Appendix 1 Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru Welsh Ambulance Service (NHS) Trust Asbestos Policy Approved by Date Review Date Target Audience Trust Board November 2007 November 2008 All Staff
CONTENTS 1.0 INTRODUCTION 1.1.1 Rationale 1.2.0 Scope 1.3.0 Principles 2.0 ASBESTOS POLICY 3.0 IMPLEMENTATION/COMPLIANCE 3.1.1 Chief Executive 3.1.4 Director of Finance 3.1.5 National Estates Manager 3.1.6 Assistant National Estates Manager 3.1.7 Contractors 3.1.8 Trust Service Leads/Managers 3.1.9 Employee Responsibilities 3.1.10 Occupational Health Advisor 3.1.11 Head of Training 4.0 DEFINITIONS 5.0 REFERENCES 6.0 PROCEDURES TO BE ADOPTED IN RESPECT OF ASBESTOS CONTAINING MATERIALS 7.0 APPENDICES 8.0 DISTRIBUTION 9.0 REVIEW 2
1.0 INTRODUCTION 1.1.1 Rationale 1.1.2 This policy sets out the commitment of the Welsh Ambulance Services (NHS) Trust to provide a safe and secure environment for its staff any persons who may visit its premises particularly contractors involved in working on the estate. 1.1.3 This document sets out the Trust s Asbestos Policy and defines the procedures which are required to meet legal obligations concerning the proper management of asbestos containing materials (ACM s). 1.2.0 Scope 1.2.1 This policy applies to all persons who have access to, or use of the Trust s premises, and all buildings - without exception. The Trust recognises its statutory responsibilities arising from the Control of Asbestos at Work Regulations and will adopt the necessary measures to identify and manage asbestos containing materials (ACM s) to reduce the risks to staff and any persons who may use Trust premises. 1.3.0 Principles 1.3.1 There is a legal requirement for the Trust to comply with the Control of Asbestos Regulations 2006 (Asbestos Regulations - SI No2739). Advice on the preferred means of compliance with the regulation is contained in the Approved Code of Practice (ACOP) The Management of Asbestos in Non domestic Premises. 1.3.2 The duties imposed by these regulations supplement the provisions of the Health and Safety at Work Act 1974 (the HSW Act) and some of the duties imposed by other sets of regulations: - a) The HSW Act requires employers to conduct their work in such a way that their employees will not be exposed to health and safety risks, and to provide information to other people about their workplace, which might affect their health and safety. The HSW Act contains general duties on employers and the self-employed in respect of people other than their own employees. Section 4 contains general duties for anyone who has control, to any extent, over a workplace b) The Management of Health and Safety at Work Regulations 1999 ( The Management Regulations ) require employers and self-employed people to make an assessment of the risks to the health and safety of employees and people not in their employment, arising out of, 3
or in connection with the conduct of their business, and to make appropriate arrangements for safeguarding health and safety of all concerned. c) The Workplace (Health, Safety and Welfare) Regulations 1992 require employers to maintain workplace buildings so as to protect occupants and workers. d) The Construction (Design Management) Regulations 2007 ( CDM ) require employers to improve health & safety on construction projects; to have the right people, for the right job, at the right time, to manage the risks on site and, to focus on effective planning and managing of risk. e) The Defective Premises Act 1972 in England and Wales, places duties on landlords to take reasonable care to see that tenants and other people, are safe from personal injury or disease, caused by a defect in the state of the premises. Any premises in such a state as to be prejudicial to health, constitute a statutory nuisance under section 79 of the Environmental Act 1990. An abatement notice can be served by local authorities, on the owner or occupier of premises requiring prevention or restriction of the nuisance. f) As well as imposing a duty to manage asbestos in premises, the Control of Asbestos Regulations requires employers to: 2.0 ASBESTOS POLICY 2.1 The Trust Policy is i) undertake risk assessments before commencing work which exposes, or is liable to expose, employees to asbestos; ii) produce a plan of work detailing how the work is to be carried out; iii) prevent exposure to asbestos To prevent exposure to the hazards associated with asbestos containing materials (ACM s) To promote awareness of the hazards of asbestos containing materials, the Trust asbestos management plan,and procedures through staff training 4
2.2 The Trust will a) establish whether there are ACM s in premises; b) presume materials contain asbestos; c) maintain records of the location and condition of all ACM s, and keep these records up to date in the Asbestos Register; d) assess the risks arising from the presence and condition of ACM s; e) prepare an Asbestos Management Plan that sets out how the risks are to be managed; f) take the necessary steps to put the plan into action; g) review and monitor the plan; h) provide information, on the location and condition of the material, to anyone liable to work on, or disturb the material, and to any persons with a relevant interest such as Staff Representatives; and i) promote awareness of asbestos, and the associated hazards amongst all staff 3.0 IMPLEMENTATION / COMPLIANCE 3.1.1 Chief Executive The Chief Executive - as the Duty Holder, holds the overall responsibility for Trust Health and Safety and implementation of this policy. 3.1.2 He/she will ensure: a) compliance with statutory legislation, approved codes of practice and Department of Health requirements regarding asbestos; b) appropriate funds are available to carry out capital and revenue works; c) that staff have received appropriate training and possess adequate knowledge in respect of ACMs. 5
