NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST. Documentation Control ASBESTOS MANAGEMENT AND CONTROL POLICY

NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST Documentation Control ASBESTOS MANAGEMENT AND CONTROL POLICY Reference HS / EI / 003 Approving Body Chief Executive Date Approved 29 Implementation Date 29 Summary of Changes from Previous Version Capture changes in legislation and guidance Reflect the changeover of responsibilities from NUH Estates to Carillion PLC as part of the EFM outsourcing. Supersedes Version 3 [October 2012] Consultation Undertaken Trust Health And Safety Committee. June 2015; Carillion (Trust FM Provider). June 2015 Date of Completion of May 2013 Equality Impact Assessment Date of Completion of We May 2013 Are Here for You Assessment Date of Environmental May 2013 Impact Assessment Legal Implications Control of Asbestos Regulations 2012 Target Audience All Trust Staff, Carillion, external Service Providers and Contractors, Tenants and Leaseholders of Trust Premises Review Date September 2018 Lead Executive Chief Executive Author/Lead Manager Andrew Camina Hard FM Compliance Manager ext. 76166 / Stephen Bernardi Head of Contract Performance and Quality Assurance 76142 Further Guidance/Information See Contact List Appendix 6 1

Section CONTENTS Title Page 1. Introduction 3 2. Executive Summary 3 3. Policy Statement 4 4. Definitions 5 5. Roles and Responsibilities 6 6. Procedural Arrangements 10 6.1 Management Procedures and Reporting Requirements 10 6.2. The Management of Asbestos Containing Materials. 14 7. Training 28 8. Impact Assessments 28 9. Monitoring Matrix 29 10. References and relevant Policies 30 Appendix 1 Record Of Suspected Exposure To Airborne Asbestos 31 Appendix 2 Asbestos Permit to Work Flowchart 33 Appendix 3 Asbestos Emergency Procedure Flowchart 34 Appendix 4 Confirmation of Type 3 and Remedial Works 35 Appendix 5 Solar Access Request Form 36 Appendix 6 Contact Information 37 Appendix 7 EQIA Form 38 Appendix 8 Environmental Impact Assessment 41 Appendix 9 We Are Here For You 45 Appendix 10 Certificate of Employee Awareness 48 2

1.0 Introduction 1.1 Breathing in air containing asbestos fibres can lead to asbestosrelated diseases, mainly cancers of the lungs and chest lining. Asbestos is only a risk to health if asbestos fibres are released into the air and breathed in. Workers who carry out building maintenance and repair activities are particularly at risk. There is usually a long delay between first exposure to asbestos and the onset of disease. This can vary from 15 to 60 years. Only by preventing or minimising these exposures now can asbestos-related disease eventually be reduced. Since 2000, it is now illegal to use asbestos in the construction or refurbishment of any premises, but many thousands of tonnes of it were used in the past and much of it is still in place. Any buildings built or refurbished before the year 2000 may contain asbestos. As long as the asbestos-containing material (ACM) is in good condition, and is not being or going to be disturbed or damaged, there is negligible risk, but if it is disturbed or damaged, it can become a danger to health, because people may breathe in any asbestos fibres released into the air. 2.0 Executive Summary 2.1 This policy describes the Trusts arrangement for the management of asbestos, and applies to all buildings owned, occupied or maintained, by Nottingham University Hospitals NHS Trust. It also covers activities where inadvertent exposure to asbestos may occur (e.g. maintenance, IT and telecoms, refurbishment and demolition work). 3

3.0 Policy Statement 3.1 The Trust is committed to so far as is reasonably practicable to managing the risks from asbestos. As part of this commitment the Trust will; maintain an Asbestos Register that will; Take all reasonable steps to identify asbestos containing materials [ACM s] that exist in all Trust premises. Determine the amount, location and condition of any asbestos containing materials found Meet the requirements of the Control of Asbestos Regulations 2012 and all other relevant legislative requirements. ensure that all duties and actions are performed in accordance with Health and Safety Executive [HSE] method HSG 264 and HSG 227 and that all work performed by external consultants are conducted to that standard. ensure that an asbestos register, risk assessments and associated asbestos management plans are produced which will describe how the risks from these materials will be managed. assess the risk to anyone being exposed to asbestos and deploy effective controls and safeguards to manage the risk. periodically review, monitor and update the asbestos register and management plan appoint competent persons and competent external consultants to assist the Trust in the management of asbestos. All consultants used will be ISO 9000 accredited and hold UKAS accreditation for asbestos surveying. implement robust management structures which are adequately resourced to manage the risks associated with asbestos. ensure that key staff and duty holders are sufficiently trained and competent to fulfil the duties outlined in this policy. 4

