Control of Asbestos Policy

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1 Control of Asbestos Policy Version Number: V1D Name of originator/author: Estates Manager Name of responsible committee: Estates and Facilities Committee Name of executive lead: Director of Finance and Estates Date V1 issued: 28 th February 2011 Last Reviewed: February 2013 Next Review date: April 2016 Scope: Trust wide MMHSCT Policy Code FE-04 Page 1 of 14

2 Document Title / Ref: Document Control Sheet Control of Asbestos Policy Lead Executive Director of Finance and Estates Director Author and Contact Estates Manager Number Type of Document Policy Broad Category Estates and Finance Document Purpose The purpose of this document is to identify how the Trust shall manage the ongoing risks to persons from potential exposure to ACM s and applies to all premises occupied by the Trust. Scope Trust-wide Version number V1D Consultation N/A Approving Committee Estates Committee Approval Date 8 th March 2013 Ratification and Date Clinical Governance Committee Date of Ratification April 2013 V1 Valid from Date December 2010 Current version is valid from approval date Date of Last Review February 2013 Date of Next Review April 2016 Procedural Documents to be read in None conjunction with this document: Training Needs Analysis Impact There are no Training requirements for this procedural document Click here to enter text. Financial Resource Impact There are no Financial resource impacts Click here to enter text. Document Change History Changes to this document in different versions must be detailed below. Rationale for the change should also be given Version Number / Name of procedural document this supersedes Type of Change i.e. Review / Legislation / Claim / Complaint Date Details of Change and approving group or Executive Lead (if done outside of the formal revision process) External references used in the creation of this document: If these include monitoring duties upon the Trust for this policy the specific details should be recorded on the Monitoring and Compliance Requirements sheet Privacy Impact N/a Any issues? Choose an item. Assessment submitted Fraud Proofing N/a Any issues? Choose an item. submitted If not relevant to this procedural document give rationale: Page 2 of 14

3 Policy authors are asked to consider each of the nine protected characteristics under the Equality Act We expect you to demonstrate that throughout the policy process you have had regard to the aims of the Equality Duty: 1. Eliminate unlawful discrimination, harassment and victimisation and any other conduct prohibited by the Act; 2. Advance equality of opportunity between people who share a protected characteristic and people who do not share it; and 3. Foster good relations between people who share a protected characteristic and people who do not share it. Please provide a brief account of how you have done this, further work to be completed and any support you have had in considering the aims and working in compliance with the Equality Duty. If you are unclear on how to do this or would like further advice and support then you may contact It is the responsibility of the approving group to ensure this statement reflects the Trusts objectives and position with compliance as set out within the NHS Equality Delivery System There is no Equality and Diversity impact. In line with the Trust values we may publish this document on our External Website. Is there any reason you would prefer this is not done? No. It is the Authors responsibility to ensure all procedural documents comply with the Trust values If you are unclear on any of the requirements in the document control sheet then please before proceeding Page 3 of 14

4 Monitoring and Compliance Requirements Sheet For audit, Registration and NHSLA purposes all procedural documents must have monitoring requirements or key performance indicators set by the authors, Committees or Lead Directors. This allows the Trust to routinely monitor the effectiveness and impact of their procedural documents on a regular basis. Procedural Document Title: Does this procedural document offer support or evidence for the Trusts registered activities and outcomes? Yes Primarily Choose an item. Additional Not Applicable Additional Choose an item. Is this an NHSLA Document? No Which Standard does this relate to? 1 Safe Environment Which Criterion Not Applicable Choose an item. Choose an item. If other Monitoring requirements are necessary i.e. Health & Safety Act and you should include them here and record them in the External References section Specify where the requirement originates Minimum Requirement / Standard / Indicator to be monitored & Section of document it appears Process for monitoring Audit Audit Audit Audit Responsible Individual / Group Additional Details i.e. Section number, Code of Practice Frequency of Monitoring Yearly Yearly Yearly Yearly Responsible Group for review of results / action plan approval / implementation Comments NB: If you have selected audit you should complete the required audit registration form and standards document and submit these with your expected timescales for completing the audit to as soon as possible and no later than 4 weeks prior to the audit commencing. The Group / Committee should also ensure the monitoring work is added to their yearly schedule of monitoring and action logs as appropriate. Page 4 of 14