3.1.3 This responsibility is delegated to the Director of Finance and the nominated Estates Officers identified below. This covers all operational aspects, and identifies all key personnel and their duties. 3.1.4 Director of Finance The Director of Finance is the Trust s Lead for the Estate and therefore asbestos. The Director of Finance will give assurance to the Trust Board regarding compliance with statutory legislation relating to the Trust s estate. He/she will provide a link with the Risk Department to ensure that all identified risks are included in the Trust s Risk Register. 3.1.5 National Estates Manager The National Estates Manager shall possess adequate professional knowledge, with appropriate training, to devise and manage the necessary procedures to ensure that ACMs within the Trust are well managed by: - a) ensuring that asbestos related work will only be carried out by specialist contractors, in accordance with current legislation and approved codes of practice and guidance; b) establishing exact specifications of project/refurbishment works to be contracted out, particularly work where ACMs are known, or presumed. This will include levels of competency of the persons employed on such work and will entail contractors making available the qualification and training records of all staff involved in the contract with the Trust; c) ensuring that all project and/or refurbishment work, likely to involve contact with ACM s, is the subject of a Permit to Work ; d) installing a monitoring system, that clearly identifies compliance with the specification, including the issue and checking of Permits to Work ; e) ensuring that all those likely to come into contact with ACM s in the course of their work are made aware of the risks to health and the action necessary if any ACM or suspected ACM is discovered, disturbed or damaged; f) ensuring that prior to attending and leaving the site, the contractor will liaise with a Trust Supervising Officer and/or the site representative. All relevant documentation required by the contract, must be provided and completed by the contractor; 6
g) ensuring that the contractor, has given the required notification to the HSE; h) ensuring that the contractor, has completed all documentation necessary for the appropriate disposal of waste; i) ensuring that, air borne fibre count monitoring, has been satisfactorily completed, and appropriate certificates issued; j) ensuring that periodic inspections take place, to record any change in condition or circumstances of ACM s and that these are recorded; and k) ensure that Health & Safety Manuals - arising from projects under the scope of the Construction Design Management Regulations, provide clear and precise information, on the products and materials contained within the works. 3.1.6 Assistant National Estates Manager The Assistant National Estates Manager is responsible for: a) maintaining up to date, comprehensive and permanent records of all known locations of ACMs (and, where subsequently, new locations are identified, these are added to the record, together with an assessment of the risks and a plan for management). The record will contain as a minimum: i) location of the ACM ii) type of asbestos (if sampled) iii) its condition iv) its extent. Furthermore, when the ACM is removed: v) the date of removal vi) the final air borne fibre count b) organising planned and regular inspections of areas known or suspected to contain ACMs, to determine any change in condition or circumstances; c) to ensure that any change in condition or circumstances noted, are recorded and the risk assessment and management plan reviewed accordingly. 7
d) ensuring that all those likely to come into contact with ACM s in the course of their work, are made aware of the risks to health and the action necessary if any ACM, or suspected ACM is discovered, disturbed or damaged. (See Procedures to be Adopted in Respect of Asbestos Containing Materials. Section 6 below and Attachment A); e) ensuring that all maintenance work likely to involve contact with ACMs is the subject of a Permit to Work ; f) ensuring that adequate and appropriate personal protective and other equipment is used by contract staff to minimise the risks to health of all persons. Ensure that the use of such equipment is included in the Permit to Work and that supervision ensures that such equipment is worn and/or used; g) ensure that staff required to work with ACM s are provided with appropriate training to ensure they are competent to carry out work in potentially contaminated areas; h) ensure that any contractors employed to treat, render safe, repair or remove asbestos are appropriately qualified and/or licensed by the Health & Safety Executive (HSE); i) ensure that all such contractors are familiar with the content of this document and their duties under current Asbestos legislation; j) maintaining local and permanent records of training undertaken; and k) identifying and incorporating any works required in respect of ACM s on any scheme and accordingly referring to the Asbestos Register prior to commencement of any works on existing Trust buildings. In the event that there is insufficient information on the location of ACM s, a full risk assessment will be undertaken prior to the disturbance of the existing building or services. 