Specifically the Trust will ensure that; an annual independent audit of the operational management function, procured by the Trust s Competent Person is formally documented and issued to the Director of Estates. A specialist consultancy company is engaged to oversee, conduct and manage asbestos surveys as determined by risk assessment. All external consultants shall be independent of any related services such as asbestos laboratory services and stripping services as recommended in the HSE guidance note on the selection of consultants all staff receive suitable and sufficient training on asbestos management practices including asbestos awareness training for relevant staff the Trust s Competent Person, with the assistance of the members of the Asbestos Management Team, will ensure that risk assessments are performed and documented for each workplace, and that they are regularly reviewed based on the level of risk and classification. the Trust s Competent Person will ensure that the information contained in the asbestos register is made available to all relevant personnel, including non-trust staff working on site This policy will form part of any service level agreement with tenants or other authorised occupiers of the Trust s building this policy is subject to an annual formal audit, and reviewed every two years, or upon the issue of new or amended regulations. 5

4.0 Definitions / Abbreviations ACM Asbestos Containing Material ACMS ACMS UK Limited AIB Asbestos Insulation Board CAR Control of Asbestos Regulations 2012 EA Environment Agency HSE Health and Safety Executive ISO International Standards Organisation IT Information Technology MDHS Methods for Determining Hazardous Substances NNLW Notifiable Non-Licenced Work NUH Nottingham University Hospitals PPE Personal Protective Equipment RPE Respiratory Protective Equipment SMT Senior Management Team THSC Trust Health and Safety Committee UKAS United Kingdom Accreditation Service 5.0 Roles and Responsibilities 5.1 Trust Board The Trust Board accepts that it has overall accountability for the activities of the organisation, which includes the management of Asbestos Containing Materials present across all Trust premises. The Trust Board delegates the responsibility for the Management of Asbestos to the Chief Executive. 5.2 Chief Executive The Chief Executive holds the managerial accountability for the adequate allocation of resources, structures and arrangements for the Management of Asbestos. The Chief Executive delegates the day to day management of Asbestos to the Director of Estates. The Chief Executive will appoint a Competent Person and Deputy, on the recommendation of the Director of Estates, who will manage and control asbestos containing materials present within Trust premises. 6

The Chief Executive to appoint competent Auditors, on the recommendation of the Director of Estates who will provide independent assurance on compliance with this Policy and legislative requirements. 5.3 Director of Estates The Director of Estates has the delegated managerial responsibility for the management of asbestos including the production of the management policy and making recommendations to the Chief Executive for the appointment of independent auditors and the Competent Person. The Director of Estates delegates the day to day responsibility for the management of asbestos to the appointed Competent Person / Deputy. The Director of Estates will monitor the implementation and compliance with the Asbestos management and Control Policy and take corrective actions where required. As part of this responsibility the Director of Estates will receive independent assurance reports via the Asbestos Management and Assurance Committee as well as independent reports from the appointed Asbestos Auditors. 5.4 Competent Person (Carillion) The Competent Person (Carillion) has been appointed as the Trust s Competent Person. Carillion will appoint a Deputy Competent Person to deputise for the Competent Person. The Competent Person will; hold day to day management responsibility for asbestos management and compliance with this policy and legislative requirements be specifically trained in the management of asbestos containing materials and will be the first point of contact for advice. act as the controller of any work undertaken on or near asbestos maintain the Trust asbestos register (See 6.2) manage the issue of Permits to Work and Limitation of access Permits as described by the Policy (See 6.2.4 and 6.2.6) chair the Trust s Asbestos Management and Assurance Committee and ensure that the terms of reference and reporting requirements are met (see 6.1.1 6.1.5) ensure that all duties described in this policy are met escalate any issues of concern or non-compliance to the Director 7

of Estates and Trust H&S Committee (See 6.1.4) 5.5 Independent Audit Consultant The Chief Executive, on the advice of the Director of Estates will appoint an external Audit Consultant to provide independent assurance on compliance against the approved Trust policies, procedures and legislative compliance. The Consultant will ensure that the Competent Person and Duty Holders have satisfactorily completed an approved training course and recommend to the Director of Estates whether the persons are suitable for appointment by the Chief Executive. Undertake an annual audit of all aspects of asbestos management and produce a written report on behalf of the Director of Estates (See 6.2.2). 5.6 Carillion, Estates Capital Projects Team and ICT Projects Team Under the Control of Asbestos Regulations the above teams act as Duty Holders when putting staff and / or contractors to work. Duty Holders will; Liaise with the Competent Person and agree asbestos management procedures prior to any work taking place; Consult the Trust Asbestos Register at the scheme concept stage; Ensure all consultants and contractors have appropriate access to the Trusts Asbestos Register externally hosted by ACMS UK Ltd using the form in Appendix 5. Provide asbestos related information at pre-contract stage in the scheme Health And Safety plan and all other plans; Carry out a pre work asbestos survey and feed the results back into the Competent person so that the Trust s Asbestos register can be updated with relevant information. Where identified by the Survey and / or Trust Asbestos Register, arrange for the removal, repair or encapsulation of any asbestos materials by HSE licensed asbestos contractors; with agreement from the Competent Person Provide Removal and Clearance Certificates to the Competent Person and to ACMS by using the form in Appendix 4. The Competent Person will be responsible for updating the Trust Asbestos Register. Only carryout work where the above steps have been diligently observed and in accordance with agreed procedures 8