5 Contents Page Section Title Page Number 1 Introduction 6 2 Purpose 6 3 Scope 6 4 Legislation The Duty to Manage Asbestos 7 5 Policy Statement 8 6 Responsibilities for Compliance with the Policy The Chief Executive The Director of Finance and Estates Other Executive Directors The Director of Estates and Finance The Estates Manager Modern Matrons/Clinical Services Manager Ward Managers All Employees Contractors responsibilities 13 7 Training 13 Appendix Have you considered using a flowchart in your document to provide easy reference for staff? If you need support in developing a flowchart contact Page 5 of 14

6 Control of Asbestos Policy 1 Introduction Asbestos is a naturally occurring, fibrous silicate mineral. There are many types of asbestos, the most prevalent of which are Crocidolite (blue asbestos), Amosite (brown asbestos), and Chrysotile (white asbestos). Asbestos is highly resistant to chemical attack, an excellent insulator (electrical, thermal and acoustic) and has a very high tensile strength. For these reasons it was commonly used in building materials particularly from the 1950 s to the mid 1980 s. All asbestos has the potential to be hazardous to health, but it only poses a risk if the asbestos fibres become airborne and are then inhaled. Most asbestos containing materials (ACM s) therefore pose a low risk unless they are disturbed and fibres are released. The importation, sale and installation of products containing all types of asbestos was completely banned in the UK in 1999, however it is still estimated that across the UK over half a million non-domestic premises still contain ACM s (source: HSE, 2005). 2 Purpose The pupose of this document is to identify how the Trust shall manage the ongoing risks to persons from potential exposure to ACM s and applies to all premises occupied by the Trust. It will comply with all relevant Health and Safety legislation regarding asbestos, including its duties under the Health and Safety at Work etc Act, 1974 and The Control of Asbestos Regulations, amended 2006, and all associated Approved Codes of Practices. This document details what steps will be undertaken by the Trust to ensure that the risk associated with asbestos is adequately managed. It also details the responsibilities of the Trust s employees and contractors, and requires the cooperation of all employees, contractors and building users to ensure a safe and healthy working environment is maintained at all times. All procedures outlined below are mandatory for all parties involved. 3 Scope This document applies to all Trust employees and contractors, as well as to any other person who may come into contact with ACM s on any Trust premises. This Policy is necessarily managed and administered by the Estates and Facilities Department. 4 Legislation Under the Health and Safety at Work Act 1974, employers have duties to ensure, as far as is reasonably practicable, the health, safety and welfare of employees and the health and safety of others that may be affected by the employers undertaking. Page 6 of 14

7 The Control of Asbestos Regulations 2006 came into force on 13 November These Regulations bring together the three previous sets of Regulations covering the prohibition of asbestos, the control of asbestos at work and asbestos licensing. The Regulations prohibit the importation, supply and use of all forms of asbestos, continuing the ban introduced for blue and brown asbestos in 1985 and for white asbestos in They also continue to ban the second-hand use of asbestos products such as asbestos cement sheets and asbestos boards and tiles, including panels which have been covered with paint or textured plaster containing asbestos. The ban applies to new use of asbestos. If existing ACM s are in good condition, they may be left in place, their condition monitored and managed to ensure they are not disturbed. The 2006 Regulations also include the duty to manage asbestos (as defined in section 4.1) in non-domestic premises. Guidance on the duty to manage asbestos can be found in the Approved Code of Practice (ACOP) L127: The Management of Asbestos in Non-domestic Premises, which explains the duties of building owners, tenants and any other parties who have any legal responsibility for the work premises. It also sets out what is required of people who have a duty to co-operate with the main duty holder. These duties are extended more specifically by the following legislation: The Construction (Design and Management) Regulations 2007 requires the client to pass on information about the state or condition of any premises (including the presence of any hazardous materials) to the planning supervisor before any works begin and to ensure that a Health & Safety file is available for inspection if required. Hazardous Waste (England and Wales) Regulations 2005 requires any asbestos product or material that is ready for disposal be defined as asbestos waste. Asbestos waste also includes contaminated building materials, tools that cannot be decontaminated, personal protective equipment and damp rags used for cleaning. If in doubt, always treat waste as Hazardous or Special. Asbestos waste is considered hazardous when it contains more than 0.1% asbestos. Management of Health and Safety at Work Regulations 1999 Section 3 states that risk assessments are a legal requirement. It also requires the need for a special risk assessment for young persons (employees or work-experience students under 18) and new and expectant mothers, taking account of their individual needs. 4.1 The Duty to Manage Asbestos Duty holders include those responsible for the maintenance and/or repair of nondomestic premises. This includes the owners of such premises, whether they are occupied or vacant, or could include the occupier depending upon the terms of occupation. The aim is to protect anyone who may come across asbestos in the course of their day-to-day activities. The duty holder must: Conduct a survey of the premises Page 7 of 14

