ASBESTOS POLICY & MANAGEMENT PLAN HS20 Version V2 Approved by: Health, Safety and Security Committee Date approved: March 2011 Ratified by: Hospital Executive Committee Date ratified 24 th April 2012 Document Lead: Head of Estates Services Lead Director: Associate Director Estates & Facilities Management Date Issued: June 2011 Review Date: March 2014 Target audience: All Trust line managers Other Policies to refer to: Health & Safety Policy, Incident Reporting Policy
Document Control Sheet Document Lead / Contact: Document ID Paul Pattinson, Deputy Head of Estates paul.pattinson@sath.nhs.uk HS20 Version 2 Status Approved by Health, Safety and Security Committee March 2011 (meeting held April 2011) Date Equality Impact Assessment Completed November 2010 Issue Date June 2011 Review Date March 2014 Distribution Key Words Available on SATH intranet Please note that the internet version of this document is the only version that is maintained. Any printed copies should therefore be viewed as uncontrolled and as such may not necessarily contain the latest updates and amendments. Control / Asbestos / Asbestoses / Hazard / Health and Safety / Risk Version History Version Item Date Author Status Comment Paul Pattinson, December Policy Deputy Head of Draft 1 2010 Estates 2 Policy March 2011 Paul Pattinson, Deputy Head of Estates Approved Consultation via December 2010 Health, Safety and Security Committee. Version 2 approved at March 2011 Health, Safety and Security Committee HS20 Page - 2 - of 10
Contents Paragraph Page 1 Aim 4 2 Arrangements 5 3 Surveys and Sampling 6 4 Asbestos Register 6 5 Risk Assessment 7 6 Asbestos Risk Management Plan 7 7 Risk Assessment for Work Activities 7 8 Action in the event of discovery of a suspect material 8 9 Exposure to Asbestos 8 10 Training and further information 10 11 Records 10 12 Management Review 10 Appendices Appendix A Asbestos Signage HS20 Page - 3 - of 10
1.0 POLICY AIM The Trust will comply with the Control of Asbestos Regulations 2006 (the Asbestos Regulations) and other relevant legislation in order to manage risk from asbestos on its premises and in its activities. The Trust policy is to prevent risk of exposure to asbestos, or to reduce it to as low a level as is reasonably practicable. The Trust will therefore: Systematically and proactively identify throughout its estate, any material containing asbestos or presumed to contain asbestos; Presume that materials contain asbestos unless there is strong evidence to suppose that they do not; Maintain a up-to-date record of the location and condition of asbestos and of materials presumed to contain asbestos (the Asbestos Register); Assess the risk of likelihood of exposure from such materials; Prepare and implement a management plan; Any material known or presumed to contain asbestos is kept in a good state of repair, and inspected / reassessed regularly; Any material known or presumed to contain asbestos is, because of risk associated with its location or condition, is repaired or if necessary removed, and; Information on location and condition of the material is given to anyone potentially at risk; Undertake risk assessments before commencing work which exposes or is liable to expose, employees or others to risk from asbestos, and; produce a plan of work detailing how such work is to be carried out; Either prevent exposure to asbestos or reduce it to as low a level as is reasonably practicable. The Trust will implement appropriate management arrangements and provide sufficient resources to carry out its legal duties imposed by the Asbestos Regulations. ARRANGEMENTS HS20 Page - 4 - of 10
2.0 MANAGEMENT ARRANGEMENTS 2.1 Chief Executive The Trust Chief Executive is the duty holder under the Asbestos Regulations. 2.2 Chief Operating Officer The Chief Operating Officer is the executive director lead for the management of risk from asbestos, and is responsible for ensuring that suitable arrangements are in place including the appropriate allocation of resources 2.3 Associate Director - Estates & Facilities The Associate Director - Estates & Facilities is responsible for the day to day management of risk from asbestos including: The systematic and proactive identification of asbestos in all SaTH NHS Trust premises. The maintenance of a record of location and current condition of asbestos and presumed Asbestos-Containing Materials (ACMs). Assessing the risk of the likelihood of exposure from these materials in accordance with the Method for Determining Hazardous Substances 100 (MHDS 100). The preparation and implementation of a documented plan to manage that risk. The preparation of risk assessments before commencing any work which exposes or is liable to expose employees or others to asbestos. Provision of appropriate training for all Estates staff and contractors engaged by the Trust. Procedures for action in the event of ACMs being discovered or suspected. 2.4 Head of Capital Projects SaTH NHS Trust The Head of Capital Projects is responsible for ensuring that the possible presence of asbestos containing materials is taken into account in risk assessments for all capital and development projects and in the induction process for all persons managing or carrying out such work. All contractors and consultants have access to the Asbestos register, and will be expected to satisfy themselves, prior to commencement, that it is safe to carry out their work. A Type 3 survey to MDHS100 will be carried out prior to all major refurbishment works and demolitions. Additional Type 2 surveys will be carried out if there is any doubt regarding the presence of asbestos. 2.5 Trust managers and Risk Assessors All Trust managers and risk assessors shall take the possible presence of asbestos into account in planning their activity and seek competent advice from the Estates and Facilities Division where appropriate. HS20 Page - 5 - of 10