(See 6.2.4 & 6.2.6) 5.7 Other Duty Holders (e.g. Tenants, Clugstons, Procurement etc.) Any person putting contractors or staff to maintenance, installation refurbishment, new building or engineering works are required to follow the procedures in section 5.6 above. If in any doubt work must NOT commence until the Competent Person is satisfied that all procedures to prevent the disturbance of, or exposure to, asbestos have been fulfilled. 5.8 Local Management Directorate and Divsional Managers need to be aware of the current situation and presence of ACMs in their areas in order that they can ensure that all staff and other persons within their area of responsibility are aware of the information available. All Trust Directorate and Divsional Managers have a responsibility to ensure that their staff are informed and reminded of procedures to use in the event of discovering asbestos damage or deterioration within their areas of responsibility The Asbestos Management and Assurance Committee are responsible for the method of disseminating asbestos guidance and information to wards and departments. This information will be updated annually or more frequently as required. 5.9 Employees Every employee, including contractors, must not interfere with materials that are known to contain asbestos which are labelled and shall contact the Competent Person, via the Carillion Helpdesk on extension 57000, if they suspect that damage has occurred. 9

Asbestos is marked with the following sign 6.0 Policy Arrangements 6.1 6.1.1 Management Structure Asbestos Management and Assurance Committee Nottingham University Hospitals NHS Trust acknowledges the need to develop a core team of individuals to manage the risks associated with asbestos, their remedial work activities and the ACM monitoring and management regime. As a result, the following individuals have been identified as members of the Asbestos Management and Assurance Committee for Nottingham University Hospitals NHS Trust: Competent Person [Carillion] - Chair Carillion Health and Safety Manager Trust Contract Monitoring Team representative Trust Health and Safety Representative Carillion Representative Trust Capital Representative Trust ICT Representative Staff Side Union Representative EFM Matron Other members will be co-opted as required. 6.1.2 Meeting Frequency The Asbestos Management and Assurance Committee shall meet bimonthly or more frequently if determined by the committee chair. Extraordinary meetings can be called at any time. 6.1.3 Asbestos Management and Assurance Committee Terms of Reference. The committee shall ensure that the following actions are implemented Oversee / seek assurance that all reasonably practicable measures have been taken to determine the location and condition of materials likely to contain asbestos [ACM s]; 10

Presume materials contain asbestos unless there is strong evidence that they do not; Oversee and monitor that an up-to-date record of the location and condition of ACM s or presumed ACM s is maintained and kept up to date; Monitor that risk assessments are in place for all locations and activities which could give rise to anyone being exposed to fibres from these ACM s; Oversee the production and implementation of a plan setting out how risk from ACMs will be managed [Asbestos Management Plan]; Oversee and monitor to ensure that the plan is implemented and escalate any areas of non-compliance; Review and monitor the plan at each meeting; Ensure that (via the Duty Holders and local managers) information on the location and condition of ACMs is available and issued to anyone, including tenants under a service level agreement, liable to work on or disturb them; Manage emergency response to any incidents or accidental asbestos fibre release; Ensure that, where there has been a suspected or inadvertent exposure to airborne asbestos that an investigation is undertaken, that records are completed for each employee and a copy of the record is placed in their personnel file and that the incident is recorded on the Trust incident register (DATIX). See appendix 1 for the employee record form. Maintain and update the Trust Risk Register relating to operations and compliance issues. Review any incidents brought to the committee and agree any actions required to reduce or eliminate the risk of any further occurrence. Oversee medical surveillance for employees undertaking notifiable 11

6.1.4 Documentation non-licenced works (NNLW) in line with CAR 2012 Regulation 22. Responsibility for the day to day management of all these issues lies with the Competent Person Duty Holders shall submit copies of all asbestos related reports to the Competent Person for recording purposes and to ensure that all asbestos information including Refurbishment and Demolition Surveys, asbestos removal works and all associated clearance, re-occupation and air re-assurance certificates are issued to ACMS using the form in Appendix 4 to so that the asbestos register remains up to date. Minutes of each meeting and any issues for escalation will be submitted to the Trust Health and Safety Committee for review and action. The Asbestos Management and Assurance Committee will submit an annual report to the Trust Health and Safety Committee. 6.1.5 Overview and interaction schematic of the Asbestos Management and Assurance Committee. Chief Executive Officer Director of Estates Competent Person SMT Policy and Procedure Document Asbestos Management & Assurance Committee Training Asbestos Register Trust Health and Safety Committee Duty Holder(s) Refurbishment and Demolition Surveys Staff or Contractor task 12

6.1.6 Business Continuity This Policy will be implemented and managed on behalf of the Trust by the Competent Person. To cover for absence and to ensure continuity of service a Deputy Competent Person will also be appointed by the Chief Executive. 6.2 The Management of Asbestos Containing Materials ACM s can be found virtually anywhere within a buildings fabric or services. It is legal requirement that a register of asbestos materials is produced, maintained and reviewed regularly for every building. The Trust operates a web/browser based asbestos register and management system hosted by ACMS UK Limited. All data relating to asbestos surveys will be stored in this system and will be hosted externally. This will enable Duty Holder s to access the database via the Internet. Access is by user name and password. Access to the online asbestos register is strictly controlled. Duty Holders requiring access should complete the access request form in Appendix 5. The legal responsibility for the management of asbestos in a property lies with the employer. The HSE have introduced the Control of Asbestos Regulations, whereby all non-domestic properties must have an asbestos risk assessment and formal asbestos register to an approved standard. The purpose of the asbestos register and risk assessments is to inform any occupants or visitors of the building, of the locations and condition of all suspect ACM s within the building, so that accidental damage can be avoided. The Trust asbestos register/risk assessment shall include: The location of all ACM s to be positively identified and analysed by type and location; their composition and the action required should they become damaged; The location of all suspect ACM s identified and the action required should they become damaged; 13