3.1.8 Locality Ambulance Officers and Team Leaders Locality Ambulance Officers and Team Leaders act as building managers and therefore have responsibilities with regard to the estate and buildings. The role of the Building Manager is to a) Vet self help schemes and projects on station and ensure the asbestos register is consulted with regard to any proposed work under self help and to liaise with the Assistant National Estates Manager as necessary; 8
b) ensure the asbestos register is kept in the designated location and that all contractors working on site consult the asbestos register prior to the commencement of any work on site; c) ensure that activities on site do not cause damage to the fabric and fittings of buildings. 3.1.9 Contractors All contractors employed by the Trust shall be competent and be responsible for ensuring that they, and any sub-contractor(s) reporting to them, carry out their activities in a way that complies with this policy. 3.1.10 Trust Service Leads/Managers Directors/Senior and Middle Managers are responsible for ensuring: a) that all staff are made aware of the content of this policy on asbestos; and b) that all staff familiarise themselves with this document, and that any suspect materials, or damage to known/suspect materials are reported immediately to their line manager and the Estates Department. 3.1.11 Employee Responsibilities In accordance with the Health and Safety at Work Act 1974 and the Trust s Health and Safety policy, all employees are required to -: a) take care of their own health and safety and that of others who may be affected by their acts or omissions at work; b) co-operate with the employer on health and safety; c) correctly use work items provided, including any personal protective equipment;. d) not interfere with or misuse anything provided for their health, safety or welfare; e) report suspected asbestos containing materials to their line manager, the Estates Helpdesk, and/or the Health and Safety Department or the Assistant National Estates Manager, without delay; f) complete a Trust Incident report, (AR1 form-available from every location that staff report to) for any incident involving either a known or suspected ACM. 3.1.12 National Risk and Health & Safety Manager The Occupational Health Advisor is responsible for contributing to the progressive reduction of risk by assisting and advising Directors, Managers and 9
employees on health and welfare issues that may arise from exposure to asbestos and/or the risk assessment process. 3.1.13 Head of Training The Head of Training is responsible for ensuring access to health and safety related training with particular reference to the risks from asbestos, to meet the needs of this policy. 4.0 DEFINITIONS Throughout this Policy and Procedure the following definitions apply: ACM - Asbestos Containing Material ACOP - Approved Code of Practice HSW - Health & Safety at Work Act CAW - Control of Asbestos at Work Regulations HSE - Health & Safety Executive 5.0 REFERENCES This policy is in response to the following legislation and approved codes of practices Health & Safety at Work. Act 1974 Control of Asbestos Regulations 2007 Management of Health & Safety at Work Regulations The Construction (Design Management) Regulations 2007 The Management of Asbestos in Non Domestic Premises, Approved Code of Practice L127. INDG 223(rev2) Managing Asbestos in Premises HSG227 A Comprehensive guide to Managing Asbestos in Premises A Guide to the Asbestos (Licensing) Regulations 1983 as amended L11 Work with Asbestos, which does not normally require a Licence, Approved Code of Practice L27 (4th Edition) 10
Work with Asbestos Insulation, Asbestos Coating and Asbestos Insulating Board, Approved Code of Practice L28 (4th Edition) Surveying, sampling and assessment of asbestos containing material MDHS 100 Managing Health & Safety in Construction HS(G)224 Approved Code of Practice Asbestos in Bulk Materials MDHS 77 Note - The following three sets of regulations have now been incorporated into the Control of Asbestos Regulations 2007 a) Control of Asbestos at Work Regulations 2002 b) Asbestos Licensing (Amendment) Regulations 1983 c) Asbestos (Prohibitions) Regulations 1992 6.0 PROCEDURES TO BE ADOPTED IN RESPECT OF ASBESTOS CONTAINING MATERIALS (ACM s) 6.1. Concerns Any staff who have any concerns or queries in respect of ACM s or questions relating to this policy should contact the ASSISTANT NATIONAL ESTATES MANAGER for the Region as follows: Region Title Telephone Mobile North Regional Estates 01745 532942 07825 365378 Manager South East Regional Estates 01495 765400 07912 998935 Manager Central & West Regional Estates 01792 562900 07891 074859 Manager Or alternatively write to: Welsh Ambulance Services (NHS) Trust National Estates Manager Trust Headquarters HM Stanley Hospital St Asaph Denbighshire LL17 0RS 6.2. Emergency Procedure for all Trust Staff:- If you suspect that asbestos has been disturbed, take the following action: 1) evacuate the area without causing alarm, cordon off or contain the area; 11
