The Newcastle upon Tyne Hospitals NHS Foundation Trust. Asbestos Management Policy and Action Plan

Transcription

1 The Newcastle upon Tyne Hospitals NHS Foundation Trust Asbestos Management Policy Action Plan Version No.:.3 Effective From: 24 August 205 Expiry Date: 24 August 208 Date Ratified: August 205 Ratified By: Trust Health Safety Committee Introduction The Newcastle Upon Tyne Hospitals NHS Foundation Trust, in recognition of its duties as a Duty Holder under the Health Safety at Work, etc. Act 974 associated Regulations, will endeavour to comply with the Control of Asbestos Regulations 202, good practice guidance as far as reasonably practicable. The Trust Recognises its duty to manage asbestos within all its premises under Regulation 4 of Control of Asbestos Regulations 202. Information held by the Trust on asbestos shall be given without hindrance to those that need to be alerted about the presence of asbestos due to potential disturbance during the undertaking of their duties in line with Regulation 0 of Control of Asbestos Regulations 202, that all staff who have the potential to come into contact with asbestos will have a minimum of asbestos awareness training. It is acknowledged that priority assessment of asbestos can only be completed satisfactorily by the Trust. Works carried out by others will always require additional work to correctly establish the required action planning. This Policy Action Plan will be given the full support of all managers employees at all levels within the Trust. Implementation of this Policy shall be the responsibility of the Nominated Person responsible for asbestos Head of & Facilities. 2 Scope The Trust s strategy is to remove asbestos whenever the opportunity presents itself as part of any alteration or refurbishment work, prior to demolitions or where maintenance work would require any potential disturbance, spread or exposure to asbestos as outlined in Regulation of Control of Asbestos Regulations 202. It is not the Trust's strategy to systematically remove asbestos but to consider risk level of any asbestos containing materials found. When it is deemed necessary to remove asbestos, this will be done in line with Regulation 6 of Control of Asbestos Regulations 202 to prevent or reduce the spread of asbestos. Page of 5

2 Occasionally it may not be possible due to operational disruption to immediately remove asbestos that presents an immediate risk. In these cases the asbestos in question may have to be managed through means other than removal. These include but are not limited to: Enclosure Encapsulated Clearly label Restrict access to the area through a permit system controlled access. Risk assessment Management Survey Refurbishment Demolitions shall be undertaken to determine the location condition of asbestos containing materials present in buildings in line with Regulation 5 Control of Asbestos Regulations 202. Risk minimization shall be implemented from the results of risk assessments carried out for any task undertaken where exposure to asbestos is possible, as far as reasonably practicable, prevention or reduction to the exposure of asbestos will be undertaken. The Management Plan shall be implemented by considering the relative risks from asbestos from carrying out a material assessment a priority assessment in line HSE HSG 227. The procedure is as Appendix. A register of all known or presumed asbestos containing materials shall be compiled kept up to date. 3 Aims The Trust shall strive to prevent or reduce exposure from asbestos, as far as reasonably practicable, to all persons visiting or working in the Trust's estate. Steps will be taken to identify the presence of asbestos located within Trust premises manage the risks from asbestos in all properties owned by the Trust within the terms of the tenure arrangements for properties not owned by the Trust. Duties (Roles responsibilities) The following chart illustrates the allocation of responsibility for managing asbestos within the Trusts estate. Page 2 of 5

3 Chief Executive Duty Person Specialise Advice from External Agencies Nominated Person responsible for asbestos Head of Facilities Nominated Duty Holder Advice from Risk Management & Trust Health Safety Management Responsible Person for Asbestos Planning Trust Maintenance Systems Responsible for asbestos computer software Site Asbestos Freeman Hospital Deputy person Site Asbestos RVI ICFL Deputy person Site Asbestos CAV Deputy person 4 Definitions Type of asbestos: Condition Location Approximate quantity Risk of exposure to patients, staff, members of the public, contractors or building consultants Approximate cost of removal Electronic copies will be maintained by on the MiCad system, with paper backup logs. Records are to be maintained via the System s. A Management Plan, from the risk assessments, shall be produced which contains a prioritized list of intended remedial works for every asbestos item whether the asbestos is known or presumed to exist. An intended date for remedial action cost for each item of asbestos shall be given in the asbestos management plan. Page 3 of 5