A risk assessment of the hazards posed by both positively identified and suspected ACM s; A asbestos management plan that addresses the long-term maintenance and inspection regime of the ACM s; An annotated plan of the property indicating the locations of all known and suspected asbestos materials. Wherever asbestos materials are identified and recorded in the asbestos register, the actual ACM s are labelled as containing asbestos and that they are not to be disturbed In addition, the following labels will be placed at points of entry to areas which contain ACMs: 14

When the asbestos register identifies ACM s on a site, the campus Competent Person must familiarise all relevant staff including local managers of the location of the ACMs. All buildings must be assessed, prior to compiling the register. Materials shall only be discounted as non-suspect with valid reason: Brick Glass Presence of records that show that the material has been analysed, or installed after 2000. Where doubt exists, materials shall be regarded as suspect and treated accordingly. Use shall be made of any/all historical documentation; including plans, specifications, site diaries etc. and maintenance staff shall be interviewed for their local knowledge. The Trust will conduct a Management Level and Assessment Survey to form the basis of a suitable and sufficient assessment under the Management of Health and Safety at Work Regulations 1992 [as amended 1999]. The Trust will conduct annual asbestos re-inspections following the requirements and methods set out in HSG264. It is a legal requirement that the asbestos register is maintained, reviewed and used on a regular basis. The information shall be checked regularly for accuracy, and the suspected ACM s shall be inspected at a frequency determined by the Risk Assessment. The Management Plan shall ensure that asbestos materials are maintained in a safe manner for the life of the building or service in accordance with current legislation. 15

6.2.1 Trust Asbestos Risk Assessment Under the Control of Asbestos Regulations [CAR] 2012 all property owners and managers will have a duty to assess the risk posed by asbestos in their buildings, and to manage that risk. Only the Competent Person (or their Deputy), Duty Holder s or appointed Consultants are permitted to produce the asbestos risk assessments, for their area of responsibility. However information obtained from historical records, the site inspection detailed on the previous pages and third party surveys will aid in the formulation. In order to accurately determine the risk from each item of asbestos, a material assessment score shall be assigned to each item as recommended in HSE method HSG 264. This score is used in order to prioritise the located items of asbestos according to relative risk. It shall be noted, however, that the actual site conditions may indicate a need for more urgent work irrespective of relative scoring. The assessment score is based on the algorithm provided in HSG 264. Once the assessment is complete, the Duty Holder will ensure that the information is made available to all relevant personnel, such as maintenance staff etc. The Regulations state that the Trust shall inform anyone likely to damage the material - depending on the nature of the material this therefore might also include occupants of the property, cleaning staff and even visitors. There will be a timetable of regular reviews of all risk assessments and documentation of these reviews and their results by the Asbestos Management and Assurance Committee. It is imperative that any resulting changes to the assessments are notified to the relevant people outlined above. 16

6.2.2 Asbestos Consultants and Survey Requirements Surveying buildings for asbestos containing materials [ACMs], is a task that shall only be undertaken by suitably trained, qualified and experienced consultants. These consultants shall be independent of any company that provides laboratory analysis services, remedial work management or activities [including stripping] or any other asbestos services [other than consultancy and training]. All Asbestos Consultants employed, directly or indirectly, by the Trust will: hold certification to at least P402 or S301; have extensive asbestos surveying experience, and operate a Quality Management Scheme [e.g. ISO 9001]. The asbestos consultants shall employ staff with a minimum of 1 year s asbestos surveying experience for all surveys commissioned by the Trust. The method to be employed shall be based upon the guidance of MDHS 77 and HSG 264, and as such the following procedural document is intended as a reference, and not an instruction manual. The HSE algorithm shall be employed, and will be cradle-to-grave in format. The system will consider and record Risk Scores, Budget Cost Values and Difficulty. 6.2.3 Revision and Audit This policy and procedure document will be reviewed every three years or as required following any structure or legislative change. The review will be conducted with the assistance of an independent specialist consultant. Further reviews and modifications will also be made if there are any significant changes to: Legislation and Regulations; Guidance; Best Practice; Personnel/Team Structure; Responsibility; Significant Site Details; 17