8 Take reasonable steps to locate materials containing or presumed to contain asbestos Complete a risk assessment to discover the likelihood of the release of dangerous fibres Make a plan to manage the above risk, including, if necessary, sealing or encapsulating the ACM s, or as a last resort, removing the asbestos Create a well maintained asbestos register, containing a written record of the location and condition of the asbestos in the building and maintain and update the register as required Put procedures in place to ensure that the employer s own employees or thirdparty contractors have full knowledge of where asbestos may be present to prevent accidental exposure 5 Policy Statement Manchester Mental Health and Social Care Trust is committed to the protection of the health and safety of all its employees, Service Users, visitors and contractors, and to the effective management of asbestos. The Trust recognises its responsibilities as a Duty Holder under The Control of Asbestos Regulations 2006 and will seek to co-operate with other Duty Holders where the duty is shared, and will ensure that: As a central point of contact, the Estates and Facilities Department will ensure that responsibilities of the Duty Holder are undertaken on behalf of the Trust In as much as is reasonably practicable, that the Trust complies with all Statutory Regulations and other guidance relating to asbestos and will ensure that its activities have a minimal impact on the environment An initial asbestos assessment is undertaken for all its occupied buildings, working together with any other joint Duty Holders to compile an Asbestos Register for the Trust, which will include the location and condition of known or suspected ACM s and will also include any historical information on previous remedial works undertaken The Asbestos Register is held in a central and accessible location within the Estates and Facilities Department and this information shall be subject to review and periodical inspection, which shall include inspections of ACM s remaining insitu An Asbestos Management Plan will be developed and will state what steps will be taken to manage the risk from known or suspected ACM s The Asbestos Management Plan will be monitored, reviewed and revised every 12 months or if there has been any significant change to the property or the known or suspected ACM s All recommendations and remedial works from the Asbestos Management Plan are undertaken as necessary as part of a planned programme of works When works require the appointment of a specialist contractor to undertake remedial work or removal of ACM s, the Trust shall have procedures in place to ensure that any contractor shall be competent and have a license issued by the Health and Safety Executive Page 8 of 14

9 Information from the up to date Asbestos Register is made available to all Trust employees, consultants and contractors appointed to undertake projects, including maintenance contracts or any works, and any other persons (including emergency services) that may be undertaking activities which may have an impact on identified or suspected ACM s All relevant parties who may have duties or responsibilities regarding asbestos management have been informed in writing, and that steps have been taken to ensure they understand all their responsibilities The Trust will provide adequate information, instruction and training for all employees who are involved in the management and maintenance of the Trust s property or who are liable to be exposed to ACM s during the course of their employment 6 Responsibilities for Compliance with the Policy 6.1 The Chief Executive As the Duty Holder, ensures that the Trust has an effective Asbestos Policy 6.2 The Director of Finance and Estates: responsible for asbestos management Ensures appropriate funds are available to resource managing asbestos effectively and to fund any capital and revenue relating to asbestos management and removal works. Ensures compliance with statutory legislation, approved Codes of Practice and the Health and Safety Executive requirements regarding asbestos Ensures there are robust systems in place for monitoring incidents associated with asbestos Provides a link with the Operational Risk Governance Committee to ensure that all identified risks are included in the Trust s Risk Register Reports to the Trust Board the details of any major accident/incident relating to the management of asbestos 6.3 Other Executive Directors Ensure this Policy is disseminated and implemented within their areas of responsibility Ensure all Clinical Services Managers, Modern Matrons, Ward Managers and all employees in their areas, are aware of and understand the Policy and that it is implemented into practice locally Will investigate failures to comply with the Policy and ensure corrective action is taken to prevent a recurrence 6.4 The Director of Estates and Facilities Ensures that the management of asbestos is co-ordinated effectively Provide all resources deemed necessary to manage the risk posed by asbestos Page 9 of 14