4 The Management Plan will be reviewed annually will be led by Robert Serson (Chief Building Officer) any Risk Assessments undertaken. The Asbestos Register shall be made freely available to those who need to know, including the emergency services. An electronic system based on the Intranet shall be used to assist in widening the availability of the asbestos information. The frequency of re-inspection shall be determined from condition risk based on the priority scores.. Very high risk items of asbestos shall be inspected weekly 2. High risk shall be inspected annually 3. Medium risk shall be inspected annually 4. Low risk shall be inspected every 2 years 5 Property Transactions Responsibility Transfers From time to time the Trust may dispose of or acquire new premises or transfer responsibility for compliance with the Control of Asbestos Regulations 202. Presently these circumstances are seen as:- 5. PFI Part of the Trust's property portfolio may at a time in the future be hed over to a PFI operator (Project Co). The PFI contract documents state that Project Co shall be responsible for complying with all health & safety asbestos legislation. A copy of this policy will be passed to Project Co with all asbestos records, management planning risk assessments for Project Co to assume responsibility. It is expected that future demolitions of buildings mainly on the RVI CAV (formerly NGH) sites shall remove a high proportion of the asbestos content within the Duty Holder reasonability. The Trust will manage the asbestos risks in these buildings until such time the responsibility is transferred. All buildings may not transfer ownership, therefore, in the first instance the estates department should be contacted to establish the demolitions programme to identify who has the remaining building responsibilities in terms of asbestos management. 5.2 Property acquisition In the case of any additions to the Trust's estate, new asbestos risks will be managed following this policy. The will seek the vendors/lessors asbestos records for this purpose. If no asbestos records can be produced, suitable surveys i.e. a Management Survey or Page 4 of 5

5 Refurbishment/Demolition Survey shall be undertaken followed by a risk assessment through Priority Material assessment. These will be used as a basis for an asbestos register for the newly acquired property fed into the Trust s overall asbestos management plan. 5.3 Property disposal In the case of disposal of surplus premises by sale or letting the will consider the merits of risks associated with asbestos removal in line with Regulation 6 of Control of Asbestos Regulations 202 prior to disposal. The Trusts asbestos records for the premises subject to disposal will be made available to the purchaser or lessee if required. 5.4 Transfer to other NHS organizations or Public Sector Bodies Occasionally the Trust may transfer parts of the estate to other NHS organizations; in these instances, the Trust will make available copies of its asbestos plan records to the NHS organisation receiving the ownership of transferred premises. 6 Training All staff that are likely to come into contact with asbestos or have a management responsibility for asbestos shall undertake suitable asbestos Training. These staff will be defined clearly by role monitoring / training will be part of an ongoing process. Staff will undertake on-line asbestos awareness training via Trust e-learning programme. 6. Management Training The Asbestos Nominated person, Responsible person for Planning, Site specific responsible persons Deputies shall undertake Asbestos management Training. {e.g. HSE Asbestos workshop. British Institute of Occupational Hygiene (BIOH), The Management of Asbestos in Buildings (P405 to a Competent Person stard. 6.2 Other Employee Training General awareness training will be given regularly tailored to the audience present. The awareness training shall give internal Estate staff the knowledge to identify asbestos materials, the knowledge of when to stop report suspect materials, how to determine if asbestos is known to be present prior start of work, who to report suspect materials to the consequences of damaging asbestos materials. Awareness training on occasions may be extended to regularly employed external contractors (see below). Page 5 of 5

6 6.3 Measured Term Contracts (MTC) All MTC contractors engaged by the Department shall be required to engage site operatives that have had asbestos awareness training. Site specific induction training shall be given by Trust for contractors working in risk areas. Records are to be kept by the Department. 6.4 Main Contractor It shall be written into tender documentation that Main Contractors their subcontractors are to engage operatives that have had suitable asbestos awareness training. If necessary the Trust shall give specific site induction training to contractors working in high risk areas. Records to be kept by the Department. 6.5 Directorate Heads The Department recognizes that any Directorate with in the Trust may from time to time employ contractors to carry out work on the building fabric; these works shall only be carried out after notifying the Department of their intentions. In order to reduce the risks from accidental exposure from this sort of activity, all Directorate Heads shall be aware that by employing contractor s directly they have legal responsibility for informing the contractors of likely asbestos materials. Information shall be given freely by the Department to the Directorate Heads. 7 Equality Diversity The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public the way we treat our staff reflects their individual needs does not discriminate against individuals or groups on any grounds. This document has been appropriately assessed. 8 Monitoring Compliance Stard / process / issue Asbestos discovered on site will be actioned in line with the procedure in Appendix 2. All Estate areas built before 2000 to have a management survey undertaken Monitoring audit Method By Commi ttee Review of Datix included in gaps review documentation Health Safety Frequency Initial Yearly Page 6 of 5