Significant Work Practices. Audit of the Asbestos Management Plan is to be conducted by an independent specialist on an annual basis. This audit is to be formally documented and issued to the Competent Person. 6.2.4 Work involving known ACM (PERMIT TO WORK) The presence of known, or suspected ACM, shall be recorded on the asbestos register and the records updated to reflect the actions taken [i.e. as soon as removal or encapsulation is carried out]. Periodic re-inspection must be undertaken to ensure that there has been no deterioration in the condition of the ACM. The inspections carried out will be visual only, to avoid unnecessary disturbance or fibre release, and will not involve the removal of any covering material, e.g. duct panels or ceiling tiles. The frequency of inspection is determined by the risk assessment score. Risk Rating Score: Inspection Frequency: >10 Once per three months, or on reported damage. 7-9 Once every six-months, or on reported damage. 5-6 Annually, or on reported damage. 0-4 To coincide with other planned survey visits, but not less frequently than once every two years, or on reported damage. Any Duty Holder commissioning work on premises must ensure that all contractors who could potentially damage and/or be exposed to asbestos are informed of its location prior to commencement of any work. This includes emergencies [e.g. repairing leaks etc.]. In ALL circumstances work involving known or suspected ACM will be controlled by a Permit-to-Work due to the potential for asbestos fibres to be released [whether by activity on ACM s, or accidental and incidental exposure]. Permits to Work will be issued by the Competent Person (or Deputy) who should be contacted via the Carillion Helpdesk on extension 57000. If, on inspection, any material containing asbestos is found to be damaged or has deteriorated; the Surveyor shall isolate the area concerned and contact the Competent Person immediately. 18

The area shall be quarantined until remedial works can be completed. Once quarantined, the site will be identified for an asbestos survey by the Specialist Consultancy as a priority. The survey will be programmed as quickly as practicably possible. The inspection priority of the site will be raised and the survey process brought forward to an earlier date. Remedial actions cannot be specified, as they will be based on the findings of the asbestos survey. 6.2.5. Work Based Risk Assessments (See also Appendix 2) The Competent Person and Duty Holder(s) will ensure that no work will be carried out which is liable to expose anyone to asbestos fibres unless a suitable and sufficient assessment of the risk has been carried out and all the control measures required identified and implemented. The HSE Approved Code of Practice And Guidance 2013 Ref. L143 Managing and Working With Asbestos give guidance on licenced contractors, licensable works, notifiable licensable works and nonnotifiable licensable works. A copy of L143 can be downloaded from the HSE website http://www.hse.gov.uk/pubns/books/l143.htm. The Asbestos Essentials Task Manual 2012 (HSG 210) is an invaluable guide for non-licenced asbestos work. A copy of HSG 210 can be downloaded from the HSE website http://www.hse.gov.uk/pubns/books/hsg210.htm. As a minimum the assessment will: describe the work and its expected duration; identify the type of asbestos and results of any analysis; describe the quantity, condition and type of asbestos containing material; detail the nature, degree and frequency of exposure that may occur in the course of work, noting whether any action level/control level is likely to be exceeded; detail the control measures required; consider the results of any previous monitoring; 19

set out steps to prevent or reduce exposure to the lowest practicable level within the exposure limits. Generic assessments are acceptable for repetitive tasks carried out in the same manner in similar locations, so long as the assessments reflect the hazards and the risks associated with the specific activities. An amended risk assessment and plan of work must be prepared before commencement of any work with asbestos and reviewed by the Competent Person: The work method is varied due to a change in work specification; or Instruction to carry out additional work is given Advice must be sought from the Competent Person as appropriate prior to commencement of work if the assessment indicates that the action level will be or is likely to be exceeded. No work will proceed until an assessment has been completed, and safe access arranged if a potential ACM is identified prior to any survey No work involving known or presumed asbestos [or which is liable to disturb asbestos] shall be carried out unless a suitable and sufficient plan of work [including a method statement] is drawn up before the work starts. As a minimum this should include the following: The nature and likely duration of the works; The address and location where the work is to be carried out; The methods to be used where the work involves the handling of asbestos The type of equipment to be used including personal protective equipment [PPE]. A copy of the plan of work should be kept readily available on site. No refurbishment or demolition work shall be conducted without the completion of a Refurbishment and Demolition Asbestos Survey. The Duty Holder responsible for the refurbishment or demolition work shall liaise with the Competent Person for advice prior to commissioning a Refurbishment & Demolition survey from a specialist asbestos consultancy via the Trust List of Approved Consultants. The Duty Holder(s) will take all reasonable precautions to determine whether asbestos is present when drawing up specifications for all building, engineering and maintenance works. 20

The Trust is committed to an ongoing programme of asbestos surveys and inspections in accordance with HSG 264 and the priority risk rating applied to the material. All information regarding the presence of asbestos shall be passed to contractors, together with a warning that not all asbestos materials may have been identified. Areas of premises that were not accessible at the time of the survey shall be clearly identified on the premises plan. When work or access is required to such areas, all materials that might contain asbestos, must be assumed to contain asbestos, and the appropriate controls implemented. A refurbishment and demolition survey shall be conducted and the results received prior to any works being started. Consultants may not supervise any remedial works for which they conducted the survey and risk assessment. The survey/risk assessment consultancy employed will be independent of any asbestos removal companies or laboratories. Any work involving the following materials [not exclusive] that contain asbestos must be undertaken by contractors in possession of a licence issued under the Asbestos Licensing Regulations: Sprayed coatings; Thermal insulation; AIB unless classified as minor works; Textured coating. For any work involving asbestos the risk assessment and plan of work must be submitted in writing to the Duty Holder and Competent Person for review before the work commences. The reviewed assessment and plan of work must be obtained from the Duty Holder and Competent Person prior to commencement of any work with asbestos. Generic assessments and plans of work are acceptable for repetitive tasks carried out in the same manner in similar locations. This is in addition to any statutory notification required from the contractor. 21

