Policy Title: Dust Control Policy Reference and Version No: EF22 Version 2 Author and Job Title: Stuart Watkin Head of Engineering Compliance and Energy Executive Lead Director of Estates and Facilities Validated By: Estates Management Group Policy Summary Dust in a hospital environment may contain micro-organisms such as Aspergillis, a fungus commonly found in building fabric. If left undisturbed, the dust is safe, but during work activities it may become airborne and then inhaled or ingested placing ill patients at risk. This policy details the actions required of the Trust in accordance with Health & Safety and COSHH to prevent dust generation. Ratified By: Health and Safety Committee Date Issued: 21 November 2016 Date for Review: 8 November 2019 Related Documents RM10 - Health and Safety Policy RM16 - COSHH Policy Control of Substances Hazardous to Health (COSHH) Regulations 1999 Health and Safety at Work Act 1974 This Policy is Intended for: Estates and Facilities The Trust is committed to the fair treatment of all, regardless of age, colour, disability, ethnicity, gender, gender reassignment, nationality, race, religion or belief, responsibility for dependants, sexual orientation, trade union membership or non membership, working patterns or any other personal characteristic. This policy and procedure will be implemented consistently regardless of any such factors and all will be treated with dignity and respect. To this end, an equality impact assessment has been completed on this policy. 1 of 9 (Date for review 8 November 2019)
CONTENTS 1. Introduction 2. Purpose 3. Aim 4. Roles and Responsibilities 5. Risk Assessment and Control Measures 6. References 7. Consultation 8. Review and Revision Arrangements 9. Monitoring APPENDICES Appendix A Risk Assessment Matrix Appendix B Risk Assessment Proforma Appendix C Audit Tool 2 of 9 (Date for review 8 November 2019)
1. Introduction 1.1 Dust in a hospital environment may contain micro-organisms such as Aspergillis, which is a fungus commonly found within the fabric of buildings (e.g. plaster, brickwork, dust deposits, filters etc.) and in soil and decaying vegetation. When left undisturbed, dust is safe, but during work activities the dust particles can become airborne and can then be inhaled or ingested. 1.2 Risks to health will vary dependent on the dust type and contamination, but to those who are immuno-suppressed or immune-compromised, risks are significantly increased. 2. Purpose 2.1 The purpose of this policy is to ensure staff are aware of the risks associated with dust, especially the potential for Aspergillus. 2.2 This Policy relates to all work undertaken on hospital premises where dust generation may occur, whether undertaken by in-house staff or external contractors. 2.3 North Tees & Hartlepool NHS Foundation Trust recognises its responsibilities and duty of care in relation to dust generation within the premises it controls and will work in compliance with the Control of Substances Hazardous to Health (COSHH) Regulations 1999, As such this policy should be read in conjunction with the Health & Safety Policy and the COSHH Policy. 3. Aim 3.1 The objective of this policy is to prevent dust generated on work sites affecting patient outcomes or affecting the health of staff. As such, the Trust will comply with legal requirements to protect staff, patients and visitors, and staff need to be aware of their responsibilities for: Planning Work activities need to be planned by informed and competent persons being aware of all the risks involved. Emergency Works All unplanned work (where consultation prior to the work is not possible) must still be completed in a safe manner. Risk Assessments A risk assessment will identify vulnerable persons, correct control measures and work procedures to control dust generation. 4. Roles and Responsibilities 4.1 Chief Executive The Chief Executive is responsible for ensuring the Trust implements the requirements of the Control of Substances Hazardous to Health (COSHH) Regulations 1999 and Health and Safety at Work Act 1974 4.2 Director of Estates and Facilities The Director of Estates and Facilities is responsible for identifying resources are available to enable compliance with this policy and appoint a suitable project officer to oversee dust control measures. 3 of 9 (Date for review 8 November 2019)
4.3 Head of Estates / Head of Design The Heads of Estates and Design are responsible for ensuring risk assessments, and any necessary method statements to implement control measures, are in place after taking appropriate advice from Health & Safety and/or Infection Control staff. 4.4 Project Officer The appointed Project Officer is: to assess the level of risk (using the matrix at Appendix A) and completing a risk assessment (Appendix B) to ensure suitable and complete method statements are received from contractors. to communicate with Health & Safety advisors and/or Infection Control staff about the specific requirements of the task. to ensure that adequate control measures are in place prior to work starting. to ensure staff carrying out the work have received appropriate awareness training. to ensure that appropriate PPE is available for staff carrying out the work. to ensure that a thorough clean of the work area is completed by domestic staff before returning it to patient use. 4.5 Health and Safety Advisor The Trust Health and Safety Advisors are to make themselves available to comment on control measures, assist in monitoring and advise the project officer where applicable. 4.6 Infection Prevention and Control Members of the Infection Prevention and Control team are to make themselves available to comment on control measures, assist in monitoring and advise the project officer where applicable. 4.7 Persons Undertaking Work Anyone completing work on Trust sites whether Estates staff or Contractor is: to work within the guidelines, following safe working practices, raising any concerns through line management to the Project Officer. to be aware of the content and control measures specified in the risk assessment and any method statement. to implement dust control measures to minimise the risk to patients and staff. to liaise with the Project Officer to advise ward staff, Health and Safety advisors and Infection Control staff with regard to the work and ongoing monitoring. 4 of 9 (Date for review 8 November 2019)
