Safety Officer will conduct inspection of work as and when necessary. 3. INTRODUCTION AND REQUIREMENTS OF GUIDANCE AND STATUTORY REQUIREMENTS. Asbestos has been used for many years in building materials and certain equipment and a considerable volume of information and advice on asbestos is available (see references). The purpose of this policy is to give general advice on the precautions that should be taken with asbestos. When planning work on asbestos reference must be made to the specific guidance available within the Regulations, Codes of Practice, H.S.E Publications, etc 7

8 Regulation/Recommendation The Health and Safety Executive publication Control of Asbestos at Work Regulation 2012 (CAWR) and Approved Code of Practices (ACoPs) and in accordance with HSG 264. The aim is to promote good practice and ensure the duty to manage asbestos, advises that owners/occupiers of buildings have properties surveyed for the presence of asbestos. Any asbestos materials identified should be duly labelled and managed as part of a risk register. Trust Procedure All buildings, subways, plant rooms, plant and equipment that are owned by the Trust must be surveyed for asbestos. Trust employees or its approved contractor who may carry out work on non-trust premises or on equipment not owned by the Trust should be aware of the hazards presented by the presence of asbestos. Where asbestos is suspected of being present the employee or approved contractor must seek advice before continuing work. Where identified, on Trust premises, asbestos shall be labelled ASBESTOS - REPORT ANY DAMAGE and clearly identified on the survey plans for the site. Wherever damaged asbestos is found it shall either be sealed, removed by a specialist asbestos contractor or the area itself sealed off and appropriate RESTRICTION OF ACCESS notices posted. Safe systems of work implemented for entry into these areas. Appropriate signs which conform to Safety Signs and Signals Regulations are required. Regulation/Recommendation The regulation introduces a duty to manage asbestos in non-domestic premises. Persons with repair and maintenance responsibilities for the premises will need to ensure that asbestoscontaining material (ACM) within those premises are properly managed, and that information about the location and condition of the materials is passed on to those likely to disturb them. Trust Procedure cont d Asbestos will be removed when there is planned refurbishment of a building/equipment or whenever planned maintenance or repair is to be carried out and must be conducted by an approved contractor. Asbestos may also be removed from the site on a programmed basis developed by the Head of Estates & Facilities, the programme to be updated on an annual basis. The criteria for programmed removal will depend upon: 1. Known future capital developments 2. Locations of plant needing regular access for maintenance Areas, which for whatever reason cannot remain sealed from access by personnel Other reasons from time to time identified by the Estates and Facilities Manager Advice received from the Health and Safety Manager that asbestos is damaged and requires approval Any contractor intending to undertake work with any asbestos must comply with the Control of Asbestos Regulations To comply with the European Asbestos Worker Protection Directive the process for removing ACM's has been altered within CAR As such ALL work with asbestos is notifiable to the Health & Safety and is classed as either: 1. NNLW - Notifiable Non-Licensed Work or: 2. NLW - Notifiable Licensed Work 8

9 All Asbestos Works which are identified as required whether through planned works or reactive response; will be channelled through the Designated Officer to the appointed Asbestos Consultant for review and referral to tender/pricing. As part of this process, all works will have a job specific scope of works produced by the asbestos consultant for obtaining prices for removal. Where the cost of removal would require tenders to be sought in line with the Trusts Standing Financial instructions, the appointed asbestos consultant will produce a detailed asbestos tender specification in line with the terms of the consultant s appointment. All sealed tenders will be instructed to be returned direct to the trust procurement team. 4. EMERGENCY REPAIR/WORK Whenever an Emergency Repair is required on plant or equipment containing asbestos, immediate advice must be sought from a Responsible Officer who may seek advice from a specialist contractor or the H.S.E as to precautions that can be taken. The following precautions must be carried out as a minimum (and in any event). 1. Limit the number of persons in the area to the bare minimum 2. Limit the damage to any asbestos 3. Where disturbance to asbestos will occur take precautions to limit its spread wherever possible by placing appropriate coverings on the floor and by wetting the asbestos to reduce fibre release. All work with asbestos should not extend beyond a 1 hour time period. 4. All personnel in the area are to wear white disposable hooded overalls and an H.S.E approved disposable face mask (both available from the Facilities Stores). 5. On completion of the emergency work and where applicable the floor covering shall be folded to limit the spread of asbestos. Disposable overalls shall be removed and placed in a black plastic bag. Finally disposable masks should be removed and placed in the bag. The bag must be tied off at the neck and labelled DANGER ASBESTOS. The bags may then be left at the site of emergency work. 6. The area shall be cordoned off to all persons without adequate P.P.E until the asbestos is either removed or sealed by an approved contractor. NOTE: ANY EMERGENCY WORK SHALL ONLY BE CONDUCTED BY THE DIRECT AUTHORISATION OF THE RESPONSIBLE OFFICER (s) 9