As a minimum the following measures shall be implemented to reduce the risk of exposure to asbestos: The removal of materials that contain asbestos prior to any major works, where the risk assessment requires it; Limiting the number of persons exposed to the lowest possible number; Restricted and controlled access through the use of a Permit-towork System; Work methods which minimise the creation of dust, breakage, abrasion, machining or cutting of asbestos containing materials; Dust suppression by wetting methods where appropriate; Segregation by not carrying out asbestos work and other work in the same place at the same time; Keeping the work area clean by clearing up at regular intervals Provision and use of appropriate Personal Protective Equipment [PPE] and Respiratory Protective Equipment [RPE]. All employees and contractors shall follow any control measures determined necessary, including the use of RPE and PPE, and must demonstrate their competence in the use of the equipment prior to use. All employees and contractors shall: follow carefully all procedures set out and all actions identified by the assessment; keep the workplace clean; eat and drink only in designated locations, and report any defects, deviation for the work plan and/or incidents to the Duty Holder [or Competent Person] immediately. All contractors carrying out work with any asbestos based product in any building to which this policy applies, must have the following documents available for inspection on site: copy of the plan of work; copy of the Refurbishment and Demolition Asbestos Survey and its result; copy of licence for work with asbestos, where appropriate; copy of the work programme; copy of the current Employers and Public Liability insurance scheme; copies of relevant medical certificates, where appropriate; 22

copies of all relevant training certificates; copies of method statements; copies of relevant plant test certificates copy of the waste carriers registration, where appropriate; copies of all consignment notes, where appropriate; COSHH assessments for all substances in use; risk assessments appropriate for the proposed work; copies of air monitoring certificates and bulk sample analysis, where appropriate. All contractors carrying out work with any asbestos containing material in any building to which this policy applies, must keep a site log of the activity on the site, including any incidents, plant failure or human error. 6.2.6 Work not directly involving ACM ( LIMITATION OF ACCESS PERMIT) For work in areas where asbestos is present but does not form part of the scope of the work a Limitation of Access permit shall be issued by the Duty Holder. All relevant staff will receive training in its use. The following procedures apply to the issue of a Limitation of Access Permit: The Duty Holder shall enter on the Limitation of Access Permit details of the work to be done and the safety precautions applicable; The top copy of the Limitation of Access Permit shall be issued to the contractor / person in charge of the work, who, after reading its contents and signifying to the Duty Holder that the instructions etc. are fully understood, shall acknowledge its receipt by signing the declaration on Part 2 of the Limitation of Access Permit document; The recipient of the Limitation of Access Permit shall retain possession of the top copy at all times whilst the work detailed on the Limitation of Access Permit is being carried out; Copies of the limitation of access permit will be issued by the Duty Holder to all contractors / persons carrying out work. Where more than one contractor / person carrying out work is present, a Limitation of Access Permit shall be issued by the Duty Holder to the contractor / person in charge of each working party; 23

A Limitation of Access Permit is not to be issued for work on any Asbestos Containing Materials as this requires a Permit to Work Carbon Copies shall not be removed from the Limitation of Access Permit book even when a Limitation of Access Permit is cancelled before issue. Procedure for cancelling a Limitation of Access Permit. When work for which a Limitation of Access Permit has been issued is suspended or completed, the contractor / person to whom it was issued shall sign the declaration on Part 3 of the document and return the limitation of Access Permit to the Duty Holder who shall cancel the document by signing the declaration in Part 3. They shall destroy the original of Part 1 in the presence of the Duty Holder. 6.2.7 Asbestos Emergency Procedure (Appendix 3) If a material suspected of containing asbestos is discovered once work has commenced and the material is undamaged, no further work shall be undertaken that could result in damage, release of fibres or deterioration of the suspected asbestos containing material. The area is to be vacated, secured and appropriate warning signs preventing access displayed. The Duty Holder and Competent Person must be contacted immediately. If the asbestos is damaged, the area shall be evacuated and sealed. Upon notification of the discovery of suspected asbestos material, the Competent Person shall contact an approved independent asbestos analyst so that samples may be taken to determine if the material does contain asbestos. The Competent Person shall liaise with the Duty Holder and independent consultant to arrange access. If the material is confirmed to contain asbestos, then the assessment by the asbestos consultant will determine whether any of the proposed works would result in people being exposed to asbestos. The Duty Holder must satisfy themselves that the assessment indicates no exposure is likely, only then the works may continue. The asbestos register shall be updated by the Competent Person. If the assessment indicates that exposure is likely, the asbestos consultant shall make recommendations as to the appropriate 24