10 Ensures that the Policy is reviewed and updated regularly in accordance with current legislation and best practice and is fully implemented Ensure an asbestos assessment is undertaken for every property occupied by the Trust Ensure an Asbestos Register and an Asbestos Management Plan is created and updated as required Ensure all works on asbestos undertaken complies with the Trust s Asbestos Policy and Asbestos Management Plan, and are compliant with all current Health and Safety legislation regarding asbestos Ensure all Trust employees or those working on behalf of the Trust, are given adequate asbestos awareness/training and/or site induction, including sites where the Trust is not the Primary Duty Holder. It will ensure that persons brought to that site for the Trust, where their work may be affected by asbestos, are given adequate information to allow them to work safely Following any survey work or work with ACM s, will ensure that all appropriate certification is in place i.e. Clearance Certificate, Test Certificate In conjunction with any other named Duty Holders, ensure all contractors working for or on behalf of the Trust are informed before they start work, of the nature and extent of any known or suspected ACM s which may affect their work Should the Trust s Duty Holder responsibilities change to another party (for example if there is a change in tenancy or sale of a building) ensure all asbestos records are collated and handed over Carry out suitable Risk Assessments of any planned or reactive maintenance works, or works done by third party contractors where that work may be affected by ACM s Ensure all known ACM s are appropriately labelled, sealed/ encapsulated and maintained so that the item poses as low a risk as practicable to members of employees, Service Users and the public Ensure, where it is not reasonably practicable to seal or encapsulate any ACM s they are segregated from all persons and strictly controlled until such time as they can be removed Ensure that the Estates and Facilities Departmental Risk Register is updated with all issues relating to asbestos Ensure the use of approved, licensed asbestos removal contractors to carry out any planned, necessary works on ACM s Work with other Duty Holders to establish, in line with Lease/SLA arrangement (where applicable) who will collate and maintain an Asbestos Register for each site, and who will coordinate the various aspects of asbestos management such as risk assessments, specific task assessments, training, site inductions and reinspection surveys Where the Trust is not the Primary Duty Holder, to ensure any concerns or queries regarding the provision for asbestos management raised by, or on behalf of, the Trust are passed on to the Primary Duty Holder/other Duty Holders in writing as soon as possible Where the Trust is not the Primary Duty Holder, to ensure any new information regarding asbestos gained by the Trust, such as any updates or changes to Page 10 of 14

11 existing information, are passed on to the relevant Duty Holder so that the Asbestos Register can be kept up to date Ensure that Contractors are made aware of the Trust s Asbestos Policy, and their responsibilities under it. Ensure that Contractor s provide adequate and suitable training to their workforce. The Director of Estates and Facilities delegates the day to management responsibilities to the Estates Manager. 6.5 The Estates Manager Ensures that the management of asbestos is co-ordinated effectively Identify to the Director of Estates and Facilities all resources deemed necessary to manage the risk posed by asbestos Carry out an asbestos assessment is undertaken for every property occupied by the Trust Develop an Asbestos Register and an Asbestos Management Plan and update as required Ensure all works on asbestos undertaken complies with the Trust s Asbestos Policy and Asbestos Management Plan, and are compliant with all current Health and Safety legislation regarding asbestos Develop and deliver adequate asbestos awareness/training and/or site induction, including sites where the Trust is not the Primary Duty Holder, all Trust employees or those working on behalf of the Trust. It will ensure that persons brought to that site for the Trust, where their work may be affected by asbestos, are given adequate information to allow them to work safely Following any survey work or work with ACM s, will ensure that all appropriate certification is in place i.e. Clearance Certificate, Test Certificate, and record this information on the Trust s register In conjunction with any other named Duty Holders, ensure all contractors working for or on behalf of the Trust are informed before they start work, of the nature and extent of any known or suspected ACM s which may affect their work Should the Trust s Duty Holder responsibilities change to another party (for example if there is a change in tenancy or sale of a building) collate all asbestos records and for hand over Carry out suitable Risk Assessments of any planned or reactive maintenance works, or works done by third party contractors where that work may be affected by ACM s Appropriately labelled, sealed/ encapsulated and maintained al known ACM s so that the item poses as low a risk as practicable to members of employees, Service Users and the public Where it is not reasonably practicable to seal or encapsulate any ACM s ensure they are segregated from all persons and strictly controlled until such time as they can be removed Ensure that the Estates and Facilities Departmental Risk Register is updated with all issues relating to asbestos Page 11 of 14