10 5. CONTAMINATED AREAS Where it is suspected that fibres have contaminated an area, the following shall be carried out 1. Seek advice from the H.S.E licensed contractor 2. Have the area disturbance air tested by a recognised body. Accredited to ISO EN45001 (EN17025) 3. If control limits are exceeded then the area shall be cordoned off to all persons without adequate P.P.E 4. The area shall be either stripped or cleaned of asbestos or the asbestos sealed and the area cleared up by an approved licensed contractor. 5. Further air tests may be necessary Testing for Asbestos The taking of samples for analysis shall only be carried out by Responsible Officers or Competent Persons who are aware of all precautions and procedures, relating to asbestos etc. Reference should be made to the Guidance Notes in Appendix I Generally the guidance given earlier in emergency repairs shall be followed with the exception that any asbestos damaged by bulk sampling is repaired and that P.P.E is disposed of in the recognised manner. Removal of Asbestos An approved licensed contractor, under the supervision of a Responsible Officer shall carry out removal of Asbestos. A Responsible Officer shall monitor the contractor to ensure that all work is carried out to current guidance and practices. The Code of Practice gives practical guidance on complying with the Regulations. The code applies to all work activities directly involving asbestos, including handling, movement, storage, manufacturing, constructions, processing, repairing, maintenance, demolition and disposal. However, it does not consider in detail those activities covered by the separate Code of Practice. Work with asbestos insulation, asbestos coating and asbestos insulating board. A brief summary is given below:- Identification and assessment Before any work with asbestos is started the Trust must ensure a thorough assessment of the likely exposure is carried out. Such an assessment must identify the type of asbestos involved in the work, or to which the employees are likely to be exposed. For the purposes of the identification requirement the employer may assume that the asbestos is asbestos other than chrysotile alone, i.e. can assume the worst case scenario and provide for the situation accordingly. The assessment must also determine the nature and degree of any exposure and the steps required to prevent or reduce the exposure to the lowest level reasonably practicable. Assessments must be reviewed regularly and when there is reason to suspect that the original assessment is invalid or there is a significant change in the work to which the original assessment related. Assessments should be revised accordingly to take account of any such changes. 10

11 6. REFERENCES NOTICES AND GUIDANCES NHSE (SAFETY NOTICES) NHSE (HAZARD NOTICES) DEPARTMENT OF HEALTH (SAFETY INFORMATION BULLETINS) NHS ESTATES POLICY LETTERS DEPARMENT OF HEALTH POLICY LETTERS CODE SN HN SIB EPL PEL South West Yorkshire Partnership NHS Foundation Trust References 1) South West Yorkshire Partnership NHS Foundation Trust Facilities Department. - Health and Safety Manual Handbook. 2) South West Yorkshire Partnership NHS Foundation Trust Facilities Department - Health and Safety Standards Guide. 11