action(s) required. In the event of any member of staff or contractor inadvertently damaging a product thought to contain asbestos or discovering damaged asbestos, the following procedure will apply: 1. Leave the room, or if not in a defined room, the immediate area, closing the door and switching off all ventilation equipment. 2. Report to the Duty Holder, who will report to the Competent Person 3. The Duty Holder will refer to any premises records to determine if the product contains asbestos. Confirmation will be made with the Competent Person 4. The Competent Person will arrange for the approved independent asbestos consultant to attend site and carry out testing and provide advice as to the appropriate action; 5. If emergency work is required to make the area safe, The Contract Administrator or member of staff will contact the Competent Person for advice; 6. Only when the area is deemed safe by the Competent Person may the work continue. In every case of suspected release of uncontrolled asbestos (no matter how small), the Competent Person must be contacted as soon as possible, and a Trust Serious Untoward Incident Report form completed. The Emergency Procedure is illustrated in the flow-chart in Appendix 3 If there has been an uncontrolled release of asbestos at a concentration that exceeds the appropriate control limit, a Record of Suspected Exposure to Airborne Asbestos shall be completed and saved on the employee s personnel record. A form is set out in Appendix 1. A copy of this form shall be given to the employee with instructions that it shall be retained indefinitely. A copy shall also be sent to the Occupational Health Unit to be placed on the individual s medical records. The main copy shall be held by the Competent Person in the Incidents File. These records shall be maintained for a minimum of 40 years. Under certain circumstances exposure to a uncontrolled release of asbestosmay need to be reported under RIDDOR. The Trust H&S advisors must be consulted prior to any reporting. 25

7.0 Training All training will meet the requirements of CAR 2012 Regulation 10, and as described in the ACOP L143. The Competent Person will undertake training to the level required to meet the needs of the role. As a minimum this will be the Duty to Manage Asbestos 2 day course accredited by BOHS, IATP, UKATA or similar suitable organisation and undertake refresher training in accordance with the regulations. Every Duty Holder will undertake training to the level required to meet the needs of the role. As a minimum this will be the Duty to Manage Asbestos 2 day course accredited by BOHS, IATP, UKATA or similar suitable organisation and undertake refresher training in accordance with the regulations. Contractors or employees undertaking any maintenance, refurbishment, installation or any works that may bring them into contact with asbestos containing materials shall as a minimum have undertaken the Asbestos Awareness course accredited by BOHS, IATP, UKATA or similar suitable organisation and undertake refresher training in accordance with the regulations. 8.0 Quality Impact Assessments 8.1 8.2 8.3 An equality impact assessment has been undertaken on this draft and has not indicated that any additional considerations are necessary An environmental impact assessment has been undertaken on this draft and has not indicated that any additional considerations are necessary A Here For You assessment has been undertaken on this document and has not indicated that any additional considerations are necessary 26

9.0 Policy Monitoring Matrix Minimum requirement to be monitored Competent individual/ group/ committee Process for monitoring e.g. audit Frequency of monitoring Competent individual/ group/ committee for review of results Competent individual/ group/ committee for development of action plan Competent individual/ group/ committee for monitoring of action plan Undertake Trust risk assessment Policy review every 3 years Review of Asbestos Management & Assurance Committee Terms of Reference Updated Asbestos Register Training in place for all key staff and Duty Holders Competent Person Author Competent Person Competent Person Competent Person Annual review and update Revised Policy Revised / updated terms of reference Updated register and assurance Updated register of training Annual Asbestos Management & Assurance Committee 3 yearly Director of Estates Annual Annual Annual Director of Estates Asbestos Management & Assurance Committee Asbestos Management & Assurance Committee Asbestos Management & Assurance Committee Asbestos Management & Assurance Committee Asbestos Management & Assurance Committee Asbestos Management & Assurance Committee Asbestos Management & Assurance Committee Trust Health and Safety Committee Trust Health and Safety Committee Trust Health and Safety Committee Trust Health and Safety Committee Trust Health and Safety Committee 27

10. References Health and Safety Executive Approved Code of Practice and Guidance 2013 Ref. L143 Managing and Working With Asbestos; Health and Safety at Work etc., Act 1974, Sections 2, 3 and 4 [HSW]; The Management of Health and Safety at Work Regulations 1999; The Workplace [Health, Safety and Welfare] Regulations 1992; The Construction [Design and Management] Regulations 2007 The Defective Premises Act 1972 The Environmental Protection Act 1990; The Waste [England & Wales] regulations 2011 The surveying, sampling and assessment of asbestos-containing materials HSG 264; Asbestos essentials task manual HSG210 2012 [Third Edition]; The Health and Safety [Safety Signs and Signals] Regulations 1996 Occupiers Liability Act 1957 & 1984 The Control of Asbestos Regulations 2012; (referenced in section 3.1 above) [This list is not exhaustive but outlines the key documents to be consulted in conjunction with the operation of this policy and procedural document]. 28

