ASBESTOS MANAGEMENT POLICY Version 5.0 File ref ASBESTOS MANAGEMENT POLICY Date approved June 2016 Date to be reviewed June 2019 To by reviewed by ASBESTOS STEERING GROUP Asbestos Management Policy June 2016 Page 1
Policy Title: Executive Summary: Asbestos Risk Management Policy. It is the Policy of East Cheshire NHS Trust (the Trust) to provide and maintain a safe and healthy environment for all staff, patients and visitors, and to provide such resources, information, training and supervision as is necessary to achieve this purpose. The Trust will do all that is reasonably practicable to manage the risk from Asbestos to its employees and others and to follow the steps laid out in the following Policy. Supersedes: Asbestos Risk Management Policy - 2012 Description of Updated reference to legislation documents. Amendment(s): Minor amendments to some job / committee titles. Re-wording of some text. Addition of sections 4, 5 & 6. This policy will impact on: The policy will be applicable to all departments within the Trust. Financial Implications: No additional financial implications Policy Area: All areas within the Document ECT002517 Trust. Reference: Version Number: Version 5.0 Effective Date: June 2016 Issued By: Director of Finance Review Date: June 2019 Author: Estates Officer - Statutory Compliance APPROVAL RECORD Impact Assessment Date: Committees / Group Date Consultation: Asbestos Steering Group. Dec 2015 Received for Information Head of Informatics February Approved 2016 Deputy Director of Corporate Affairs February 2016 And Governance Clinical Lead for Occupational Health February 2016 Risk Management Sub Committee Head of Estates (Responsible Person) N/A June 2016 June 2016 Director of Finance (Designated Person) June 2016 Asbestos Management Policy June 2016 Page 2
CONTENTS 1 POLICY STATEMENT AND SCOPE 1.1 Scope of the Policy 4 1.2 Policy Statement 4 2 LEGISLATION AND GUIDANCE 4 3 ROLES AND RESPONSIBILITIES 3.1 Duty Holder 5 3.2 Designated Person 5 3.3 Responsible Person 5 3.4 Deputy Responsible Person 6 3.5 Asbestos Coordinator 6 3.6 Health & Safety Manager 6 3.7 Head of IT 6 3.8 Project managers 6 3.9 Head of Service & Department Manager 7 4 IMPLEMENTATION 4.1 Asbestos Steering Group 7 4.2 Asbestos Survey 7 4.3 Risk Assessment 7 4.4 Asbestos Register 8 4.5 Risk Management Plan 8 4.6 Labelling 8 4.7 Asbestos records 9 4.8 Training 9 4.9 Communication 9 4.10 Projects: Alteration & upgrading 9 5 PERFORMANCE 9 6 AUDIT 10 7 POLICY REVIEW 11 8 Appendices 1. Asbestos Steering Group: Terms of Reference & Agenda 12 2: Asbestos Management Structure 15 Asbestos Management Policy June 2016 Page 3
1 POLICY STATEMENT AND SCOPE 1.1 Scope of the policy 1.1.1 The HSE has reported that in 2012 there were in excess of 5,000 deaths caused by exposure to asbestos (2535 deaths in the UK due to mesothelioma, and similar number of asbestos related lung cancer deaths). 1.1.2 The time between first exposure to asbestos and people falling victim to the disease is normally in excess of 25 years. As a result of asbestos regulations first introduced in the 1980s the incidence of people contracting asbestos related conditions is expected to fall after 2020. 1.1.3 The main principles of asbestos management are to Assess, Record, Inform and Monitor. This policy provides a framework for the Trust to meet these principles and to implement asbestos legislation and guidance so that the occupants of all trust premises are protected from asbestos related risks. 1.1.4 It covers activities where inadvertent exposure to asbestos may occur in the use, alteration or demolition of premises, or use, alteration or de-commissioning of plant and services. 1.1.5 This document and the procedures outlined, require the cooperation of all employees, all staff, building users and contractors who also have responsibilities to ensure a safe and healthy working environment is maintained at all times. 1.2 Policy Statement 1.2.1 The East Cheshire NHS Trust (the Trust)is committed to the effective management of asbestos. This policy enables East Cheshire NHS Trust to manage the risk arising because of asbestos containing materials to its employees (& others) in all of their workplaces. 