12 Appendix 1 PRINCIPLE LEGISLATION AND GUIDANCE There are a large number of official publications relating to Asbestos at Work. The following list contains the most significant and relevant items, but is not exhaustive. For an up to date list refer to: Control of Asbestos Regulations HSE Health and Safety at Work Act 1974 The Control of Asbestos Regulations 2012 The Control of Asbestos Regulations Legislation.gov.uk Management of Health and Safety at Work Regulations 1999 The Environmental Protection Act 1990 The Classification, Packaging and Labelling of Dangerous Substances Regulations (2008) The Control of Pollution (Special Waste) Regulations 1980 as amended. The Personal Protective Equipment at Work Regulations 1992 Reporting of Incidents, Diseases and Dangerous Occurrence Regulations 1995 Control of Substances Hazardous to Health Regulations Confined Spaces Regulations 2007 Chemical (Hazard Information and Packaging for Supply) Regulations 2009 Construction (Design and Management) Regulations 2007 Work at Height Regulations 2005, as amended by the Work at Height (Amendment) Regulations The Fire Safety (Employees Capabilities) (England) Regulations 2010 Health and Safety (Offences) Act 2008 Corporate Manslaughter and Corporate Homicide Act The Confined Spaces Regulations 1997 The Employment Rights Act 1996 Public Interest Disclosure Act 1998 (PIDA) The Control of Lead at Work Regulations 2002 The Control of Noise at Work Regulations 2005 The Electricity at Work Regulations 2007 The Working Time Directive Regulations 1998 The Gas Safety (Installation & Use) Regulations 1998 The Occupiers Liability Acts 1957 and HSE Approved Codes of Practice (ACOP) L21: Management of Health and Safety at Work Regulations 1992 L27: The Control of Asbestos Regulations 2012 L127: The management of Asbestos in non-domestic premises, HSE Guidance Notes Relating to Duties of Licensed Contractors HS (G) 37: An Introduction to Local Exhaust Ventilation. HSG 53: Respiratory Protective Equipment at work: A practical guide, HSG 248: The Analysts Guide for Sampling, Analysis and Clearance procedures, HSG 264: Asbestos; The Survey Guide. 12

13 HSG 247: Asbestos: Licensed Contractors Guide, EH10: Asbestos: The Analysts guide for sampling, analysis and clearance procedures. EH40: Occupational Exposure Limits Further information on the duty and the HSE implementation campaign and HSE Books can be found on. and ASSOCIATED DOCUMENTATION Health & Safety Policy Control of Contrators Trust Permit to Work Forms Asbestos Management Plans Asbestos Register (s) Asbestos Surveys Incident Management and Investigation Policy Working at Heights Policy Fire Safety Management Policy Waste Management Policy. Infection Control Policy Security Management Policy Lone Worker Policy Violence at Work Policy Manual Handing Policy Risk Management Strategy Risk Assessment Policy 13

14 Appendix 2 Procedures for Sampling of Asbestos Materials and For Airborne Contamination The following procedures are to be adhered to whenever sampling for asbestos or contamination is suspected. The Responsible Officer should always be responsible for the initiation, implementation and supervision of sampling of materials or air sampling and for keeping all records up to date. The Responsible Officer may delegate core sampling to a competent person. Labels showing the date, exact location of sample, name address & telephone number of contact, and whether the sample is suspected of containing asbestos should identify all samples. All samples should be double bagged. Air sampling must only be carried out by a recognised body. Accredited to ISO EN45001 (EN17025); Further guidance is included in HSE HSG264. A Responsible Officer shall be responsible for the authenticity of the sample and that there is no question of the filter being substituted for any other filter. Each air filter to be analysed should be enclosed in a container specifically made for the transport of the filter. It should be labelled to show the exact location of the air sample (As for core sampling) The Responsible Officer shall ensure that the asbestos register and files are kept up to date. The files should be such that easy and dependable references can be made whenever asbestos contamination is suspected. The files should be carefully indexed and cross referenced with separate files containing detailed location maps showing the locations of asbestos or (with pipework lengths or ceiling areas where applicable), clearance certificates, bulk sampling analysis, air monitoring, clearance tests and waste consignment notes. 14