Appendix 1 Record Of Suspected Exposure To Airborne Asbestos A copy of this form will be given to the employee and the original kept on the employee s personnel record. The employer will keep this record for 40 years. Personal Details: Name: Address: Date Of Birth: Job Title: During the course of my work on [date[s]] I discovered what I believe to be asbestos, the details of this being as follows: Name of Premises / Address Where Exposure Suspected To Have Occurred Number & Block: Name: Address: Date of Suspected Exposure: Location of Suspected Asbestos: Post Code: Please detail the exact location of the suspected asbestos below] Specify use if known: Asbestos accidently damaged / disturbed by you: Yes / No [circle appropriate] Asbestos damaged / disturbed before work? Yes / No [circle appropriate] Type of work being done and equipment used: Name Of Employee: Signature Of Employee: Name Of Competent Person: Date: Signature of Competent Person: Date: 29

Appendix 1 Corporate Safety Inspection into Suspected Asbestos Exposure Details of material which has been disturbed? Who was exposed? When did exposure occur? How did exposure occur? Date and time Competent Person informed? Date Specialist Consultants requested to attend site? Date of sampling and consultants risk assessment? Remedial works implemented? Date and brief details? Date results relayed to employee? Comments: Signature of Competent Person: Date: 30

Work Potentially Involving Asbestos Emergency Procedure Discovery of damaged, or disturbance of, suspected asbestos containing materials. Refurbishment/Demolition Maintenance/Minor Works APPENDIX 2 Emergency Procedure Follow section 7.8 Asbestos Emergency Procedure Flow Chart Refurbishment/Demolition: Carryout refurbishment and demolition survey prior to commencing work Review of risk screen A review of the building, equipment, location, construction type and age. Identify risk score as either high medium or low. What is the nature of the work? Does it involve the disturbance or removal of any of the following? Pipe insulation Ceiling tiles Board materials Sprayed thermal/acoustic insulation Asbestos cement products Textured coatings and paints Roofing felts Sealants PVC/Thermoplastic floorings Alterations to electrical or mechanical services Fire protection NO YES Do existing asbestos/building records indicate the presence of ACMS? Permit to work required NO YES What is the risk screen score for the building? Limitation of access issued HIGH MEDIUM LOW Permit to work issued Limitation of access issued No permit to work or limitation of access required

APPENDIX 3 EMERGENCY PROCEDURE FLOWCHART Discovery, damage or disturbance of suspected asbestos containing material Evacuate & secure area to prevent access & post signs. Report to Duty Holder Confirmed as non-asbestos The Duty Holder will refer to premises records & inform Competent Person No records or no confirmation that product does not contain asbestos REOCCUPY AREA Only on the receipt of a Clearance certificate can the Duty Holder allow reoccupation of the area Independent asbestos consultant investigates and takes samples If emergency work is required to make the area safe, the Duty Holder will contact a Licensed Asbestos removal Company Presence of asbestos confirmed, risk assessment conducted by consultant Risk assessment indicates asbestos can be left as found Risk assessment indicates asbestos requires removal, and cannot be left as found Risk assessment indicates that asbestos requires sealing Asbestos is left in place, the asbestos register is updated and a management plan implemented. Clearance certificate issued by the analysis Consultant prepares specification for removal Consultant prepares specification for encapsulation works REOCCUPY AREA Contractor selected from approved list (received training etc) Asbestos is sealed, the asbestos register is updated and management plan implemented. Clearance certificate issued by the analysis Contractor prepares plan of work for asbestos removal Competent Person agrees the plan of work Asbestos removal work is conducted Clearance Certificate given by the analyst and, the asbestos register is updated REOCCUPY AREA 32

APPENDIX 4 CONFIRMATION OF TYPE 3 & REMEDIAL WORKS Please ask for: Insert Name Ref: Author/Sec/Scheme Number Insert Date ACMS UK Heathcoat Building Science and Technology Park University Boulevard Nottingham NG7 2QJ Dear Sir Re: Completion of Scheme Notification Insert Scheme Name Insert Scheme Location Please find attached the following information regarding the above scheme: - Refurbishment & Demolition Survey (in accordance with HSG 264) Photographs of Asbestos Containing Materials. Air Quality Tests to the areas affected by the removal. Updated drawings of the ACMS Record Drawings. The location of the building(s) is as followed: - Location / Site Building Number / Block Name Building / Area Name Floor Room Numbers Please update Nottingham University Hospitals Asbestos Register with this information. Yours faithfully Insert Name Insert Job Title Cc Competent Person 33

APPENDIX 5 SOLAR ACCESS REQUEST FORM Please ask for: Insert Name Ref: Author/Sec/Scheme Number Insert Date ACMS UK Heathcoat Building Science and Technology Park University Boulevard Nottingham NG7 2QJ Dear Sir Re: Request for Asbestos Information Site Building Number or Block Can you please allow controlled access to the Nottingham University Hospitals NHS Trust Asbestos Register for the following persons for a duration of **Insert Duration** Name Company Email Address Consultant or Contractor The location of the building(s) is as followed: - Location / Site Building Number / Block Name Building / Area Name Floor Room Numbers I will await an electronic response from you providing the above persons with a hyper link to the appropriate documentation. Yours faithfully Insert Name Insert Job Title Cc Carillion Competent Person 34

APPENDIX 6 CONTACT INFORMATION Steve Walker has been appointed the Certified Competent Person for Carillion. He can be contacted via the Carillion helpdesk on 57000 to provide the appropriate support and response. 35