Issue Date: January 2016 Review Date: January 2018

Transcription

1 1 Trust Policy and Procedure Document Ref. No: PP(16)089 Control of Asbestos at Work For use in: For use by: For use for: Document owner: Status: Trust Wide All Trust staff and Contractors Management of Asbestos Containing Materials Nominated Officer Management of Asbestos Approved Purpose of this document The Control of Asbestos at Work Policy sets out what measures and controls the Trust are taking to ensure the safety of the Patients, Staff, Contractors and Visitors to the Hospital in respect of Asbestos Containing Materials used in the original Construction of the Hospital and any other buildings built before the year Any buildings built after the year 2000 are presumed to be free from Asbestos and Asbestos containing materials as advised by the HSE and a specialist Asbestos Surveyor and therefore are not applicable to this policy. Aim To ensure, as far as is reasonably practicable, no uncontrolled release of Asbestos fibres into the atmosphere takes place within the Trust premises. To ensure that works to remove Asbestos Containing Materials are properly planned, executed and managed. To ensure systems and procedures are in place to deal with the accidental release of Asbestos. To ensure any Asbestos Containing Materials are managed and monitored in accordance with Regulation 4 of the Control of Asbestos Regulations This Policy is to be read in conjunction with Procedure Document Control of Asbestos at Work Asbestos Management Plan Procedure Document Control of Asbestos at Work Asbestos Awareness Training WSH Policies PP ( ) 018 Health, Safety and Welfare PP ( ) 039 Control of Substances Hazardous to Health PP ( ) 046 Occupational Health Service PP ( ) 105 Incident Reporting and Management PP ( ) 132 Risk Assessment PP ( ) 179 Waste Management Content 1.0 Policy statement Introduction Scope Organisation, Roles and Responsibilities Removal of Asbestos Non-Compliance Policy Review Monitoring Arrangements (Reporting to the Trust) Asbestos Management Plan Asbestos Awareness Training Reference Documents 12 Annex A Emergency Procedure for identifying damage to ACM 13 Annex B Emergency Procedure for potential fibre release 14 Issue Date: January 2016 Review Date: January 2018

2 Annex C Asbestos Incident Switchboard action card 15 Issue date: January Review date: January 2018

3 1. Policy Statement Statement of Intent The West Suffolk NHS Foundation Trust, under the Health and Safety at Work etc, Act 1974 and the Control of Asbestos Regulations 2012, has a responsibility to take all reasonable precautions to prevent or control the harmful effects of Asbestos to residents, patients, visitors, staff and other persons working at or using its premises and will provide a structured framework to manage any Asbestos contained within its properties. This Asbestos policy document applies to all Trust premises constructed prior to the year 2000 and its aim is to maintain a structured Procedure and Reporting Schedule, for the Management and Control of Asbestos risks in compliance with current Legislation, Guidelines and best practice current at the time of application. The primary defence strategy for reducing the risks posed by Asbestos will be through a risk based approach. This regime may be supplemented by additional training requirements and extra Asbestos management procedures to reduce the risk from exposure to Asbestos as far as reasonably practicable. The Trust will: - Ensure the safety and welfare of our patients, employees and any other parties affected by our activities, so far as is reasonably practicable; Support the allocation of adequate management time and resources to ensure that the risks from Asbestos are controlled at all times; Promote the co-operation of all our employees through clear senior management commitment, staff consultation, and by the provision of awareness and training programmes; Appoint the staff designated in this policy and empower them to complete their designated roles and responsibilities; Monitor this policy to ensure that objectives are being achieved. It will be reviewed, and if necessary amended in light of legislative or organisational change; Ensure that the Asbestos management team is represented by key stake-holders and that it is empowered with the required authority to make necessary decisions; Ensure that suitable and sufficient risk assessments are carried out annually, or when risk dictates in accordance with legislation. The risk assessment will be representative of the site, systems and services present at each site and will clearly identify all hazards, risks with a recommended action plan within each risk assessment; Ensure that any Contractors or Service Providers adhere to this policy and the supporting legislation and guidance; Appoint formally the designations stated in this document, and ensure that they are suitably trained and competent. Employ the services of an Independent Asbestos advisor to carryout annual audits of the Trusts Asbestos management/monitoring process in order to provide assurance to the Trust board of compliance to Asbestos regulations or to advise otherwise. Professor Dr Stephen Dunn Chief Executive Officer Issue date: January Review date: January 2018