2.6 Trust managers and The Health and Safety Team All Trust Managers shall involve the Health and Safety Team if there are any areas of concern in relation to asbestos. 2.7 All Staff Estates Manager s will ensure that all staff are made aware of the procedure to follow in the event of damage to known or presumed ACMs and in the case of discovery of such materials. Where a risk management plan is in place to manage asbestos or material presumed to contain asbestos, all staff are responsible for ensuring that the requirements of the plan are adhered to and to report any concerns over the effectiveness of those arrangements. Any work on asbestos materials on the site will be conducted solely by contractors holding the appropriate licensing, training, equipment and insurance. 3.0 SURVEYS AND SAMPLING A systematic site wide survey in accordance with MDHS100 Type 1 & 2 is being carried out to build on the information held in existing Asbestos register. Surveying and sampling is carried out by UKAS (ISO 17020) accredited consultants under the direction of the Head of Estates. SaTH NHS Trust consists of the Royal Shrewsbury Hospital (RSH) and the Princess Royal Hospital (PRH). Due to the varying age of the RSH site it is acknowledged that there are ACM products in many of the buildings. PRH was occupied in 1989 and as such it is widely assumed that no asbestos products were used in the construction. However it has been identified that some products such as gaskets do contain asbestos so surveys for PRH will be on the same basis as RSH. The survey report contains the material assessment score as calculated according to MDHS100. Additional survey work is carried out in areas where project or task activity is planned and the existing records are not sufficient to allow an appropriate risk assessment to be carried out. When significant refurbishment, plant removal or demolition is planned, a MHDS100 Type 3 survey is carried out beforehand. 4.0 ASBESTOS REGISTER The SaTH NHS Trust Asbestos Register is a public record and has been in existence for many years. The Register is maintained by the Estates Department and is available to all staff, contractors and others. It is reviewed by the Head of Estates annually and its review status recorded within the Register. The Register is continually updated by the surveying and sampling activity, and the implementation of the management plans. The Register contains information on the location and condition of all asbestos or materials presumed to contain asbestos on the SaTH NHS Trust site, together with the associated risk assessment and risk management plan. The register is currently being reviewed and it is anticipated that it will utilise CAD plans and digital photographs as well as written assessments and sample certificates. It will be made available both electronically and in hard copy. It is intended that the Register will be made available through the SaTH NHS Trust Intranet once the survey is completed. HS20 Page - 6 - of 10
In accordance with CAR 2006, statutory re-inspections and risk assessment re-evaluation will be conducted for all identified ACM (asbestos containing material) locations at no less than six-monthly for high-risk ACM s and annually for lower risk ACM s. 5.0 RISK ASSESSMENT Specific asbestos risk assessments, following the identification of asbestos or of materials presumed to contain asbestos, are carried in accordance with MDHS 100 and the Trust risk assessment template. MHDS 100 provides a material assessment algorithm which indicates the potential of the material to release fibres when disturbed. This algorithm takes into account: Product type Extent of damage or deterioration Surface treatment Asbestos type The location of the material Its extent The use to which the location is put The occupancy of the area The activities carried on in the area The likelihood and frequency with which maintenance activities take place This risk assessment is recorded in the Asbestos register and must be reviewed if there is significant change in the material assessment or any of the other factors included in the original assessment. 6.0 ASBESTOS RISK MANAGEMENT PLAN The Trust Asbestos Risk Management Plan is drawn up and implemented by the Estates Department. This plan deals with ACMs on a case by case basis using the MDHS 100 guidance and the Trust risk assessment to determine if the ACM should be removed or retained and managed. Removal of ACM or suspected ACM is carried out by competent persons utilising guidance published by the HSE. Where required by the guidance, the work will be carried out by competent contractors appropriately licensed and approved for such work. Where appropriate notification to the HSE is made by the contractor, the notification and agreed safe system of work must be made available to the Estates department prior to the work commencing. Subsequent sampling and clearance certification is included in the Risk Register. A specific management plan for each retained ACM is drawn up, indicating a regime of regular inspection and reassessment to minimise the risk of exposure. This plan is implemented as part of the planned preventative maintenance (PPM) regime by the Estates Department, and is reviewed after each inspection. 7.0 RISK ASSESSMENTS FOR WORK ACTIVITIES Persons responsible for planning projects and work activities must take the possible presence of asbestos into account when carrying out risk assessments for these activities. This is especially important where the work involves disturbing any building element by HS20 Page - 7 - of 10