12 Ensure the use of approved, licensed asbestos removal contractors to carry out any planned, necessary works on ACM s Work with other Duty Holders to establish, in line with Lease/SLA arrangement (where applicable) who will collate and maintain an Asbestos Register for each site, and who will coordinate the various aspects of asbestos management such as risk assessments, specific task assessments, training, site inductions and reinspection surveys Where the Trust is not the Primary Duty Holder, to ensure any concerns or queries regarding the provision for asbestos management raised by, or on behalf of, the Trust are passed on to the Primary Duty Holder/other Duty Holders in writing as soon as possible Where the Trust is not the Primary Duty Holder, to ensure any new information regarding asbestos gained by the Trust, such as any updates or changes to existing information, are passed on to the relevant Duty Holder so that the Asbestos Register can be kept up to date Ensure that copies of the Trust s Asbestos Policy is provided to Contractors prior to commencement of any works. Obtain confirmation from Contractor s that all staff employed are adequately and suitably trained with regard to asbestos safety and management. 6.6 Modern Matrons/Clinical Services Managers That all employees are made aware of the content of this Policy on asbestos That all employees familiarise themselves with this document and that any suspect materials or damage to known/suspect materials are reported immediately to their line manager and the Estates and Facilities Department 6.7 Ward Managers To be aware of asbestos in their area of influence and ensure others in their control are aware of the location of the Asbestos Policy and the location of ACM s To ensure that the Estates and Facilities Department is informed immediately if asbestos is found or suspected so that assessments can be made and the appropriate actions taken To ensure that their department implements any procedures deemed necessary by the Estates and Facilities Department in relation to asbestos To ensure all employees, Services Users, visitors and contractors are not at risk of exposure to ACM s To ensure any work likely to affect ACM s is carried out after consultation with, and in agreement with, the Estates and Facilities Department To ensure new equipment or apparatus erected, installed, purchased or gifted on behalf of the Trust is free of ACM s 6.8 All Employees Take care of their own health and safety and that of others who may be affected by their acts or omissions at work Page 12 of 14

13 Correctly use work items provided, including any personal protective equipment Not interfere or misuse anything provided for their health, safety or welfare Refrain from any activities which may disturb known or suspected ACM s Refrain from accessing any previously inaccessible areas Not undertake any refurbishment or redecoration works prior to consultation with the Estates and Facilities Department Report suspected ACM s to their line manager and Estates and Facilities Department without delay. Complete a Trust Electronic Incident Reporting Form (DIF1) on DATIX for any incident involving either a known or suspected ACM 6.9 Contractor responsibilities Consider at the initial outset of the project, the possibility of disturbing ACM s and the potential for the completion of additional surveys dependent upon the nature of the project to be completed, in order that any previous unidentified ACM s that may be discovered, can be managed Consult with the Trust s Estates and Facilities Department with specific regard to the review of the existing asbestos registers, site plans and any other documentation pertaining to the management of ACM s Receive suitable and sufficient awareness and practical training from their employer prior to any site activities; evidence of such training and subsequent refresher training must be provided prior to the commencement of work on site Halt work and inform Manager in charge if a suspected ACM is discovered during the course of any works and seek advice from an asbestos consultant Ensure that all works comply with the requirements of any relevant legislation, guidance and approved codes of practice, and any project specific specifications issued Implementing emergency procedures in the event that any ACM s or suspect ACM s are disturbed in an uncontrolled manner 7 Training Contractors working on Trust occupied properties should receive training by an appropriate competent person. This should include the following: A basic introduction as to the type of materials and products, which may contain asbestos and typical locations within buildings That the main risk associated with asbestos exposure relates to the inhalation of airborne fibre That any exposure to asbestos should be avoided and the risk increases as the level of duration, and frequency of exposure increases That where ACM s are in a good condition they should be left in place and undisturbed What emergency procedures to follow if damaged asbestos or materials suspected to be asbestos are found which have not previously been recorded in the register system Page 13 of 14

14 The Estates and Facilities Department will ensure that all relevant employees will or have undertaken initial training and then annual refresher training to ensure they are kept updated on new developments in the management and control of asbestos to ensure competent performance of their specific duties. Page 14 of 14

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