ASBESTOS CONTAINING MATERIALS POLICY

ASBESTOS CONTAINING MATERIALS POLICY Document Control Version 3 Ratified by Risk Management Sub Group Date Ratified 19 December 2012 Name of Originator/Author Head of Estates and Facilities Name of Responsible Risk Management Sub Group Committee/Individual Date Issued 20 December 2012 Review Date December 2015 Target Audience All staff and contractors

SECTION CONTENTS PAGE 1. INTRODUCTION 3 2. PURPOSE 4 3. SCOPE 3.1 Policy statement 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4.1 Chief Executive 4.2 Head of Estates and Facilities 4.3 Estates Operations Manager 4.4 Estates Officers/Managers 4.5 Assistant Directors/ Heads of department/ Service Managers 4.6 All Staff 4.7 Head of Information Management and Technology 4.8 Contractors 4 5 6 6 7 7 8 8 8 9 9 5. PROCEDURE / IMPLEMENTATION 10 6. TRAINING IMPLICATIONS 10 7 MONITORING ARRANGEMENTS 11 8. EQUALITY IMPACT ASSESSMENT SCREENING 11 9. LINKS TO ANY ASSOCIATED DOCUMENTS 12 10 REFERENCES 11 11 APPENDICES 13 Appendix 1 - Asbestos Emergency Procedures 13 Page 2 of 13

1. INTRODUCTION This document contains the Trusts policy on the management of asbestos containing materials (A.C.M s) in premises that are owned, occupied or maintained by the Trust. It sets out the policy for the planned management and emergency actions involving A.C.M s. Asbestos is a generic term for a number of silicates of iron, magnesium, calcium, sodium and aluminium, which appear naturally in a fibrous form. The fibres are chemically inert, incombustible and insoluble in solvents and water, although some of them may be attacked by strong acids and alkalis. Combined with its fibrous nature these properties enabled its application in a wide variety of products. Its most common uses were as an asbestos insulation or coating used for: Thermal insulation of boilers, ancillary plant and pipe-work (often hidden under floors and ducts). As a spray coating on steel work, concrete walls and ceilings for fire protection and insulation. Acoustic insulations of buildings. Some textured coatings and paints (e.g. Artex). Insulating board which was used in a wide variety of places such as: Fire protection on doors, protected exists, structural steelwork etc. Cladding on walls, ceilings (e.g. Asbestolux and Marinite). Internal walls and partitions Ceiling tiles in a suspended ceiling. Asbestos cement which is found as: Corrugated sheets (roofing and cladding for buildings). Flat sheeting for partitioning, cladding and door facing, and Rain water goods (i.e. gutters, down pipes). Roof tiles, cold water tanks. As ropes and fabrics, used for: Insulation and gaskets. Fire blankets. Protective clothing. The presence of asbestos containing materials does not in itself constitute a risk, however they may become hazardous when disturbed or damaged and must be treated accordingly. Activities that give rise to airborne dust e.g. abrasion, breaking, cutting, drilling or machining are most likely to present risks. The use of asbestos insulation and most types of asbestos is banned in the United Kingdom but many thousands of tonnes of asbestos were used in buildings in the past. Much of this asbestos is still in place and it cannot easily be identified from its appearance. Page 3 of 13

2. PURPOSE The purpose of this policy is to identify how the Trust will manage the ongoing risks to persons from potential exposure to asbestos containing materials. This policy applies to all buildings owned or occupied by the Trust, and other buildings where Trust employees may carry out work, including residential and non-domestic lettings This policy and any supporting documents are intended to ensure that the Trust meets the requirements of the Control of Asbestos Regulations. This policy is also intended to ensure that the Trust continues to comply with requirements of the Health and Safety at Work Act (1974) in relation to A.C.M. s. These requirements include: Implementing an effective management plan so that appropriate measures, such as monitoring, encapsulation, sealing, labelling, inspection or removal of the materials is undertaken. Where practicable, to prevent exposure to asbestos containing materials. Ensuring that all work undertaken on A.C.M. s is carried out in accordance with current legislation. Promoting awareness through appropriate training courses on the hazards of A.C.M. s together with awareness of the Trust s Policy, surveys and procedures. Providing and maintaining an asbestos register and to make this information available to all persons who may need to be aware of it. Ensuring that a periodic review of the Trust s policy on management of asbestos is carried out. 3. SCOPE The Trust and its management have a duty, so far as is reasonably practicable; to ensure that there is a regime for the management of asbestos. There are a number of Regulations that place a duty on an employer with regard to asbestos. These include: The Health and Safety at Work Act (1974). This Act requires an employer 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 Construction (Design and Management) Regulations (2007). These regulations require the Trust to pass on information about the state or condition of any premises (including the presence of hazardous materials such as asbestos) to the C.D.M Co-ordinator before any work begins and to ensure that a health and safety file is available for inspection by any person who needs the information. The Control of Asbestos Regulations requires employers to prevent the exposure of their employees to asbestos, or where this is not practicable, to reduce the exposure to the lowest possible level. This includes a Regulation placing a duty on those who have repair and maintenance responsibilities for premises, due to a contract or tenancy, to manage the risk from asbestos in those premises. Where there is no contract or tenancy the person in control of the building will be the duty holder. There is also a duty of cooperation on other parties. Page 4 of 13