7 including completion of the priority score assessment All records detailed below will be kept by the Department made freely available to Staff Contractors, via electronic or paper files The Asbestos Register shall be kept up to date, coincide with aforementioned inspection frequency on all known presumed asbestos containing materials Asbestos management system plan reviews shall be documented shall be of the management processes records as well as the asbestos materials themselves. Material reviews shall be documented kept with their re-assessment plans. Training records for all staff externally inducted contractors will be kept. Documents related to asbestos remedial works shall be kept. Records of any asbestos exposure shall be kept whether considered reportable or not Records shall be kept of any asbestos works. included in included in included in included in Completio n rates included in s review documentation Health Safety Health Safety Health Safety Health Safety Health Safety Health Safety Health Safety Yearly Quarterly Training Permits to work records on or near asbestos shall be kept. Planned asbestos removal works will be carried out by licensed contractors. Permit monitoring arrangem ents HSE licenced Manag ement Manag Monthly review Monthly review Page 7 of 5

8 All kept recorded documentation relating to asbestos works shall either be kept as a working document throughout the use of the building or archived as the building is demolished contractor Review checked prior to work. ement Manag ement review 9 Consultation review This policy shall be reviewed periodically or when there is significant change i.e. change in legislation. The review shall focus on, but not be exclusively restricted to, the following.- Legislation Guidance Best Practice Responsibility management structure Personnel Training Changes to site details Work Practices. Review of asbestos register, risks priorities. Reviews shall be documented with the changes being fully disseminated. Incidents Active Reactive monitoring Effectiveness of management action An independent audit / review of asbestos management, procedures, asbestos records register survey reports will be carried out on a periodic basis. 0 Implementation (including raising awareness) Management of the Risks from asbestos shall be carried out during routine day to day maintenance of properties. The risks of accidental exposure to asbestos shall be managed by ensuring management staff undertake the necessary risk assessments surveys prior to maintenance works being undertaken. Clear concise information on known asbestos will be given to maintenance staff working adjacent to or on asbestos containing materials or where the presence of asbestos is presumed. A precautionary approach shall be adopted i.e. suspect materials will be presumed to be asbestos until proven otherwise. If in doubt work shall be stopped reported. Non-licensed asbestos (asbestos containing materials ACM s e.g. asbestos cement products, textured coatings, floor tiles, composites etc.) are to be removed by a Page 8 of 5

9 competent persons who have undergone suitable training. All non-licensed asbestos removal will be double bagged clearly labelled put in sealed skips disposed in accordance with current guide lines. All contractors staff will have free access to on-line register for asbestos. Access to the register will be via the responsible persons or his deputy on each site. Labelling shall be used to indicate the presence of known ACM s whenever the Nominated Duty Holder deems necessary. All relevant works orders are to include for asbestos warning labels on the site. Major works typically involve closure of accommodation to undertake works. Refurbishment demolition surveys will be undertaken before major works progress. The responsibility for asbestos on a major scheme can be transferred from the to the Specialist Contractor if the area is hed over to the Contractor for the duration of the works. In such cases all known information will be given without encumbrance to the Main Contractor. Responsibility shall be clearly set out in the contract documents. References & Further Information AAA Training Co Ltd, 203. BOHS P405 - Management of Asbestos in Buildings. 7th ed. Sudbury: AAA Training Co Ltd. Health Safety Executive, n.d. Asbestos health safety. [Online] Available at Health Safety Executive, HSG227 A comprehensive guide to Managing Asbestos in premises. Sudbury: Health Safety Executive. Health Safety Executive, HSG247 Asbestos: The licensed contractors guide. Sudbury: Health Safety Executive. Health Safety Executive, HSG248 Asbestos: The analysts guide for sampling, analysis clearance procedures. Sedbury: Health Safety Executive. Health Safety Executive, ANNEX 8 Method Statement Aide Memoire. Guidance. London: Health Safety Executive Health Safety Executive. Health Safety Executive, 202. HSG264 Asbestos: The survey guide. 2nd ed. Sedbury: Health Safety Executive. Health Safety Executive, 202. INDG223 Managing asbestos in buildings: A brief guide. 5th ed. Sedbury: Health Safety Executive. Health Safety Executive, 203. L43 Managing working with asbestos. 2nd ed. Sedbury: Health Safety Executive. Page 9 of 5

