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The Newcastle upon Tyne Hospitals NHS Foundation Trust

Lift Safety Policy

Version No.: 1.0

Effective From: 18 January 2016

Expiry Date: 18 January 2019

Date Ratified: 22 December 2015

Ratified By: Estates Management Team

1 Introduction The Trust, accepts its responsibility under the Health and Safety at Work Act 1974 (HSAWA), the Management of Health and Safety at Work Regulations 1999 (MHSW), the Lifting Operations and Lifting Equipment Regulations (LOLER) 1998, the Testing and assessment of lifts 1998 LG1, the Safety Assessment Federation Ltd and of BS7255 (1989), the Code of practice for safe working on lifts, ACOP L113, Safe use of lifting equipment, HTM 08 02 – lifts, the Electricity at Work Regulations 1989 (EAWR), IEE 17th Edition Regulations (BS 7671), place a duty on Newcastle upon Tyne NHS Foundation Trust (NUTH) to publish, issue and implement a lift safety policy, which outlines the organisation and procedures required to achieve the objectives set out in those legislative documents. The Trust recognises that the lowest acceptable standards of lift safety are contained in legislation and it is the aim of the Trust, as an organisation committed to quality performance, to improve upon these standards. The aim of this policy is to ensure the provision of safe lift equipment, thereby ensuring the safety of the user. 2 Scope This Policy applies to all Trust premises whether owned or occupied by the Trust under lease or other Service Level Agreements (SLAs) and Private Finance Initiatives (PFI). Where the management of buildings/areas occupied by Trust staff and/or patients is carried-out by others, the requirements of this Policy remain applicable although implementation of the site specific Risk Management requirements is managed by local Policies. It remains; therefore, the Trusts responsibility by the Estates Governance Manager and Facilities and Capital Development Manager, to ensure that the requirements of this Policy are notified to and complied with by all other parties described above.

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3 Aims The Trust is committed to the safe operation of all the lift systems for which it has a responsibility. To determine the management arrangements for safe working when using and maintaining lifts. To ensure all powered lifts and associated equipment will be designed and installed such that they may be operated and maintained safely when approved operational procedures are followed correctly. To ensure that all powered lifts and equipment installed within Trust premises are installed, serviced and used so as to protect staff, patients or members of the public from personal injury or any other damage arising its use, as far as is reasonably practical. The Trust regards lift safety at work as also being a responsibility of every employee in order to safeguard themselves, their colleagues and other persons within the sphere of the Trust’s interests. The Trust proposes to continue to promote and develop a pro-active safety regime by providing information, training and instruction for all employees, together with safe workplace procedures and rigorous maintenance routines for all lifts and associated equipment. The Trust reviews procedures for health and safety matters. Identification of hazards and elimination of risks shall also take account of the lift systems, with the safety codes guidance and HTM 08-02 to ensure compliance with statutory legislation. The effectiveness of the lift safety policy and procedures depends, to a large extent, on the full co-operation and active participation of all employees to implement safe working practices and to report on any perceived risk of danger arising from the use of the lift system and associated equipment. This safety policy will apply wherever any Trust employees are working, and to all lift equipment of the Trust, wherever it is located. Suitable and sufficient risk assessments and safe systems of work will be undertaken by management. Management will ensure that employees are competent to undertake tasks involving lift maintenance and safety. Management will ensure correct safety signs are provided to ensure compliance with legislation.

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4 Duties (Roles and responsibilities) 4.1 Chief Executive The Chief Executive has overall responsibility for ensuring that the Trust’s premises comply with all statutory requirements and also has an overriding duty of care as the duty holder under the HASWA.

This responsibility is delegated to the Director of Estates & Facilities within the Trust. To help with such responsibility, the Authorised Person will help with the day-to-day management and control of the electrical safety policy. 4.2 Designated Person (Lifts) – Director of Estates & Facilities The Director of Estates & Facilities is the individual appointed by the Trust (a board member or a person with responsibilities to the board) who has overall authority and responsibility for lifts and their safe operation. They have a duty to prepare and issue a general policy statement in relation to lifts and their safe operation, including the organisation and arrangements for carrying out that policy. The policy should include reference to mandatory examinations, record-keeping, emergency procedures and training of personnel.