This policy shall apply to all Trust staff, contractors and others who may be affected by A.C.M s. The Trust has many different arrangements in relation to the properties that are occupied by its staff and service users. The accountability for the management of asbestos is the organisation with the overall control of the building. These other host organisations may have their own policies in relation to the management of asbestos. Trust managers in these buildings should follow any local policies and procedures that may apply in addition to those outlined in this policy and Trust managers should also determine that appropriate measures are in place for the management of asbestos. Some of the activities associated with the management of A.C.M s overlap with those of other policies and procedures. Specific Regulations and guidance cover the hazards of these other activities and the precautions to be taken in relation to these. It is not the intention of this policy to provide details of the overlapping Regulations and guidance or the related hazards and precautions to be taken. 3.1 Policy Statement The Trust acknowledges and accepts its responsibilities under the Control of Asbestos Regulations. Where appropriate, Approved Codes of Practice and supporting guidance published by the Health and Safety Commission (H.S.C), and the Health and Safety Executive (H.S.E), shall be taken as the adopted standard. The Trust aims to provide and maintain safe and healthy working conditions, in particular ensuring, as far as reasonably practicable that: Where the Trust has a responsibility for a building where asbestos containing materials are present, or liable to be present, then the Trust shall ensure that an asbestos register is compiled identifying the location of all A.C.M s. The condition and historical data pertaining to any completed remedial works shall be retained. The register shall be subject to periodical inspection and review, which shall include inspections of asbestos containing materials remaining in-situ. As far as reasonably practical the register and accompanying reports shall remain unambiguous and up to date. Priorities identified with the register should be reviewed on a regular basis. Where the Trust is in control of premises, the Trust aims to prevent exposure to asbestos to a reasonably practicable minimum of anyone who may be affected by the Trust s activities by utilising the information available from the asbestos register. Where this is not reasonably practicable, the Trust will reduce exposure to the lowest level reasonably practicable, by measures other than the use of personal protective equipment. The Trust will also reduce the numbers of people exposed to as low as reasonably practicable. If asbestos containing materials are identified (or area liable to be present) and are found to be in good condition, sealed and unlikely to be disturbed or damaged, the assessment may show that it is safe to leave in-situ. The person responsible for the management of the premises must identify and introduce the measures to manage the risk. This will include making the relevant section of the asbestos register available for inspection, as and when applicable, checking the labels identifying asbestos containing materials are in place, and monitoring the condition of the identified or presumed asbestos containing material. Page 5 of 13

Information from the up to date asbestos register shall be made available to the Trust employees, consultants and contractors appointed to undertake building related projects, including maintenance contractors and any other persons (including emergency services) who may be undertaking activities which by their very nature may have an impact on identified or suspected asbestos materials. Where the surveys identify that remedial works may be required the Trust shall appoint a competent U.K.A.S. approved consultant to manage the works. Independent consultants, who may undertake testing, sampling, monitoring and supervision, shall have in place the relevant level of U.K.A.S accreditation issued by an appropriate body complying with ISO17025. In addition to this and for the supervisory facet of their services the consultant shall also have in place a licence issued by the Health and Safety Executive. The Trust will provide adequate information, instruction and training (including supervision) for all employees who are involved in the management and maintenance of properties or who are liable to be exposed to asbestos containing materials during the course of their employment. All contractors who may carry out works in areas where asbestos containing materials have been previously identified shall be required to provide evidence of similar information, instruction and training (including supervision) to their employees It is the intention of the Trust to ensure effective implementation of the aforementioned statements and to keep them under consideration in all aspects of resource management and decision making. 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4.1 The Chief Executive The Chief Executive has the overall responsibility for ensuring compliance with all statutory regulations. The accountability for the management of asbestos containing materials is devolved to Directors, Managers, Heads of Department and to appropriate Trust employees. The Trust has many differing arrangements in relation to the properties that are occupied by its service users and staff. The accountability for the management of A.C.M s may be the responsibility of the organisation with the overall control of the building. For buildings where the Trust has overall control of the building, the accountability for the management of A.C.M s is given to the Head of Estates and Facilities who devolves this responsibility to officers of the Estates Department. Page 6 of 13