drilling, cutting, sanding or scraping for example or entry into any space not normally accessed by non-estates staff such as ceiling voids, plant rooms ducts etc. The asbestos register must be consulted and if sufficient information is not available further investigation must be carried out. If there is any doubt about the presence of asbestos, the Estates Department must be involved at an early stage in the planning of the activity. The Estates Department will assist in organising surveys and in the interpretation of the results for the risk assessment. In the case of demolition or major refurbishment a MDHS100 Type 3 survey must be carried out to identify any possible location for asbestos that may be affected by the works. Where asbestos is identified as being present and liable to be disturbed, the risk assessment and safe system of work for the activity must be approved at a senior level in the Estates Department prior to work commencing. All persons carrying out work where asbestos is present or there is a risk of exposure must be given sufficient information about the risk and the arrangement for reducing risk so that they can carry out their activity safely. This is the responsibility of the supervising manager. Where contractors are carrying out work where asbestos is present or there is a risk of exposure, documentary proof that individual employees have received appropriate (CAR 2006-compliant) asbestos awareness training is required prior to their commencing work on site as per the Trust Control of Contractors Policy. 8.0 ACTION IN THE EVENT OF DISCOVERY OF A SUSPECT MATERIAL All staff and contractors carrying out work on the SaTH NHS Trust Estate have responsibility for the health and safety of themselves and others who may be affected by their activities. In the event of asbestos material being suspected or of known asbestos being disturbed: STOP work, Vacate and secure the immediate area against the spread of the material Inform the Estates Department through the helpline (4255- PRH, 1034-RSH) or the on-call Estates Engineer through the SaTH NHS Trust Switchboard. Do not attempt to clear up suspect material or collect samples Do not re-enter the area to collect tools, documents etc The Estates Department will arrange for sampling, assessment and the appropriate subsequent risk management activity. A Trust incident form must be completed even if the material turns out to be innocuous In the event of the discovery of suspect material or exposure, this information needs to be shared with the Trust s Health and Safety Team. 9.0 EXPOSURE TO ASBESTOS Any staff member or contractor who thinks that they may have been exposed to asbestos as a result of their activities on the SaTH NHS Trust site are required to complete a Datix Report or an Trust incident form (IR1 form) and also report their concerns directly to the Estates Department. HS20 Page - 8 - of 10
Managers should refer staff to Occupational Health for an assessment as to the likelihood of exposure and the details of the assessment recorded. A record entry will be made on the Occupational Health record of the member of staff. Asbestos often creates concern and anxiety, with unrealistic expectations of medical tests and treatment. The HSE does not advocate routine X-Rays for people exposed to asbestos in most circumstances. Occupational Health will offer prompt and reasoned advice about the risks associated with an individual s exposure to asbestos. The Trust s Health and Safety Team will investigate any exposure to Asbestos independently from the Estates Department. 10.0 TRAINING & FURTHER INFORMATION All Estates maintenance staff and their managers are required to attend asbestos awareness training which will be refreshed annually. This will normally be provided by an external training provider or through the Trust health and safety team. Newly employed maintenance staff and managers will receive asbestos awareness training as part of their local induction. This will be delivered by Estates managers or through the Trust health and safety team. All contractors carrying out maintenance activities on site where there is a risk of exposure to asbestos identified in the specific risk assessment for the activity, must also have undergone asbestos awareness training. Proof that specific individuals have received training will be required prior to them starting work as per the Trust Control of Contractors Policy. Further information on asbestos management can be obtained through Estates and Facilities or the Trust Health and Safety Team. The Health and Safety Executive publications on the subject are extensive and detailed. Much of this is freely available from their website (www.hse.gov.uk). These include a number of good practice guidance documents which can be utilised in creating specific safe systems of work. 11.0 RECORDS All records created as a result of the management of asbestos are public records and therefore subject to the NHS Code of Practice on Records Management. All records pertaining to specific buildings are retained for at least the life of the building. If the responsibility for a building changes the records are transferred to the new duty holder. All records pertaining to individuals and their possible exposure to asbestos are retained through Occupational Health for at least 40 years after the last relevant entry. 12.0 MANAGEMENT REVIEW The Asbestos policy and arrangements will be reviewed in the event of change of legislation or guidance, if it is deemed necessary to further minimise risk, or as detailed on the front sheet of the policy document The Asbestos register will be reviewed regularly due to the nature of the management plan which includes for reassessment. All incidents involving Asbestos will be reported and investigated, as per the Trust Risk and Policy and Procedure. HS20 Page - 9 - of 10
Asbestos Signage APPENDIX 1 TATIO N T HS20 Page - 10 - of 10