2) consult the asbestos register for that area; 3) report situation to Estate helpdesk or the Assistant National Estate Manager for the Region; 4) complete an ARI Form and record the names of all persons affected; 5) if asbestos is suspected, complete the Asbestos Identification Recording Sheet (sections 1-7)( Attached as Appendix A to this document) paying particular attention to the condition of the material and hand this to the Team Leader of Locality Ambulance Officer. The Team Leader of Locality Ambulance Officer will make an assessment of risk by completing (s)8 of the Asbestos Identification Recording Sheet and will liaise with the Assistant National Estate Manager for the Region, regarding the presence of asbestos, its condition and the associated risk. The recommended action will be based on the condition of the materials and the potential for damage/deterioration in its current location as follows: Good Condition Minor Damage 1. Register presence on the Asbestos register 2. Monitor the condition of the material at regular intervals 3. Where practical, the material should be labelled 4. Inform maintenance employees/contractors and any other worker likely to work on, or disturb the material Minor Damage 1. Register presence on Asbestos register 2. The material should be repaired and/or encapsulated following a risk assessment by a competent person/contractor 3. Monitor the condition of the material at regular intervals 4. Inform contract staff or any other person likely to disturb the material Poor Condition 1. Register presence on the Asbestos register 2. If in poor condition and likely to deteriorate further, arrange for suspect material to be sampled and tested 3. If asbestos is confirmed, arrange for removal by licensed removal contractor Damaged/Broken/Dusty 1. Register presence on the Asbestos register 2. If material has been disturbed, arrange for suspect material to be sampled and tested 3. If asbestos is confirmed, arrange for removal by licenced removal contractor 12
7.0 APPENDICES: Attachment A 8.0 DISTRIBUTION Distribution of this policy shall be to all the Trust s designated locations. 10.0 REVIEW This Policy will be reviewed 12 months from the date of ratification. 11.0 ASBESTOS MANAGEMENT PLAN The Asbestos Management Plan for the Welsh Ambulance Service (NHS) Trust is held by the Estates Department and is located at Headquarters. Contact Estates Department,, Welsh Ambulance Services NHS Trust, St, Asaph, Denbighshire, LL17 ORS. Tel: 01745 532900 13
ATTACHMENT A Welsh Ambulance Services NHS Trust ESTATES DEPARTMENT Asbestos Identification Recording Sheet 1. Premises (full postal address): Post Code: 2. Exact location: 3. Brief description of material: 4. Further information e.g. Prone to damage 5. Are there any HAZARD warning signs posted? YES. NO 6. Condition of material (circle appropriate description) 14
GOOD condition MINOR deterioration POOR condition DAMAGED/Broken/Dusty 7. Name: Date: 8. MANAGEMENT ACTION Inspected by: Date: Risk Score (see A overleaf): Date entered on Register: Recommended Action/Timescale: Signed: Name: Date: Date copied to Assistant National Estates Manager Date copied to National Estates Manager Date copied to Occupational Health Adviser 15
Date copied to Health & Safety Adviser Welsh Ambulance Services NHS Trust ESTATES DEPARTMENT Asbestos Identification Recording Sheet RISK MATRIX Likelihood of the material in its current condition of releasing fibres, or of being damaged or deteriorating further. Level Descriptor Description 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 in box (1) below Consequence: On health due to exposure Level Effect Exposure Result 0 Negligible NONE NONE 1 Minor No release of fibres No adverse effect 2 Serious Casual one off exposure with MAY result in adverse minimal release of fibres 3. Major Substantial release of fibres/coupled with personal health factors health effect in time WILL result in adverse health effect in time 4 Fatality Prolonged/heavy exposure Prolonged illness followed 16
5 Multiple fatality Prolonged/heavy exposure ENTER the consequence Score in box (2) below Risk Calculator: by death of ONE person Prolonged illness followed by death of a number of persons (1) LIKELIHOOD (2) CONSEQENCE (1) X (2) = RISK SCORE Key: 0 = No risk; 1-3 = Low, 4-6 = Moderate; 8-12 = Significant; 15-25 = HIGH Risk Action Levels: Risk Action Tick 0 = No risk No Action 1 3 = Low Action within one month 4 6 = Moderate Action within one week 8 12 = Significant URGENT Action within 48 hours 15 25 = HIGH IMMEDIATE Action within 24 hours B Date Samples (if appropriate) Type White: Chrysotile Blue: Crocidolite Brown: Amostie Sampled by: (Company name) Tick. Copy report attached VALID ON DATE OF PRINT ONLY 17