4.2 Head of Estates and Facilities The Head of Estates and Facilities shall ensure that suitable and sufficient arrangements are in place for the management of A.C.M s in the areas of his control. This includes setting a suitable and sufficient policy for management of A.C.M s in accordance with the Control of Asbestos Regulations and to develop and monitor procedures for effective implementation. Some of these duties are delegated to the Estates Operations Manager. 4.3 Estates Operations Manager The Estates Operations Manager has the delegated responsibility for the management of A.C.M s in the areas of his control. The Estates Operations Manager has the delegated responsibility for ensuring that all Statutory Instruments and guidance relating to the management of A.C.M s in the areas of his control are implemented and maintained where resource allows and that adequate resources are available for staff training and the management of asbestos within Trust agreed financial limits. This responsibility is further delegated to other managers and officers in the estates department. The Estates Operations Manager should ensure that suitable and sufficient arrangements are in place for implementing the procedures necessary for compliance with the Control of Asbestos Regulations in areas of his control. In particular this will include: Implementing a pro-active management action plan for managing A.C.M s for the premises controlled by the Trust. Ensuring that advice and information on A.C.M s is available to employees, contractors and others. Ensuring that all staff under his control are given appropriate training. Ensuring that any person organising work in the Trust under his control, who may disturb A.C.M s has access to up-to-date information and understands the requirement to avoid disturbing the material. Advising and assisting other Trust employees of their duty in relation to the Control of Asbestos at Work Regulations. Maintaining a record of A.C.M s and ensuring that up-to-date risk assessments are available. Ensuring that suitable re-inspections of known A.C.M s are undertaken, as least on a two yearly basis and more frequently should the location or other factors dictate otherwise. Where asbestos exists in a public accessible area, discreet labelling will be used to ensure that persons undertaking any work which may increase the risk of exposure are warned appropriately but not so as to cause public concern. When it is not possible to label asbestos e.g. external items and floor tiles, the survey should state this. Implementing emergency procedures in the event that any A.C.M s or suspect A.C.M s are disturbed in an uncontrolled manner. Ensuring that records relating to asbestos are kept permanently. Page 7 of 13

4.4 Estates Officers/Managers Estates Officers/Capital Project Managers/Contract Administrators, or estates managers responsible for organising works in buildings, particularly those works which may affect the fabric of the structure or equipment within it, shall have regard to the possibility of disturbing A.C.M s. In particular they shall; - Ensure that all project specifications and works comply with the requirements of any relevant legislation, guidance and approved codes of practice. Assess areas of potential disturbance at the planning stage to identify any known risk from asbestos by interrogating the asbestos register and, if appropriate, arranging for a type 3 survey to be carried out. This will apply to all refurbishment work and demolition and is requirement of the Construction Design Management Regulations (2007). Inform appropriate staff and liaise with Managers and department heads in relation to asbestos If necessary halt work and inform staff if suspected asbestos material is discovered during the course of any works and seeking advice from an asbestos consultant. Implement emergency procedures in the event that any A.C.M s or suspect A.C.M s are disturbed in an uncontrolled manner. 4.5 Assistant Directors/Heads of Departments/ Service Managers/ Trust Managers have a key responsibility for ensuring that there is a proactive approach to organising, planning, controlling and reviewing health and safety. They have a responsibility to ensure that staff under their control are provided with suitable information, instruction and training in relation to all relevant health and safety matters which includes asbestos containing materials. Trust Managers should ensure that they have a copy of the asbestos register for all buildings where the Trust provide services from. The Head of Estates can provide a register for all buildings that are in control of the Trust. The register should be made available to staff. Trust managers may challenge any person carrying out work on building fabric to determine if the area of work has been checked for the presence of asbestos. Estates personnel can provide advice and assistance in this matter. 4.6 All staff With specific reference to asbestos containing materials (A.C.M s) all Trust staff should be aware of the following: - Should any employee accidentally disturb identified A.C.M s they are to report the incident immediately to their direct line manager, who shall report to the person in control of the building and to the Trust estates department, so that any emergency procedures can be initiated as soon as is practicable. An incident report should be submitted if this occurs. Page 8 of 13

All Trust staff have a responsibility not to disturb, or commission any other person (such as a contractor) to disturb any part of the fabric of any building without consultation with the organisation in control of the building or the Trusts estate department, for example, drilling walls, window sills, ceilings, installing telephone or data cables in ducts and voids. Staff may wish to see the asbestos register for the buildings that they occupy. This should be made freely available. 4.7 Head of Informatics Services The Head of Informatics Services and other staff within the service may arrange for ICT infrastructure work to be carried out in areas where A.C.M s are present. These staff should have due regard to the possibility of disturbing A.C.M s and must ensure that prior to any work being carried out the by either Trust or contract staff the estates department have been contacted and advice sought If suspected asbestos containing materials are found the work must be halted and advice sought from estates personnel. 4.8 Contractors All contractors responsible for organising works in buildings, which may affect the fabric of the structure, or equipment within it, should have regard to the possibility of disturbing A.C.M s. In particular they should: - Consider at the initial outset of the project, the possibility of disturbing A.C.M s. Dependent upon the nature of the work to be completed, consider whether additional surveys may be required. Consult with the Trust s estates department with specific regard to the review of the existing asbestos of A.C.M s. They should ensure that all their employees receive suitable and sufficient information, instruction and training (including supervision) relevant to the task they are to undertake, and including any specific procedures relative to the presence of known or suspected A.C.M s Evidence of such training and subsequent refresher training (usually every 3-5 years) must be provided prior to the commencement of any work. Page 9 of 13