4 2.0 Introduction Asbestos and Asbestos Containing Materials (ACM s) have been widely used, until November 1999 (most ACM s were banned in 1984, with the last ACM s being banned in 1999) in the manufacture of building materials/components, including ceiling tiles, corrugated roofing sheets, wallboards, fire retardant insulation and thermal insulation. Some of which can be applied by spraying, and all of which may be present in the Trust s buildings. Current legislation prohibits the use of such Asbestos based products. The presence of ACM s does not in itself constitute a danger, however ACM s do become hazardous when disturbed or damaged and must be treated accordingly. The risks associated with the disturbance and/or handling of Asbestos products is well known. The Control of Asbestos Regulations 2012 specifies the statutory requirements for working with Asbestos, with regards to its handling, removal, disposal and management. Staff, patients, visitors and contractors are not expected to be exposed to Asbestos in any property under the ownership of the West Suffolk NHS Foundation Trust or any premises maintained by West Suffolk NHS Foundation Trust personnel. This policy details the Trust s responsibilities and procedures considered appropriate for compliance with the statutory duties associated with the Duty to Manage Asbestos in Non-Domestic Premises Regulation 4. This policy is not an authoritative interpretation of the Regulations or other laws: the Courts can only make such interpretations. 3.0 Scope Control of Asbestos Regulations 2012 applies to all West Suffolk NHS Foundation Trust sites where there is a risk of a hospital employee being exposed to Asbestos fibres. Moreover, the Trust s duties under the Regulations extend to Contractors, Visitors, Patients and persons in the neighbourhood who might be inadvertently exposed to Asbestos arising from the work or accidental release. 3.1 Control of Asbestos Regulations 2012 The Regulations primary aim is to ensure that exposure to Asbestos fibres of those at risk is prevented or is as low as reasonably practicable. Those at risk include anyone who could be exposed to Asbestos fibres. The Control of Asbestos Regulations 2012 came into force on the 6 th April 2012; updating previous Asbestos regulations to take account of the European Commission s views that the UK had not fully implemented the EU Directive on exposure to Asbestos (Directive 2009/148/EC). In practice the changes are fairly limited. They mean that some types of non-licensed work with asbestos now have additional requirements, i.e. notification of work, medical surveillance and record keeping. All other requirements remain the same. The Regulations require that Employers should prevent exposure of employees and any other persons on, or near their sites, to asbestos fibres. Where this is not reasonably practicable, the employer shall enact whatever control measures are necessary, relying on respiratory protective equipment in the final analysis, to reduce the concentration of asbestos fibres inhaled by the affected person(s), to below the defined Control Limit. In order for the Enforcing Authority to exercise an audit and control role over employers the Regulations require that the employer shall notify the Health and Safety Executive (HSE) in writing of their intention of carrying out work involving asbestos. The Control of Asbestos Regulations is a collective of 37 regulations combined into a single legislative document. Issue date: January Review date: January 2018