15 Appendix 3 - Equality Impact Assessment Tool To be completed and attached to any policy document when submitted to the Executive Management Team for consideration and approval. Equality Impact Assessment Questions: Evidence based Answers & Actions: 1 Name of the policy that you are Equality Impact Assessing Asbestos Policy 2 Describe the overall aim of your policy and context? Who will benefit from this policy? The overall aim of the policy is to describe the Trust s approach to the management of asbestos provision in the organisation All staff 3 4 Who is the overall lead for this assessment? Who else was involved in conducting this assessment? Director of Human Resources & Workforce Development Estates Manager Corporate Services 5 Have you involved and consulted service users, carers, and staff in developing this policy? What did you find out and how have you used this information? N/A N/A 6 7 What equality data have you used to inform this equality impact assessment? What does this data say? N/A N/A 8 Taking into account the information gathered. Does this policy affect one group less or more favourably than another on the basis of: Where Negative impact has been identified please explain what action you will take to remove or mitigate this impact. If no action is to be taken please explain your reasoning. 15

16 NO Race Disability Gender Age Sexual Orientation Religion or Belief Transgender N N N N N N N 9 Carers What monitoring arrangements are you implementing or already have in place to ensure that this policy: promotes equality of opportunity who share the above protected characteristics eliminates discrimination, harassment and bullying for people who share the above protected characteristics promotes good relations between different equality groups, This policy aims to outline the steps that managers and staff should approach when considering Asbestos and clearly define the trusts approach to meeting its statutory obligations. 10 Have you developed an Action Plan arising from this assessment? 11 Who will approve this assessment and when will you publish this assessment. 12 Once approved, please forward a copy of this assessment to the Equality & Inclusion Team: inclusion@swyt.nhs.uk Yes The Policy is supported by the Asbestos Management Plan where specific elements/requirements of the policy are been closely monitored and detailed action plan formulated. N/A N/A 16

17 Appendix 4 - Checklist for the Review and Approval of Procedural Document 1. Title Title of document being reviewed: Is the title clear and unambiguous? Is it clear whether the document is a guideline, policy, protocol or standard? Is it clear in the introduction whether this document replaces or supersedes a previous document? 2. Rationale Are reasons for development of the document stated? 3. Development Process Is the method described in brief? Are people involved in the development identified? Do you feel a reasonable attempt has been made to ensure relevant expertise has been used? Is there evidence of consultation with stakeholders and users? 4. Content Is the objective of the document clear? Is the target population clear and unambiguous? Are the intended outcomes described? Are the statements clear and unambiguous? 5. Evidence Base Is the type of evidence to support the document identified explicitly? Are key references cited? Are the references cited in full? Are supporting documents referenced? 6. Approval Yes/No/ Unsure EMT Comments 17

18 Title of document being reviewed: Does the document identify which committee/group will approve it? If appropriate have the joint Human Resources/staff side committee (or equivalent) approved the document? Yes/No/ Unsure N/A Comments 7. Dissemination and Implementation Is there an outline/plan to identify how this will be done? Does the plan include the necessary training/support to ensure compliance? 8. Document Control Does the document identify where it will be held? Have archiving arrangements for superseded documents been addressed? 9. Process to Monitor Compliance and Effectiveness Are there measurable standards or KPIs to support the monitoring of compliance with and effectiveness of the document? Is there a plan to review or audit compliance with the document? 10. Review Date Is the review date identified? Is the frequency of review identified? If so is it acceptable? 11. Overall Responsibility for the Document Is it clear who will be responsible implementation and review of the document? 18

19 Appendix 5 - Version Control Sheet Version Date Author Status Comment / changes 1 Sept Sept Sept Oct Dec 2013 Estates Technical Manager Estates Technical Manager Estates Manager Corporate Services Estates Manager Corporate Services Estates TAG Final Final Final Draft Final Draft Final version approved by Estates Team Procedure for the Safe Management of Asbestos Final version approved by Estates Team Procedure for the Safe Management of Asbestos Final version approved by Estates Team Procedure for the Safe Management of Asbestos Revised Policy & Management Plan circulated for comments/action to Estates/Capital Team. Asbestos Policy & Management Plan submitted for approval Note the Asbestos Policy has been formulated following the merger of Barnsley CSD Estates Department, as there is a requirement to assimilate both Asbestos Management arrangements into a common policy. Previously the guidance document used was covered under the Procedure for the Safe Management of Asbestos in Wakefield with NHS Barnsley having a policy and therefore the decision has been made to align these two documents into this Asbestos Policy with supporting Asbestos Management Plan. 19