5 PROCEDURE / IMPLEMENTATION 5.1 Safety of staff. Guidance for estates staff on the safety aspects related to A.C.M s is set out in this policy and the references therein. Advice from the Trusts asbestos consultant shall always be sought on asbestos related matters. The Trust has many differing arrangements in relation to the properties that are occupied by its service users and staff. The responsibility for the management of asbestos containing materials is the organisation with the overall control of the building; however the Trust owes a duty of care to all staff and service users which includes as far as is reasonably practicable, preventing exposure to asbestos fibres. 5.2 Records of asbestos containing materials within buildings. Where the Trust has responsibility for a building, records of surveys, re-inspections, test results and previous asbestos removal schemes are available from the estates records files or from the electronic database. Where the Trust does not have responsibility for a building, the asbestos register or a statement from the organisation in control of the building should be held by the service manager and should be available to all staff. 6. TRAINING IMPLICATIONS Estates staff should receive training by an appropriate competent person. This should include the following: - A basic introduction as the type of materials and products, which may contain asbestos and typical locations within buildings. That the main risk associated with asbestos exposure relates to the inhalation of airborne fibres. That any exposure to asbestos should be avoided and the risk increases as the level duration, and frequency of exposure increases. What emergency procedures should be followed if they find damaged asbestos or materials suspected to be asbestos which may be not recorded in the register. Asbestos Containing Materials Policy Staff groups requiring training How often should this be undertaken Length of training All Estates staff Asbestos Awareness Training Every 1-2 years Delivery method 3 hours Classroom based Training delivered by whom Specialist Consultant Where are the records of attendance held? Personal file plus ESR All Trust staff should be made aware of the key points within sections 4.5, 4.6, 5.1 and 5.2 of this policy. This will be achieved by team brief/weekly news letter. Page 10 of 13

7. MONITORING ARRANGMENTS Area for Monitoring Compliance with policy Policy remains upto-date How Who by Reported to Frequency Audit Monitoring of regulations and guidance Health & Safety Lead Estates Operations Manager Head of Estates and Facilities Head of Estates and Facilities Yearly On-going 8. EQUALITY IMPACT ASSESSMENT SCREENING - The completed Equality Impact Assessment for this Policy has been published on the Equality and Diversity webpage of the RDaSH website click here 8.1 Privacy, Dignity and Respect The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi s review of the NHS, identifies the need to organise care around the individual, not just clinically but in terms of dignity and respect. Indicate how this will be met There are no effects on the provision of privacy and dignity or respect within this policy. As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided). 8.2 Mental Capacity Act Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individuals informed consent, or the powers included in a legal framework, or by order of the Court Therefore, the Trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible. Indicate How This Will Be Achieved. All individuals involved in the implementation of this policy should do so in accordance with the Guiding Principles of the Mental Capacity Act 2005. (Section 1) Page 11 of 13

9. LINKS TO ANY ASSOCIATED DOCUMENTS Incident Reporting Policy Waste Management Policy 10. REFERENCES The Control of Asbestos Regulations. Health and Safety Executive. HSE books. Health and Safety at Work Act (1974). Health and Safety Executive (1974). HSE books. Health and Safety Executive A Comprehensive Guide to Managing Asbestos in Premises (HSG 227). Health and Safety Executive (2002). HSE books The Construction Design and Management Regulations (2007). H.M.S.O. London (2007) Page 12 of 13

11. Appendices APPENDIX 1 Asbestos Emergency Procedures Anyone suspecting asbestos containing materials has been disturbed; the following action should be taken immediately: Evacuate the area immediately, without causing alarm. Cordon/lock off the area until a full assessment has been completed. Contact the Estates Helpline who will then arrange for a U.K.A.S approved analyst to attend site. Consultation of the Asbestos Register may assist in identifying the type of suspected asbestos containing material. Background air sampling may be required depending on the extent of the damage. This will determine the correct procedure for making safe the damage. Anyone who may have been exposed to asbestos may be referred to Occupational Health. In all circumstances an individual s line manager or the Trust manager engaging a contractor is to complete an incident report. Page 13 of 13