5 The Trust is concerned with the following regulations (most notably Regulation 4) Regulation 2: Interpretation Regulation 3: Application of these regulations Regulation 4: Duty to manage asbestos in non-domestic premises Regulation 5: Identification of the presence of asbestos Regulation 6: Assessment of work which exposes employees to asbestos Regulation 7: Plans of work Regulation 8: Licensing of work with Asbestos Regulation 9: Notification of work with asbestos Regulation 10: Information, instruction and training Regulation 11: Prevent exposure to asbestos Regulation 15: Arrangements to deal with accidents, incidents and emergencies Regulation 16: Duty to prevent or reduce the spread of asbestos Regulation 18: Designated areas Regulation 19: Air Monitoring Regulation 22: Health records and medical surveillance Regulation 23: Washing and changing facilities Regulation 24: Storage, distribution and labelling of raw asbestos and asbestos waste Regulation 30: Labelling of products containing asbestos Schedule 2: Labelling of asbestos waste and products containing asbestos 3.2 Policy Document This Policy conforms to the Health and Safety at Work Act 1974 and the current Control of Asbestos Regulations The policy applies to all parts of the West Suffolk NHS Foundation Trust without exception. The primary purpose of this Policy is to state the Trust s mandatory requirements for carrying out work activities affected by the Control of Asbestos Regulations The Policy Document lays down a framework for a systematic approach to working with asbestos, comprising of:- Identification and Condition Duties and Responsibilities Control and Monitoring Assessing risk in accordance with HSG264 (previously MHDS100) Records And as such, addresses the key issues associated with the actual implementation of the procedures necessary to seek compliance with these Regulations. 3.3 Hazards (Reg 2) Asbestos is a general term for fibrous silicates, minerals which have crystallised to form long thin fibres, it is a naturally occurring mineral that is mined. Asbestos falls into two groups amphibole (brown/blue) and serpentine (white). Amphibole asbestos is a greater hazard than serpentine although both can cause the same health issues. This Trust has a combination of both groups. When asbestos is disturbed or damaged, invisible fibres are released into the air, it is the exposure to these airborne concentrations of asbestos fibres and dust that can develop into asbestos related illnesses such as Asbestosis, Pulmonary Fibrosis, Lung Cancer or Mesothelioma (Reference HSE publication MDHS 39/4 Asbestos Fibre in Air), this is why asbestos is a CLASS A CARCINOGEN (substance with the potential to cause Cancer) Issue date: January Review date: January 2018

6 4.0 Roles and Responsibilities Structure Figure 1 Issue date: January Review date: January 2018

7 4.1 Reporting Structure Figure Chief Executive (Duty Holder) The Chief Executive for the Trust has the overall authority and responsibility for the control and execution of this policy and its procedures and ensuring compliance to the Control of Asbestos Regulations 2012 for sites under the Trusts Ownership and Occupancy. The Trust shall appoint in writing a responsible person for the management of Asbestos and competent persons to the roles of Nominated Officer Management of Asbestos these appointments shall be written into their Job Description. Issue date: January Review date: January 2018

8 4.3 Estates Manager (Responsible person) The Estates Manager for the Trust has overall responsibility for ensuring compliance with the Asbestos Policy and to ensure the appointed Nominated Officers carry out their duties as detailed in section 4.3 Authorise the issue of the Control of Asbestos at Work Policy, and any subsequent changes as required by the Nominated Officers, by obtaining approval of the Policy through the Health and Safety Committee. Present to the Health and Safety Committee the Annual report prepared by the Nominated Officer Management of Asbestos. Review the effectiveness of the Policies and Procedures put into place to comply with the Control of Asbestos at Work Regulations, with the Nominated Officers. Ensure that appropriate systems are in place to implement the requirements of the Control of Asbestos Regulations at the locations for which they are responsible. Ensure that any health surveillance records are kept secure and accessible for a period not less than 40 years by the Occupational Health Department from the date of the last entry. Ensure that appropriate training arrangements are in place. Audit the Control of Asbestos policy and the Management Plan to ensure compliance. Employ the services of an Independent Asbestos advisor to carryout annual audits of the Trusts Asbestos management/monitoring process in order to provide assurance to the Trust board of compliance to Asbestos regulations or to advise otherwise 4.4 Nominated Officer (Estates personnel) The Trust shall appoint an officer/s to the role of Nominated Officer Management of Asbestos duties, who shall act as the focal point for assessing and authorising all work with Asbestos Containing Materials (ACM s) on Trust sites and ensure that Asbestos contractors carry out their duties as defined in this policy. Shall produce the Control of Asbestos at Work Policy and audit its application, undertaking a formal review of its contents on an annual basis, referring any changes required to the Estates Manager for authorisation. Maintain a sign off sheet to record approval. Shall produce the procedure documents Asbestos Management Plan and Asbestos Awareness Training and audit its application, undertaking a formal review of its contents on an annual basis, referring any changes required to the Estates Manager for authorisation. Ensure that a survey to identify, as far as reasonably practicable, the location, type and physical condition of any ACM s on Trust premises has been conducted by means of a Management Survey and ensure a Refurbishment and Demolition Survey is carried out prior to any works commencing. Keep concise records of all Asbestos removal works and the results of environmental monitoring for record purposes, in one central location, copies to be kept in the project file. To carry out audits of asbestos removal contractors, ensuring that when contractors are working with Asbestos, they comply with the requirements of the Regulations. Also check the credentials of Licensed Contractors (documents to be held in the office of the Nominated Officer Management of Asbestos ). Have some responsibility for all asbestos related works on Trust properties, therefore giving the authority to review, check and make recommendations to method statements for works organised by Estates Officers. Issue date: January Review date: January 2018