1.2.2 The Trust recognises its duties under legislation and guidance is committed to the effective management of asbestos. These include duties under the Health and Safety at Work Act 1974, the Control of Asbestos Regulations 2012, associated Approved Codes of Practices, and best practice guidance. 1.2.3 The Trust recognises its duties as a registered healthcare provider under the Health and Social Care Act Regulations 2014 regarding the safety and suitability of premises (CQC outcome 10). 1.2.4 It also recognises its duties construction works under the Construction (Design and Management) Regulations 2015 and Regulation 4 of the Control of Asbestos Regulations 2012. 2 LEGISLATION AND GUIDANCE 2.1 Health & Safety Legislation 2.1.1 The main health and safety legislation relating to the management of asbestos is: Health and Safety at Work etc. Act 1974 Control of Asbestos Regulations 2012 The Workplace (Health, Safety and Welfare) Regulations 1992 Management of Health and Safety at Work Regulations 1999 Construction (Design and Management) Regulations 2015 (CDM2015) Asbestos Management Policy June 2016 Page 4
The defective Premises Act 1972 in England or Wales or the Civic Government. 2.2 Healthcare Legislation 2.2.1 Section 2 of the Health and Social Care Act Regulations 1 sets fundamental standards for the provision of services by Trusts. These require that the provision of premises and equipment must be safe, clean, and secure. 2.2.2 15(1)2 of the regulations require that users of premises are protected against the risks associated with unsafe or unsuitable premises by means of adequate maintenance and proper operation of the premises. 2.2.3 The outcome expected is that people are in safe, accessible surroundings that are being adequately maintained and that comply with any legal requirements relating to the premises. 3 ROLES AND RESPONSIBILITIES 3.1 Duty Holder (Chief Executive) 3.1.1 The Chief Executive is the statutory duty holder for the control of Asbestos. 3.1.2 He/she will ensure that: The management of asbestos on Trust premises is undertaken in accordance with this policy; A Responsible Person (Asbestos) and a Deputy Responsible Person (Asbestos) are appointed in writing. Has appointed an Asbestos Steering Group An Asbestos Operations Group Asbestos Co-ordinator Health and Safety Risk Manager These groups / persons are charged with the responsibility of ensuring a satisfactory policy and procedure is established for the control of asbestos throughout the Trusts properties. 3.2 Designated Person The Director of Finance is accountable for the implementation of this policy and assumes the delegated responsibility of the Chief Executive to provide assurances to the East Cheshire HNS Trusts board at board level. 3.3 Responsible Person (Asbestos) 3.31 The Head of Estates is responsible for the implementation of this policy and will ensure that: Assurance is provided regarding the management of asbestos; Arrangements are in place for information regarding asbestos risks to be made available to all relevant personnel. 3.32 Director Corporate Affairs and Governance. 1 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (H&SCA 2008) Asbestos Management Policy June 2016 Page 5
The Director of Corporate Affairs and Governance has executive responsibility for health and safety arrangements across the Trust. 3.4 Deputy Responsible Person (Asbestos) 3.4.1 The role of Deputy Responsible Person (Asbestos) will be undertaken by the Senior Estates Manager (property & projects). He/she will support the Responsible Person in the implementation of this policy and undertake the duties of Responsible Person when required and is responsible for the day to day management of the asbestos coordinator. 3.5 Asbestos Coordinator 3.5.1 The role of Asbestos Coordinator will be undertaken by the Estates Officer, Projects & Design. He/she will coordinate the: 3.5.2 Preparation and maintenance of asbestos risk assessments and the asbestos management plan; 3.5.3 Day to day management of asbestos; 3.5.4 Surveys, management systems and records; 3.5.5 Delivery of asbestos training 3.5.6 Manage the asbestos Risk Register ensuring it is kept up to date 3.5.7 All relevant information is available regarding the location and management of asbestos for persons who require it; 3.5.8 Appropriate assurance regarding the management of asbestos is provided to the trust through the management structure. 