10 Health Safety Executive, n.d. HSG20 Asbestos essentials. Sudbury: Health Safety Executive. UK Parliament, 974. Health Safety at Work etc Act 974. Norwich: The Stationary Office Parliament. UK Parliament, 999. Management of Health Safety at Work Regulations 999. Norwich: The Staionary Office UK Parliament. UK Parliament, 202. Control of Asbestos Regulations 202. Norwich: The Stationary Office UK Parliament. 2 Associated documentation None Page 0 of 5

11 Appendix Sample No. Asset ID.. Date.. Surveyor Hospital. Location.. Asbestos product Type.. Material risk (Mark -2) Location risk (Mark -2). Total risk assessment (Mark out of 24). Management Plan for identified asbestos Label Marking text Drawing updated Data base updated Re-inspection period Yes/No Yes/No ( Confirmed asbestos, reference no see asbestos register ) Yes/No Yes/No 6 month/ year/ 5 years PPM no Approximate cost of removal Next inspection date List of previous inspection dates Page of 5

12 Priority Assessment Algorithm PRIORITY ASSESSMENT ALGORITHM Assessment factor: Variable(s) selected: Score for each variable NORMAL OCCUPANT ACTIVITY Overall Score Main type of activity in area LIKELIHOOD OF DISTURBANCE Location: Accessibility: Extent/amount: average = HUMAN EXPOSURE POTENTIAL Number of occupants Frequency of use of area Average time area is in use average = MAINTENANCE ACTIVITY Type of maintenance activity Frequency of maintenance activity average = Total priority assessment score Material assessment score (supplied by surveyor) Total of material priority assessment scores Page 2 of 5

13 Material Assessment Algorithm MATERIAL ASSESSMENT ALGORITHM Sample Variable Score Examples of Scores Material Score Asbestos reinforced composites (plastics, Product type resins, (or debris from product) mastics, roofing felts, vinyl floor tiles, semi-rigid paints or decorative finishes, asbestos cement, etc.) 2 Asbestos insulating board, mill boards, other low density insulation boards, asbestos textiles, gaskets, ropes woven textiles, asbestos paper felt. Thermal insulation (e.g. pipe boiler lagging), sprayed asbestos, loose asbestos, asbestos mattresses packing. Extent of damage/ deterioration Surface treatment 0 Good condition: no visible damage. Low damage: a few scratches or surface marks; broken edges on boards, tiles, etc. 2 Medium damage: significant breakage of materials or several small areas where material has been damaged revealing loose asbestos fibres. 3 High damage or delamination of materials, sprays thermal insulation. Visible asbestos debris. 0 Composite materials containing asbestos: reinforced plastics, resins, vinyl tiles. Enclosed sprays lagging, asbestos insulating board (with exposed face painted or encapsulated), asbestos cement sheets, etc. 2 Unsealed asbestos insulating board, or encapsulated lagging sprays. Asbestos type 3 Unsealed laggings sprays. Chrysotile 2 Amphibole asbestos excluding crocidolite. 3 Crocidolite Total Score Page 3 of 5

14 Average Result Average Result Average Result PRIORITY ASSESSMENT ALGORITHM Priority Assessment Algorithm Assessment Factor Score Examples of score variables Normal occupant activity Main type of activity in area Secondary activities for area Likelihood of disturbance Location Accessibility Extent/amount Human exposure potential Number of occupants Frequency of use of area Average time area is in use Maintenance activity Type of maintenance activity Frequency of maintenance activity 0 3 As above Rare disturbance activity (e.g. little used store room). Low disturbance activities, (e.g. office type activity). Periodic disturbance (e.g. industrial or vehicular activity which may contact ACMs) High level of disturbance, (e.g. fire door with asbestos insulating board sheet in constant use) As Above Outdoors Large rooms or well-ventilated areas Rooms up to 00 m 2 Confined spaces Usually inaccessible or unlikely to be disturbed Occasionally likely to be disturbed Easily disturbed Routinely disturbed Small amounts or items (e.g. strings, gaskets) >0m 2 or >0m pipe run >0m >50m 2 or >0m >50m pipe run >50m 2 or >50m pipe run None to 3 4 to 0 >0 Infrequent Monthly Weekly Daily > hour > to 3 hours >3 to <6 hours >6 hours Minor disturbance (e.g. possibility of contact when gaining access) Low disturbance (e.g. changing light bulbs in asbestos insulating board ceiling) Medium disturbance (e.g. lifting one or two asbestos insulating board ceiling tiles to access a valve) High levels of disturbance (e.g. removing a number of asbestos insulating board ceiling tiles to access a valve or for recabling) ACM unlikely to be disturbed for maintenance < per year > per year > per month Page 4 of 5

