Asbestos Management Plan. Policy. The whole of the Trust. Intranet. The Trust Board/Executive Management Team

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1 Document name: Document type: What does this policy replace? Staff group to whom it applies: Distribution: Asbestos Management Plan 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 Policy. Page 1 of 18

2 ASBESTOS MANAGEMENT PLAN for SOUTH WEST YORKSHIRE PARTNERSHIP NHS FOUNDATION TRUST Page 2 of 18

3 CONTENTS Page 1. Introduction 4 2. Asbestos Management Survey Register 4 3. Asbestos Assessments 5 4. Action Plan 5 5. Asbestos Awareness & Training 6 6. Management Structure 7 7. Emergency Procedures 8 8. Emergency Toolkit Review Appendix 1 Equality and Impact Assessment 11. Appendix 2 Checklist for the Review and Approval of Procedural Document 12. Appendix 3 Version Control Sheet Page 3 of 18

4 1. INTRODUCTION The duty to manage asbestos is contained in regulation 4 of the Control of Asbestos Regulations This requires those who are responsible (the duty holders ) for the maintenance and repair of non-domestic premises to establish if asbestos is present in their buildings, and, depending on its condition, either remove it or manage it. It is also the duty holder s responsibility to ensure that sufficient information is made available to anyone who may come into contact with asbestos in their buildings to minimise their exposure. The purpose of this document is to provide information on the asbestos-containing materials (ACM s), present within South West Yorkshire Partnership NHS Foundation Trust (SWYPFT) owned premises. Other sites, occupied or managed by SWYPFT should have their own sitespecific documents & guidance s and should be followed at all times. ACM s have been identified and assessed for risk of exposure. An action plan is to be formulated setting out any necessary abatement or remediation to be undertaken, especially with respect to those materials identified as posing an unacceptable risk to either staff, patients or visitors. This document contains details and the methods & procedures designed to prevent or reduce the exposure or spread of asbestos fibres by controlling the activities of all those likely to disturb the ACM s. This document should also be read in conjunction with the departments approved Asbestos Policy 2. ASBESTOS MANAGEMENT SURVEY REGISTER The asbestos survey register contains information that sets out the details of the survey together with details of any caveats and any areas not accessed, or any environmental conditions that affected the survey. The register is also a database of all samples taken including a description of the location of the sample point, extent or amount and where appropriate - a digital photograph of the sample point together with the results of the laboratory analysis and the risk assessments. The survey register is available electronically via the Trust s Planet FM Enterprise system. A copy of the register for all the sites is available to all estates & facilities staff and engaged contractors to enable maintenance and other works to be planned & undertaken safely. It is the duty of all staff and engaged contractors to report amendments accordingly so that the register is updated to record such work done to either maintenance/protection or removal of the ACM s or the results of re-inspections. The database carries the building plans and a record of samples taken showing all points, all visually similar materials, all positive & negative samples as well as all areas not accessed. The Trust aims to hold all plans in CAD/PDF format, where the full extent of different ACM s may be overlaid and the layers switched on or off to aid interpretation, or to enable photocopies to be marked by hand. Trust survey reports are sent initially to the Estates Manager Corporate Services who will ensure that the Records Officer the Trust Information Officer will record / update the Trusts database accordingly. Page 4 of 18

5 3. ASBESTOS ASSESSMENTS The Control of Asbestos Regulations 2012 requires those who are responsible (the duty holder ) for the maintenance and repair of non-domestic premises to establish if asbestos is present in their buildings, and, depending on its condition, either remove it or manage it. It is also the duty holder s responsibility to ensure that sufficient information is made available to anyone who may come into contact with asbestos in their buildings to minimise their exposure. As the duty holder All SWYPFT properties have been re-surveyed / re-assessed over the last 3-years for ACM s by an approved/accredited asbestos surveying contractor carrying out management type surveys. Visual (non-intrusive, non-destructive) with sampling to provide data suitable for normal occupation in align with the current guidance, i.e. HSG264 requirements. To ensure no misunderstanding, there will definitely be ACM s that are have not been detected and recorded by previous & existing surveys, therefore all relevant activities should be undertaken with this in mind. Note: structures which were constructed after 1999 can be assumed not to contain any ACMs (but items of a greater age brought into any such structure may contain ACMs). 4. ACTION PLAN Monitoring: The HSE guidance strongly recommends the use of systems which are comprehensive, easily updateable and visually simple, such requirements imply the need to use systems which integrate and interact with software such as AutoCAD. The outcome of this portfolio survey has produced a comprehensive database using the IOM electronic system which can interact with other Trust software such as Planet FM Enterprise and AutoCAD to record and give all supervising staff access to the database to ensure that relevant known information is available, as and when required, through data and plan drawings recorded in electronic and hard copy format providing easily accessible records. Site Plans: The Trust holds electronic AutoCAD/PDF drawings/plans in the form of floor layout plans showing individual spaces identified by a unique reference number. This information is held on the IOM database system to which all asbestos survey details has been recorded / linked. Site, building, floor and room/area details shall be updated to the AutoCAD system as and when modifications have been completed to ensure as current a database as possible. Re-inspections: The Trust will continue to monitor known ACM s and carry out periodic re-assessments to its portfolio as appropriate within the above regulations. All planned surveys of buildings/structures services, fixed plant, equipment and machinery in accordance with Regulation 4 CAWR and ACoP L127 - The Management of Asbestos in Non-Domestic Premises. Page 5 of 18