3.6 Health & Safety Manager 3.6.1 The Health & Safety Manager will with the Asbestos Coordinator to ensure preventative and corrective actions are taken to reduce risk of asbestos exposure. 3.7 Head of Informatics 3.7.1 The Head of IT is responsible for ensuring that: 3.7.2 The management of IT Networks is undertaken in accordance with this policy and relevant asbestos legislation and guidance; 3.7.3 The installation, alteration and de-commissioning of IT & Telephone systems is undertaken in accordance with this policy and relevant asbestos legislation and guidance. 3.8 Project Managers Estates 3.8.1 Project managers are responsible for ensuring that all works of upgrading & alterations of Trust premises, plant and equipment are undertaken in accordance with this policy, and all relevant legislation and guidance. 3.8.2 Project managers are responsible for ensuring that all works of upgrading & alterations of Trust computer, telephone & other networks are undertaken in accordance with this policy, and all relevant legislation and guidance. Heads of Service and Department Managers Asbestos Management Policy June 2016 Page 6
3.8.3 Heads of Service and Department Managers are responsible for ensuring that all activities undertaken within their area of responsibility are undertaken in accordance with this policy. 4 IMPLEMENTATION 4.1 Asbestos Steering Group 4.1.1 The Asbestos Steering Group will be responsible for the coordination and oversight of asbestos risks and remedial activities. The meetings will be formally documented, and will form part of the asbestos risk management records. 4.1.2 The Group will receive and review reports of progress regarding the management of asbestos risks, and reviews of assurance regarding the safe management of asbestos. 4.1.3 Terms of reference and agenda for the asbestos group meetings is attached as appendix 1. 4.1.4 Annual assurance reports are to be prepared by the Performance Compliance Manager and will include assurance of the following: Reasonable steps have been taken to determine the location and condition of Asbestos Containing Materials (ACM s); Materials are presumed to contain asbestos unless there is strong evidence that they do not; Accurate records are maintained of the location and condition of ACM s or presumed ACM s; The risk of exposure to asbestos fibres is assessed; An asbestos management plan has been prepared which sets out how risks from asbestos materials is to be managed; The asbestos management plan has been put into action and is regularly monitored and reviewed; Information regarding the location and condition of materials is provided to anyone liable to work on or disturb them; 4.2 Asbestos Surveys 4.2.1 Asbestos surveys of Trust premises will be carried out as required by the Control of Asbestos Regulations 2012. 4.2.2 The purpose of the survey is to determine the presence, or otherwise, of asbestos containing materials (ACM s) through sampling. If ACMs are the survey is to record its specific location, the quantity of asbestos present, and its condition. 4.3 Risk Assessment 4.3.1 The Trust will maintain and regularly update a documented risk assessment of all known and presumed asbestos materials in all premises owned and/ or occupied by the Trust and its employees. 4.3.2 The risk assessment will be based on the findings of the asbestos survey. 4.3.3 The Asbestos Action Plan will be periodically updated and will amended to include proposals for the management of asbestos risks identified in the revised asbestos Asbestos Management Policy June 2016 Page 7
risk assessments. 4.4 Asbestos Register 4.4.1 The asbestos regulations require that non-domestic properties must have an asbestos risk assessment and an asbestos risk register of an approved standard. 4.4.2 The risk register and the asbestos risk assessments will provide information to occupants of the building, and those working in it, of the locations and condition of all suspect materials within the building, 4.4.3 This information is held and provided to reduce the risk of damage to asbestos bearing materials. 4.4.4 The register is to be maintained and reviewed regularly. The information should be checked regularly for accuracy, and the suspect materials themselves should be inspected on a proscribed basis. 