9 Ensure that members of staff receive information, instruction and training to carry out their defined responsibilities effectively and safely, refer to section 9.0 Instructing, directing and liaising with external consultants, accredited environmental analysts, surveyors and specialist licensed asbestos removal contractors. Appropriate disseminating of the information contained within the asbestos register. Ensure that sufficient information is given to any Contractor employed for Asbestos work concerning local site conditions and procedures, which are likely to influence his method of, work (i.e. site-specific hazards etc.). Shall keep concise records of Air Test s/ Background Air Test s/ Reoccupation Certificate s from licensed contractors on completion of the removal of ACM s. Be responsible for keeping abreast of the latest legislation and guidance relating to Asbestos Containing Materials, Asbestos Management and Updated Procedures. Be responsible for the monitoring and recording of all Asbestos and Asbestos containing materials in Trust properties. Also to update the Asbestos register after any removal or encapsulation of Asbestos or Asbestos containing materials have taken place. Note: The Responsible person or their delegated Nominated officers shall be the Lead Investigating Officer for all Incidents involving Asbestos or Asbestos related materials. Risk Office to continue any investigations once confirmed as a RIDDOR. 4.5 Asbestos Monitoring officer Ensure that a survey to identify, as far as reasonably practicable, the location, type and physical condition of any ACM s on Trust premises has been conducted by means of a Management Survey and ensure a Refurbishment and Demolition Survey is carried out prior to any works commencing. Carry out and/or ensure that regular checks are carried out on the condition of existing ACM s to ensure that they are fit for continued service. Records of these checks are to be kept of record/audit purposes. Assessing, reviewing and recommending management actions in light of re-inspection findings and changes in regulations and good/best practice. Keep concise records of all Asbestos removal works and the results of environmental monitoring for record purposes, in one central location, copies to be kept in the project file. 4.6 Estates Officers Ensuring that all maintenance employees and contract staff under their control are made aware of the presence of ACM s within buildings and that consultation of the asbestos register takes place before any task(s) are undertaken by directly employed staff and externally contracted companies. To report any suspect materials discovered whilst carrying out day-to-day maintenance activities. Ensure that all personnel under their control carry out their duties as defined in Section 4.7 Be responsible for ensuring that no work is started on systems/equipment containing Asbestos until a suitable and sufficient Risk Assessment of the activity has been carried out and the appropriate control actions decided upon to achieve Safe-Systems-of-Work are in place. This is to be communicated to the Asbestos contractor to write these into the Method Statement. Liasing directly with and advise, ward/department managers on works to be undertaken. Issue date: January Review date: January 2018