15 Appendix 2 Error! ACTIONS TO BE TAKEN ON DISCOVERY OF SUSPECT ASBESTOS MATERIAL Any person working on the building fabric or services installation who discover suspected asbestos material Stops work; seals area around Material attaches warning sign; reports immediately to the site asbestos or his/her Deputy Sample to be collected analysed by specialist contractor Air monitoring if necessary Results are returned to the Asbestos of the site. The Risk Assessment is re-evaluated on which a decision is based; Priority of risk will determine necessity to remove or record seal any confirmed asbestos Site Asbestos completes WIMS warning updates updates risk assessment over sees updates to drawings Micad documentation PPM is created if required for remedial works Incident reported on the datix system } Page 5 of 5

16 The Newcastle upon Tyne Hospitals NHS Foundation Trust Equality Analysis Form A This form must be completed attached to any procedural document when submitted to the appropriate committee for consideration approval. PART. Assessment Date: 2/08/ Name of policy / strategy / service: Asbestos Management Policy Action Plan 3. Name designation of Author: Rob Serson, Chief Building Officer 4. Names & designations of those involved in the impact analysis screening process: Tim White, Health Safety Lead 5. Is this a: Policy Strategy Service Is this: New Revised x Who is affected Employees Service Users Wider Community 6. What are the main aims, objectives of the policy, strategy, or service the intended outcomes? (These can be cut pasted from your policy) To ensure that arrangements are in place to meet the duty to manage responsibilities, prevent unplanned disturbance minimise exposure to Asbestos Containing Materials within Newcastle Hospitals NHS Foundation Trust 7. Does this policy, strategy, or service have any equality implications? Yes No x If No, state reasons the information used to make this decision, please refer to paragraph 2.3 of the Equality Analysis Guidance before providing reasons: Complies with the Control of Asbestos regulations.

17 8. Summary of evidence related to protected characteristics Protected Characteristic Race / Ethnic origin (including gypsies travellers) Evidence, i.e. What evidence do you have that the Trust is meeting the needs of people in various protected Groups Does evidence/engagement highlight areas of direct or indirect discrimination? If yes describe steps to be taken to address (by whom, completion date review date) None relevant to this policy No No Sex (male/ female) None relevant to this policy No No Religion Belief None relevant to this policy No No Sexual orientation including None relevant to this policy No No lesbian, gay bisexual people Age Disability learning difficulties, physical disability, sensory impairment mental health. Consider the needs of carers in this section Audiometry carried out by Occupational Health The policy supports prevention of hearing loss Gender Re-assignment None relevant to this policy No No Marriage Civil Partnership None relevant to this policy No No Maternity / Pregnancy Pregnancy risk assessment carried out on all pregnant members of staff No No 9. Are there any gaps in the evidence outlined above? If yes how will these be rectified? No No No Does the evidence highlight any areas to advance opportunities or foster good relations. If yes what steps will be taken? (by whom, completion date review date) 0. Engagement has taken place with people who have protected characteristics will continue through the Equality Delivery System the Equality Diversity Human Rights Group. Please note you may require further engagement in respect of any significant changes to policies, new developments or changes to service delivery. In such circumstances please contact the Equality Diversity Lead or the Involvement Equalities Officer. Do you require further engagement? Yes No x No No

18 . Could the policy, strategy or service have a negative impact on human rights? (E.g. the right to respect for private family life, the right to a fair hearing the right to education? No PART 2 Name: Tim White Date of completion: 2/08/205 (If any reader of this procedural document identifies a potential discriminatory impact that has not been identified, please refer to the Policy Author identified above, together with any suggestions for action required to avoid/reduce the impact.)