4.4.5 The risk register will address the following: The location of all asbestos materials positively identified and analysed; their composition and the action required should they become damaged. The location of all suspect materials identified and the action required should they become damaged. A risk assessment of the hazards posed by the above materials. A management plan, which addresses the long-term maintenance of the materials. 4.4.6 All managers of properties containing asbestos should be made aware that: It is present; The location of materials that they may encounter, and : What to do if it becomes damaged. 4.5 Risk Management Plan 4.5.1 The Trust will prepare and maintain an Action Plan setting out in detail how the risk from any ACM s in its premises will be managed. 4.5.2 The main principles of asbestos management are to Assess, Record, Inform and Monitor. 4.5.3 The Asbestos Management Plan will be periodically updated and will be amended to include proposals for the management of asbestos risks identified in the revised asbestos risk assessments. 4.5.4 The Trust Board is made aware of the financial implications of compliance. 4.6 Labelling 4.6.1 All asbestos materials (ACMs) are to be labelled in accordance with Control of Asbestos Regulations 2012. Labels should state that materials containing asbestos and that they are not to be disturbed. 4.6.2 In rooms containing ACMs a 30mm diameter red sticker is to be affixed to the main entry door, adjacent to the room number. The asbestos management team should be contacted when access is required to rooms with labeled doors. Asbestos Management Policy June 2016 Page 8
4.7 Asbestos records 4.7.1 The asbestos records include: Surveys of premises, with asset/uprn number; Asbestos Risk register; Certificates of occupation; Air monitoring tests. 4.7.2 An up-to-date plan or drawing is kept for each of the Trust s premises. 4.7.3 Any changes occurring between annual reassessments are fully documented and existing records updated accordingly. 4.7.4 Records are to be retained for a period of 40 years, or life of the building (whichever is the longest). 4.7.5 All asbestos related reports will be submitted to the Asbestos Co-coordinator who will co-ordinate data entry to the Trust Asbestos Risk Management database. 4.8 Training 4.8.1 Estates staff are to receive initial Asbestos Awareness Training to ensure that they are familiar with the content of the Policy, and the legal duties to: Manage asbestos risks, and: Co-operate with whoever manages the risk. 4.8.2 Refresher training is to be provided every two years. 4.8.3 Staff are to receive training appropriate to their next role. 4.9 Communication 4.9.1 Information on the location and condition of the material is provided to anyone who is liable to work on it or disturb it. This will include contractors to the Trust and the Emergency Services. 4.9.2 The Asbestos Steering Group is to ensure that staff are kept up-to-date on asbestos issues. 4.10 Alterations & upgrading projects 4.10.1 The Deputy Responsible Person will manage the procedures for projects and ensure that they comply with the requirements of the Policy and of relevant legislation and guidance. 5 PERFORMANCE 5.1 Measuring and monitoring performance 5.1.1 As a minimum requirement, the following key performance Indicators for the management of asbestos will be monitored. KPIs Monitored by: Monitoring frequency Information reported to Asbestos Management Policy June 2016 Page 9
Review of Service line (asbestos) performance information and KPI reports Asbestos Coordinator Quarterly E&F Statutory Compliance Group Detailed audit undertaken to ensure statutory compliance Compliance Manager Annual E&F Statutory Compliance Group Sample audits on service delivery undertaken for inclusion in E&F Assurance data Asbestos Coordinator 6 monthly E&F Statutory Compliance Group Periodic assurance statements, service review, and review of risk rating Compliance & Performance Manager Annual Risk Management Group 5.2 Monitoring compliance 5.2.1 The Estates Statutory Compliance Group is to receive and review: Service reviews providing assurance regarding considerable risks (RR of 14 & under); Monitor actions plans and remedial works. 