10 Ensure that no work is started without either a Permit-to-work or an Asbestos Clearance certificate being issued by the Nominated Officer Asbestos Management. 4.7 Asbestos Removal Contractors All Asbestos Removal Contractors will be members of ARCA (Asbestos Removal Contractors Association). Comply with current legislation and associated approved codes of practice and guidance. When the removal of ANY asbestos material from West Suffolk Hospital properties is required it must be undertaken in full accordance with the HSE, Management of Asbestos Regulation 2012 and associated guidance covering Notifiable, Notifiable Non-licensed Work (NNLW) and Non Licensed Work (not notifiable). Attend site to assess and prepare quotations against asbestos related works requests. Provide the necessary method statements and risk assessment for the works to the Nominated officer and statutory authority. Methods of work for emergencies must be discussed and agreed with the Nominated Officer Asbestos, or in their absence the Trust appointed Asbestos analyst. The method statement is to show the resources and timetable allocated for the project. Provide statutory notice to the notifying authority prior to commencing asbestos work or by agreement at the request of the Nominated Officers applying for a wavier against the minimum notice period. To carry out their obligations under their works contact, including monitoring high standards of safety and hygiene in asbestos work areas, supplying labour, materials and equipment of a high standard with all necessary supporting documentation. Arranging transport and disposal of asbestos waste materials in accordance with current regulations and best practice. Carrying out regular inspections of the work environment and defects found or reported by the Nominated Officers or the consultant/analyst. Provide copies of HSE Notification, consignment notes, air tests or re-occupation certificates and other related documents as soon as available, to the Nominated Officers. Ensure that sufficient information about the work to be carried out is given to the Contract Manager before commencing work. This shall include Method Statements, Risk Assessments, which shall be agreed for application by the Contract Manager, before the start of any work. Prepare and present a plan of work for the proposed work comprising such issues as: Start time and estimated completion Site Plan and location of any equipment to be used on site Walk routes to be supplied and consideration to any staff/visitors/patients Control Measures Safety Considerations and Procedures Emergency Procedures Site Emergency Fire - First Aid Predicted manning levels Work Methods/Working patterns Site management/communications Need for recourse and documentation including site clearance Certificate etc. Defining individual responsibilities for all aspects of the work 4.8 Asbestos Analyst Maintain UKAS accreditation relevant to instructed tasks. Issue date: January Review date: January 2018

11 Will be employed by the Trust or names of approved independent Analyst will be supplied to the Asbestos Removal contractor to carry out air monitoring or reoccupation testing for certification of clearance works to ensure the analyst shall be independent from the licensed contractor. 4.9 All Staff / Employees Any Non Licensed Work (not notifiable) may be carried out by suitably trained employees of the Trust in line with HSE guidance Asbestos Essentials. Estates and Facilities directorate staff that has the potential to work with or nearby Asbestos containing materials, may interact with the materials and could potentially cause damage which leads to an incident. There is an incident flowchart which can be found at Annex B. For Trust employees who do not work with or around Asbestos materials, but are suspicious of broken or cracked boards or panels, they should follow the flowchart for advice at Annex A. Trained employees in Non-licensed not notifiable work must use any devices provided for their safety, follow any procedures and attend any training provided for the purpose of asbestos safety. Report to their head/line manager immediately if any disturbance/damaged insulation, boarding, tiles, or other products either containing or suspected containing Asbestos takes place, so that appropriate action can be undertaken by the Nominated Officers. Work in compliance with the requirements of this Policy Document, and refer any deficiencies or issues requiring clarification or explanation to the Nominated Officer Asbestos, for resolution. Comply with any requirements laid down in the Asbestos assessment, with particular attention to the proper use and maintenance of any control measures. Co-operate with the employer in his requirement to comply with the Regulations Occupational Health The Control of Asbestos Regulations 2012 states that where the risk assessment identifies employees who are exposed to a level which exceeds the control limit of 0.01 fibres per cm 3 of air averaged over a continuous period of 4 hours, then Health Surveillance is required. If the work involves short-non-continuous maintenance activates or the removal of material in which Asbestos fibres are firmly linked in the matrix, Health Surveillance is NOT required. All that is required is a note in their health records to indicate when an incident of exposure may have occurred (ie Datix incident form should be completed) The occupational health department will ensure that any employee exposed to asbestos receives appropriate medical screening where required and maintain all Health Surveillance records for 40years from the last exposure Risk Office To carryout RIDDOR notification to HSE following Investigation by the Responsible person or Nominated Officer Management of Asbestos as to whether an incident is an actual incident and is therefore reportable. All Asbestos incidents are to be reported to the HSE by the Risk Manager if appropriate to do so Switchboard Operators The Trust switchboard plays a vital role upon the discovery of damaged Asbestos materials or as a result of damaged caused to Asbestos materials by persons carrying out work near or by the Asbestos materials. The Switchboard operator s flowchart can be found at Annex C. Issue date: January Review date: January 2018