6 Demolition & Refurbishment: A separate set of instructions should be included to cover work that will disturb the fabric in any way, and direct those planning such work to arrange for a refurbishment and demolition survey of all fabric in the area. Work should not be commenced until the results of the survey have been obtained and any ACM identified is removed or rendered safe (taking into consideration the possibility of the works damaging it). These instructions will not apply if the building is post 1999, but in such cases the age of plant, equipment and fittings should be considered, and these should be surveyed if necessary. 5. ASBESTOS AWARENESS & TRAINING To ensure staff s are aware of the dangers posed by asbestos, the Trust will provide relevant awareness training. In addition to Trust staff having asbestos awareness training, all contractors personnel (except those working on entirely new structures) should have asbestos awareness training before commencement of employment on Trust premises. All training should be in line with guidance set out in the Control of Asbestos Regulations 2012, Approved Code of Practice and guidance Work with materials containing asbestos L143 or subsequent documents. Page 6 of 18

7 6. MANAGEMENT STRUCTURE Chief Executive Trust Nominated Person Head of Estates & Facilities Records Officer Information Officer Responsible Person (Asbestos) Estates Manager Corporate Services Trust Health & Safety Manager Estates Staff and/or others engaging Contractors Asbestos Management Group The Asbestos Management Group co-ordinates all aspects of the management of asbestos within the Trust. The permanent members who meet regularly will include the Responsible Person (Asbestos), the Records Officer (Asbestos), and the Trust Health & Safety Manager. Others may be invited to attend on a needs basis. Estates Manager Operations, Estates & Facilities Co-ordinator (s) & Estates Officer (s) All Contractors & All Trust Staff Page 7 of 18

8 7. EMERGENCY PROCEDURES 7.1. PROCEDURE TO BE ADOPTED ON DISCOVERY OF SUSPECTED ASBESTOS CONTAINING MATERIALS. (ACM's) This procedure is for use by all maintenance / contractor personnel employed by the Trust and should be read in conjunction with departments approved Asbestos Policy. The Trust has a duty to identify the location and condition of ACM s, to record them and to ensure that risks from exposure are minimised. To this end all maintenance personnel will be trained in asbestos awareness to ensure that they have sufficient knowledge to identify potential sources / locations of ACM s. All Trust maintenance / contractor personnel will be trained in the use of this procedure and its accompanying record sheet. The Estates Manager Operations, Estates and Facilities Coordinators, Estates Officers and Health & Safety Manager are responsible for ensuring that ALL maintenance / contractor staff are aware of and are trained in the use of this procedure and that this knowledge is regularly updated. If asbestos is suspected, complete the Asbestos Identification Record sheet below completing Sections 1 to 7 paying particular attention to the condition of the suspect material. Immediately pass the completed record sheet to your Supervisor / Estates Officer. The Estates Officers will make an assessment of the risk by completing section 8 of the Asbestos Identification Record Sheet. The recommended action will be based on the condition of the material and its potential for being damaged in its current location, as follows: - Good Condition: Register presence on the Asbestos register. Monitor the condition of the material at regular intervals. Where appropriate, the material should be labelled. Inform maintenance employees and any other worker likely to work on or disturb the material. Reasonable Condition: Register presence on the Asbestos register. The material should be encapsulated following a risk assessment by a competent person/contractor. Monitor the condition of the material at regular intervals. Inform maintenance employees and any other worker likely to work on or disturb the material. Poor Condition: Register presence on the asbestos register. If in poor condition and likely to deteriorate further. Arrange for suspect material to be sampled - if confirmed arrange for the removal or encapsulated by an approved licensed contractor. Page 8 of 18

9 Ensure details are recoded / updated on the asbestos register. There are no options set out here to remove ACM s in good or reasonable condition. However, the Trust will generally aim to remove all such material when practicable. Page 9 of 18