5.2.2 The Risk Management Sub Committee Group will review and approve: Review of Asbestos Policy and periodic policy updates; Assurance Framework Reports. KPIs Monitored by: Monitoring frequency Information reported to Review corporate level entry on Risk Register Compliance Manager Quarterly E&F Director, Risk Management Group Detailed audit undertaken to ensure statutory compliance Independent Body Annual E&F Director Compliance Group Policy review Asbestos Coordinator 3 Yearly Sample audits on service delivery undertaken for inclusion in E&F Assurance data Periodic service reviews to meet the requirements of the Risk Management Strategy Asbestos Coordinator Compliance & Performance Manager 6 monthly Annual E&F Director Compliance Group E&F Statutory Compliance Group Risk management Group 6 AUDIT 6.1.1 A review of management of asbestos will be coordinated annually by the Compliance Manager.The review will include comments on the policy and operational performance made by the independent asbestos specialist in his annual report and will be taken to the Risk Management Sub Committee. 6.1.2 The review will incorporate an audit of the performance of the Trust in managing and controlling asbestos risks against the aims set out in this policy. 6.1.3 It is to include a report on the operational performance in respect of monitoring, testing, dealing with incidents, remedial works, etc. 7 POLICY REVIEW The Asbestos Coordinator (Asbestos) will coordinate a formal review of this policy within 3 Asbestos Management Policy June 2016 Page 10
years of the date of issue or as necessary due to the publication of new legislation and guidance. The review will address issues identified in the annual audit and performance review. Asbestos Management Policy June 2016 Page 11
Appendix 1 East Cheshire NHS Trust Authors Name: Head of Estates ( Responsible Person) Scope: Trust Wide Classification: Trust Organisation Structure and Minutes Replaces: Terms of Reference Asbestos Steering Group To be read in conjunction with the following documents: None Asbestos Risk Management Policy Unique Identifier: Review Date: March 2015 Issue Status: V5 Issue No: 1 Issue Date: TBA Authorised by: Statutory Compliance Group Authorisation Date: Document for Public Display: No After this document is withdrawn from use it must be kept in an archive for 6 years. Archive: Date added to Archive: Officer responsible for archive: Director of Corporate Affairs and Governance 1. Asbestos Steering Group - Terms of Reference Purpose The Asbestos Steering Group is responsible for the coordination and oversight of asbestos risks and remedial activities. The meetings will be formally documented, and will form part of the asbestos risk management records Functions of the Group The group will receive and review reports of progress regarding the safe management of asbestos. Reporting Arrangements The group shall report via the chair to the appropriate persons Asbestos Management Policy June 2016 Page 12
Risk Management Group Statutory & Mandatory Group Asbestos Steering Group Chair The group shall be chaired by the Trusts Responsible Person, the lead may be delegated chairmanship to a nominated deputy in times of their absence. Membership Responsible Person (Asbestos) Deputy Responsible Person (Asbestos) Nominated Officer from Governance Occupational Health Manager Cheshire ICT Representative Asbestos Coordinator Authorising Engineer (Asbestos)/ Asbestos Analysts Quorum This must be the group chair or deputy and no less than 51% of the membership group. Majority 51% of the meeting. Meeting Frequency Quarterly intervals Agenda, Minutes and documentation A typical agenda for the asbestos group meetings is: 1. Present / Apologies; 2. Notes of last Meeting; 3. Matters Arising; 4. Asbestos surveys a. Management Surveys b. Refurbishment & Demolition 5. Risk Register; Asbestos Management Policy June 2016 Page 13
6. Management Plan; 7. Training; 8. Any Other Business; 9. Date of next Meeting; Asbestos Management Policy June 2016 Page 14
Appendix 2 ASBESTOS MANAGEMENT STRUCTURE CHIEF EXECUTIVE DIRECTOR OF FINANCE DIRECTOR OF GOVERNANCE RESPONSIBLE PERSON M&TAM COMPLIANCE MANAGER DEPUTY RESPONSIBLE PERSON ASBESTOS CO-ORDINATOR AUTHORISED ENGINEER ASBESTOS AUTHORISED BODY CAPITAL TEAM MECHANICAL ENGINEERING MANAGER ELECTRICAL ENGINEERING MANAGER HEAD OF IM & T PROJECTS TEAM Asbestos Management Policy June 2016 Page 15