4.8 Domestics During the post-work clean, Domestic team members are to use appropriate equipment and techniques to collect dust and hence reduce the chance that it remains uncontrolled in the ward areas. 5. Risk Assessment and Control Measures 5.1 A dust control risk assessment must be undertaken ahead of any building works, seeking all appropriate advice from specialists and, once complete, communicated to all affected staff. The assessment will need to consider: the activity type the patient area involved and the vulnerability of patients control measures that need to be implemented. To assist a matrix has been devised see Appendix A. 5.2 Special consideration must be given in areas where patients are at the greatest risk: Theatres Haematology / Chemotherapy Critical Care Neo-natal Respiratory Care 5.3 The control measures are listed to achieve dust control compliance against the level of risk, this might include some or all of the following: Full screening Close area up sealed off from the rest of the hospital Wall up to ceiling height Doors and other openings sealed with tape Removal of at risk persons Damping down Sealing of holes Vacuum using H-type filtration Dust control mats at works entrances Monitoring of dust levels Preventing activities that generate large amounts of dust cement mixing, electric saws. etc.. Covered external skips for waste Post-work clean by Domestics team 6. References Health and Safety at Work Act 1974 Control of Substances Hazardous to Health (COSHH) Regulations 1999 Trust Policies: RM10 - Health and Safety Policy 5 of 9 (Date for review 8 November 2019)
RM16 - COSHH Policy 7. Consultation The Dust Control Policy has produced by the Estates Management Group in consultation with the Design Team, Health and Safety Advisors and the Infection Prevention and Control team. 8. Review and Revision Arrangements This policy will be reviewed, as and when there are any changes to the current legislation, by the Estates Management Group. The policy will be formally reviewed in line with Trust policy on a 3- yearly basis. 9. Monitoring 9.1 This policy will be monitored by continually reviewing working practices whilst building works are being completed, so that Best Practice can be achieved. 9.2 The Project Officer, supported by the Health and Safety advisors and Infection Control staff, needs to ensure that the control measures recommended in the dust control risk assessment are being implemented correctly and that the staff members and contractors are aware of the reasons for such measures. 9.3 An audit tool is provided at Appendix C. Any corrective actions need to be implemented immediately, and appropriate revisions made to the risk assessment, method statement or if necessary this policy. 6 of 9 (Date for review 8 November 2019)
RISK ASSESSMENT MATRIX Appendix A Risk Level Activity Type Areas Involved / Exposed Low Risk Non-invasive activities e.g. removal of tiles for Offices, corridors, plant inspection in non-clinical areas, painting and rooms, service ducts preparation in corridors/non-clinical areas, minor plumbing and activities that do not generate dust Moderate Risk Significant Risk Small scale short duration activities creating a minimum of dust e.g. installation of telephone cabling, removal of limited numbers of ceiling tiles in low risk clinical area, cutting of walls where dust migration can be controlled in clinical areas Work which generates moderate to high level of dust, requires demolition e.g. sanding walls, removal of floor coverings, new wall construction, major cabling activities, replacement of fixed equipment that requires minor constructional works Radiology, Out-patient departments, examination rooms, general wards Radiology, Out-patient departments, examination rooms, general wards Or higher risk areas: Oncology, Haematology, Critical Care Control Measures Immediately replace any ceiling tiles displaced for visual inspection Execute work be methods intended to minimise dust production Isolate heating/ventilation if appropriate Damp down surfaces to minimise dust Seal off unused doors with duct tape Block off and seal air vents Contain construction waste before transport Wet mop and vacuum area before leaving If the dust is generated outside close & seal windows Use of covered external waste skips Isolate heating/ventilation if appropriate Implement dust control measures/barriers before works begins Use HEPA equipped filtration unit if available Do not remove screens until work area is clinically clean Wet mop during work Vacuum using filtered vacuum during work Contain construction waste before transport If the dust is generated outside close & seal windows Use of covered external waste skips High Risk Major demolition and construction projects Any clinical areas Isolate heating/ventilation if appropriate Implement dust control measures/barriers before works begins Use HEPA equipped filtration unit if available Seal holes, pipes, conduits and punctures appropriately Do not remove screens until work area is clinically clean Wet mop during work Vacuum using filtered vacuum during work Contain construction waste before transport Remove barrier material carefully to minimise spreading of dust If the dust is generated outside close & seal windows Use of covered external waste skips Consider wind direction and weather conditions. 7 of 9 (Date for review 8 November 2019)
RISK ASSESSMENT PROFORMA Appendix B Date: Assessment completed by: Work to be completed: Area of Works: Work discussed with Infection Control Work discussed with Health & Safety Yes / No Yes / No Description of Risks: Generation of dust Creating an Infection Control or H&S hazard Control Measures to be implemented: Risk Category after implementation of Control Measures: Person responsible for implementation: 8 of 9 (Date for review 8 November 2019)
DUST PREVENTION MANAGEMENT AUDIT TOOL Appendix C Date of Audit.Ward/Department Auditors Question Yes No N/A 1 Is a Risk Assessment available with control measures outlined? 2 Is there evidence of dust outside of the area of work? 3 Is appropriate screening in place? 4 Is all waste bagged within the work area? 5 Has appropriate extra input from domestics been arranged? 6 Is a HEPA-filtered vacuum cleaner / unit in use? Comments 9 of 9 (Date for review 8 November 2019)