10 7.2. ASBESTOS IDENTIFICATION RECORD SHEET SOUTH WEST YORKSHIRE PARTNERSHIP NHS FOUNDATION TRUST ASBESTOS IDENTIFICATION RECORD SHEET 1. Premises (full postal address) Post Code Exact location Brief description of material Further relevant information e.g. prone to damage Are there any HAZARD Warning signs posted NO 6. Condition of material: (Tick Box) GOOD condition MINOR condition POOR condition Damaged / Broken / Dusty (contact estates helpdesk) 7. NAME. Date. 8. ESTATES ACTION: Inspected by:..... Date..... Risk Score (see risk matrix)... Date entered on Register..... Recommended Action / Timescale Signed... Name Date.. Are materials subsequently shown (by testing) to be ACM s. NO Signed... Name Date Informed Estates & Facilities Co-ordinator... Date Informed Estates Officer..... Date Informed Information Officer Page 10 of 18

11 7.3. ASBESTOS RISK MATRIX Likelihood: of the material in its current condition of releasing fibres, of being damaged or deteriorating further. Valid on date of use only. Level Descriptor Description / Guide 0. Impossible cannot happen under any circumstances 1. Rare may occur; only in exceptional circumstances 2. Unlikely could occur at some time 3. Moderate should occur at some time 4. Likely expected to occur in most circumstances 5. Certain will occur in most circumstances ENTER the likelihood score (1) Consequence: of the material in its current condition of releasing fibres, of being damaged or deteriorating further. Valid on date of use only. Level Effect Description / Guide 0. Negligible external areas 1. Minor infrequent visited plant rooms / service ducts 2. Serious frequently visited plant rooms / service ducts 3. Major staff base, ward & circulation areas 4. Fatality demolition & refurbishment works ENTER the consequence score (2) Risk Calculator: (1) LIKELIHOOD x (2) CONSEQUENCE = RISK SCORE KEY: 0 = No risk; 1-2 = Low; 3-6 = Moderate; 8-12 = Significant; = High Risk Action Type: (tick) 0 = No risk - No Action 1 2 = Low - Action within one month 3 6 = Moderate - Action within one week 8 12 = Significant - URGENT Action in 48 hours = HIGH - IMMEDIATE Action in 24 hours White: Chrysotile Blue: Crocidolite Brown: Amosite Date Samples (if appropriate) / / Sampled by:... Company name. (attach copy report) Page 11 of 18

12 7.4. ASBESTOS IDENTIFICATION FLOWCHART Discovered or damaged materials that could contain asbestos? STOP WORK IMMEDIATELY Keep everyone else out of the area Is there dust or debris on clothing? Report the problem to the person in charge as soon as possible Put up a warning sign possible asbestos contamination Trained personnel to give client a sample to send for analysis A little, e.g. dust on sleeve, on shoes Get help ALL put on RPE Wipe down with damp rags A lot, e.g. contaminated clothes, hair, footwear Stay put Call for help. ALL put on RPE, helper put on PPE Wipe down with damp rags Does it contain asbestos? No action required Undress, Shower, Wash hair The information should be added to the existing asbestos management plan. If the release of fibres has occurred, air sampling should be carried out to demonstrate that the area has been cleaned up. Put contaminated clothes, towels etc in a plastic bag for a specialist laundry. Leave washing facilities clean. Dispose of rags as asbestos waste Keep a record of the event PROCEDURES:- Stop work immediately. Follow this chart or do a risk assessment to decide who must do work you or licensed contractor. Minimise the spread of contamination to other areas. Keep exposures as low as you can. Trained personnel to clean up the contamination. Source HSE Page 12 of 18

13 8. EMERGENCY TOOLKIT The Trust has made available an Emergency Toolkit which is located within the Estates Department at Fieldhead & Barnsley Hospitals and comprises the following items: - FFP3 disposable masks Type 5/6 disposable paper suits Pairs of disposable nitrile gloves Spray bottle with water/wetting agent solution Warning signs Instruction Sheet Log sheet to record use of kit The instructions for use are as follows: - Do not try and brush off dry fibres Put on a mask Deploy warning signs Lightly spray hair/ clothing Put on a paper suit Spray visible debris Await Licensed Contractor Follow specified decontamination procedures The above instructions are also held within the toolkit for further reference. It is the duty of anyone using the toolkit to inform their Supervising Estates Officer of any of the equipment that has been used and in need of replacement. 9. REVIEW This plan will be reviewed in line with the Trust s Asbestos Policy or if there are any significant changes to guidance or procedures in the management of asbestos within SWYPFT s property portfolio. Page 13 of 18

14 Appendix 1 - 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 Management Plan 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. NO Race Disability N N Page 14 of 18

15 9 Gender Age Sexual Orientation Religion or Belief Transgender 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, N N N N N This asbestos management plan 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: Yes The Asbestos Management Plan supports the Asbestos Policy and provides the operational guidance required to ensure the trusts statutory duties to management asbestos are been executed. N/A N/A Page 15 of 18

16 Appendix 2 - 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 Does the document identify which Yes/No/ Unsure EMT Comments Page 16 of 18

17 Title of document being reviewed: 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? Page 17 of 18

18 Appendix 3 - 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 Page 18 of 18

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