12 5.0 Removal of Asbestos Where ACM is found to be in good condition and is unlikely to be disturbed or damaged it is best left in place, with a system introduced to manage it rather than remove it. When the removal of ANY asbestos material from West Suffolk Hospital properties is required it must be undertaken in full accordance with the HSE, Control of Asbestos Regulation 2012 and associated guidance covering Notifiable, Notifiable Non-licensed Work (NNLW) and Non Licensed Work (not notifiable). Any works with Asbestos be it Notifiable, Notifiable Non-licensed Work (NNLW) commissioned by the Trust, must only be carried out by an Asbestos Contractor, who holds a valid licence (FOD ASB02a) issued by the HSE and is a current member of the ARCA. Any Non Licensed Work (not notifiable) may be carried out by suitably trained employees of the Trust in line with HSE Asbestos Essentials guidance. Works involving the removal of asbestos shall be monitored by an independent UKAS accredited Analyst. Once removed from situ the disposal of any asbestos from site MUST only be undertaken by an appropriately licensed asbestos operator and in accordance with the Control of Asbestos Regulation Non-compliance Failure to comply with this policy will result in a full investigation involving all relevant bodies and any persons deemed necessary. A written report will be produced and forwarded to the appropriate Trust manager for further action. The result of the investigation and further action by the appropriate manager may result in disciplinary action. Any unauthorised work on asbestos, or where the correct fibre containment procedures have not been adopted will be reported to the Health, Safety and Risk Manager using the Hospital Datix Incident Reporting System (policy ref PP( )105). 7.0 Policy Review The asbestos policy and arrangements will be reviewed in the event of change of legislation, guidance, change of person involved in the responsibility of Asbestos, an incident which requires a change of the policy to implement further controls or on a 2 yearly basis whichever is sooner. The asbestos register will be updated as and when the condition of any ACM s change, including any planned removal or emergency works. A policy review by an Independent Advisor will be carried out periodically to ensure the Trusts compliance with the regulations. 8.0 Monitoring Arrangements (Reporting to the Trust) Having drawn up a policy, stating the organisational and arrangements for Asbestos Management, it is essential to monitor the Trust s compliance and assess the Asbestos Managerial performance of the Trust. The following topics will be used to measure performance and determine key performance indicators: 1. Details of Asbestos Related Incidents and remedial action taken. 2. Update on the Asbestos Register including the number of High Risk items. 3. Details of any issues where ACM assessments are out of date. 4. Details of Completed and forthcoming works, to either remove or manage. 5. Details of training delivered to staff and attendance figures 6. Audits of compliance with legal requirements and approved codes of practice relating to asbestos Issue date: January Review date: January 2018

13 7. Changes in legislation affecting the Trust or best practice which should be adapted The responsibility for monitoring performance and enabling improvements in the above mentioned areas lies with the Nominated Officers, the Estates Manager, and the Health and Safety Committee. The Nominated Officer Management of Asbestos shall audit compliance of this policy on an annual basis and submit the findings in the form of a report to the Health and Safety Committee group in April each year to enable the committee to assess the Trusts Asbestos arrangements and provide assurance of compliance to the Control of Asbestos Regulations 2012, this report shall be presented by the Estates Manager. Where issues of concern are raised regarding the control of asbestos or non-compliance to any aspect of the relevant regulations, detailed work plans for how compliance and control can be achieved will be required and the issues will be escalated to the Corporate Risk Committee. 9.0 Asbestos Management Plan The HSE states that the Asbestos Management Plan should be a separate document, therefore please refer to the Asbestos Management Plan for information relating to Trusts intensions with regards to how it will manage and control Asbestos on their sites. 10 Asbestos Awareness Training The training module has been separated out to allow the training module to be printed and handed out as a separate handout for training purposes, therefore please refer to the Asbestos Awareness Training module for information relating to Training for those who work near ACM s REFERENCE DOCUMENTS There are a large number of official publications relating to Asbestos at Work. The following list contains the most significant and relevant items, but is not exhaustive. Health and Safety at Work etc. Act 1974 The Control of Asbestos Regulations 2012 Construction Design and Management Regulations 2015 L21: Management of Health and Safety at Work Regulations 1999 L127: The Management of Asbestos in non-domestic premises Regulation 4 of the Control of Asbestos Regulations 2012 L143: Work with materials containing Asbestos, Control of Asbestos Regulations 2012 (ACOP) HSG 189/2: Working with Asbestos Cement Asbestos Essentials HSG 210: Asbestos Essentials task manual HSG 213: Introduction to Asbestos Essentials HSG 227: Managing asbestos in premises HSG 247: Asbestos: The licensed contractors guide HSG 248: Asbestos: The analysts guide for sampling analysis and clearance procedures Issue date: January Review date: January 2018

14 HSG 264: Asbestos: The Survey guide (replaces MDHS100) MDHS39/4 Asbestos fibres in air MDHS100 Surveying, Sampling and Assessment of asbestos containing materials (replaced by HSG 264) ASB5 Notification Form Issue date: January Review date: January 2018

15 Annex A West Suffolk NHS Foundation Trust All Staff Emergency procedure for identified damaged asbestos containing materials Discovery of damaged materials that potentially could contain asbestos? Keep everyone else out of the area. Put up a warning sign and restrict access. Ring helpdesk on 5555 and Estates Team Leaders -Ext 3607, bleep 337 or Ext 3451, bleep 333 advise there is a potential asbestos damaged panel and location Estates Team leaders to check Asbestos register. Does it contain asbestos? Yes No Estates Team Leaders to contact switchboard to bleep asbestos team Place reactive job on system to repair panel Issue date: January Review date: January 2018

16 Annex B West Suffolk NHS Foundation Trust Estates and Facilities Emergency procedure for potential asbestos fibre release Immediate action as a result of damage caused to materials that could potentially contain asbestos? STOP WORK IMMEDIATELY, isolate, cordon and control the area. As part of the cordon control put up warning signs and restrict access Ring switchboard on 2222 and advise there has been an asbestos incident with the location. Switchboard to bleep Asbestos team Is the incident located within a clinical area? Are patients, visitors, other members of staff in the area? Yes Switchboard to communicate a potential Major Incident situation. No Stay put, assistance will arrive with RPE and PPE. Place on RPE and decontaminate by wiping down with Tack ragscontaminated waste to be double bagged. Place on clean PPE Individuals will be escorted to the closest area to shower and wash hair. Put contaminated clothes, towels etc. in an asbestos plastic bag for disposal as hazardous waste. Leave washing facilities clean. Contaminated waste to be taken to Estates Department, for disposal in asbestos containment facility. Responsible person to record incident on DATIX Issue date: January Review date: January 2018

17 Annex C WEST SUFFOLK NHS FOUNDATION TRUST ASBESTOS INCIDENT SWITCHBOARD OPERATORS ACTION CARD Switchboard receive 2222 call for an Asbestos incident In-hours Out of hours Switchboard to send a group 401 call out to Asbestos team with the location Ring the on call Engineer Asbestos team to confirm message to Switchboard On call engineer to ring Responsible person or deputy for advice Asbestos team/on Call Engineer to advise 888 Bleep holder of initial findings, and whether any area has to be evacuated or service delivery affected. if a MAJAX situation is required 888 to complete a METHANE Sitrep and inform SMOC immediately Issue date: January Review date: January 2018

18 Author(s): Compliance Officer Other contributors: Estates Manager. Asbestos Management team. Approvals and endorsements: Health & Safety Committee Facilities Management Team Asbestos Management Team Consultation: Senior Estates and Facilities Officers and Managers External specialist consultants in Asbestos. (IA) Issue no: 4 File name: O:\Facilities Documents\Facilities Health + Safety Documentation\06, Asbestos\Asbestos Policy PP(16)089.pdf Supercedes: PP(14)089 Equality Assessed Yes Implementation Policies will be checked by IG Manager. Policy number will not be issued and policy not approved unless standards contained in this policy are met. Monitoring: (give brief details how Implementation, compliance and effectiveness of this policy this will be done) will be monitored by the Information Governance Committee on an annual basis. This will be achieved through reporting against defined key performance indicators as described in Appendix 4 of PP(06)001 as part of the annual policy review Other relevant policies/documents & references: Additional Information: process. Facilities Health & Safety Policy Contractors Code of Conduct Construction Design & Management (CDM) Policy Health and Safety at Work, etc Act 1974 Control of Asbestos Regulations 2012 Risk Assessment PP( )032 CoSHH PP( )039 Freedom of Information PP( )155 Health Safety and Welfare PP( )018 Incident Reporting and Management PP( )105 Occupational Health Service PP( )046 Issue date: January Review date: January 2018