He/she will oversee the management arrangements and advise the Trust Board accordingly and ensure that the Trust’s risk register is maintained with regard to lift safety management. He/she will appoint, in writing, an Authorising Engineer to implement, administer and monitor the safety arrangements for the Trust’s lift systems. He/she will review the appointment of the Authorising Engineer on an annual basis. He/she will agree any deviation from HTM 08-02 He/she will ensure that sufficient resources are made available to the Estates and Facilities Department to comply with their duties outlined in this policy. 4.3 Designated Person (Electrical) – Director of Estates & Facilities

The Director of Estates & Facilities is the individual appointed by the Trust (a board

member or a person with responsibilities to the board) who has overall authority and

responsibility for the low voltage electricity system within the premises and who has a

duty under the Health and Safety at Work etc. Act 1974 to prepare and issue a general

policy statement on health and safety at work, including the organisation and

arrangements for carrying out that policy. This person should not be the Authorising

Engineer (LV).

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4.4 Authorising Engineer (Lifts) The Authorising Engineer (Lifts) is a chartered engineer with appropriate experience,

whose appointment is the responsibility of the Designated Person (Lifts). The person

appointed should possess the necessary degree of independence from local

management to take action within this guidance including the implementation,

administration and monitoring of the safety arrangements defined in BS 7255.

4.5 Authorising Engineer (Electrical) A Chartered or incorporated electrical engineer or company possessing the necessary degree of independence from local management and appointed in writing by the management to implement, administer, monitor and audit the safety arrangements for the low voltage electrical supply and distribution systems of that organisation to ensure compliance with the Electricity at Work Regulations 1989 and to assess the suitability of appointment of candidates in writing to be “Authorised persons”. He/she will assess and recommend, in writing, an appropriate number of Authorised Persons. He/she will define the exact area of responsibility for each Authorised person, and may remove an Authorised Person from their post if appropriate. He/she will audit compliance of the Trust against HTM 08-02 and produce an Action Plan for completion by the Trust, and review progress of the Action Plan. 4.6 Authorised Persons (Lifts) The Authorised Person (Lifts) is nominated by the Authorising Engineer (Lifts) and has the key operational responsibility for the specialist service. The person will be qualified and sufficiently experienced and skilled to fully operate the specialist service. The person nominated should be able to demonstrate a thorough familiarisation with the system by having attended appropriate professional course. He/she will follow the duties and responsibilities laid down in HTM 08-02.

4.7 Authorised Persons (Electrical) An individual possessing adequate technical knowledge and having received

appropriate training, appointed in writing by the Authorising engineer to be Responsible

for the practical implementation and operation of management’s safety policy and

procedures on defined electrical systems. He/she will follow the duties and

responsibilities laid down in HTM 06.

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4.8 Competent Person (Lifts) A Competent Person (Lifts) is a person, suitably trained and qualified by knowledge and

practical experience, and provided with the necessary instructions to enable the

required work to be carried out safely (from BS 7255). In this context it is the lift

specialist contractor.

4.9 Lift Steward Lift Steward is a person nominated by the Authorised Person (Lifts) to undertake simple

daily monitoring of lifts in order to check their correct operation.

4.10 Lift Wardens Appointed by management, a Lift Warden will help to evacuate occupants during

emergencies by using an escape lift. There are three types of lift warden:

1. Lift Warden (Floor); 2. Lift Warden (Control); and 3. Lift Warden (Car). 4.11 Lift Release Warden A Lift Release Warden is a person, suitably trained and qualified by knowledge and

practical experience, and provided with the necessary instructions to enable the safe

release of passengers from lifts. They should be recommended by the Authorised

Person (Lifts), be formally appointed by management, and should undergo refresher

training annually.

5 Definitions HSAWA – Health and Safety at Work etc. Act 1974 MHSWR – Management of Health and Safety at Work Regulations 1999 EAWR – Electricity at Work Regulations 1989 ACOP – Approved Code of Practice LOLER - Lifting Operations and Lifting Equipment Regulations IET – Institute of Electrical Technology HTM – Health Technical Memorandum

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6 Safety Rules & Operational Procedures 6.1 Operating Systems All work on lifts systems and associated equipment must be carried out using the safety procedures, which are formalised as written instructions and safety rules, as appropriate. The safety procedures are to be subject to annual review with regard to safe systems of work and the competence of staff for their assigned duties. Programmed work and testing is only to be carried out under formal safety documentation procedures using written instructions and safe systems of work. The following shall be read in conjunction with these regulations, safety rules and

procedures.

the Lifting Operations and Lifting Equipment Regulations (LOLER) 1998;

the Testing and assessment of lifts 1998 LG1;

the Safety Assessment Federation Ltd and of BS7255 (1989);

the Code of practice for safe working on lifts;

ACOP L113, Safe use of lifting equipment, Electrical Regulations 1989, IET

Wiring Regulations (BS 7671);

HTM 08 02 - lifts.

6.2 Contractors Compliance with Safety Standards

The Contractor will be expected to comply with the requirements of the Trust at all times

including safety, access arrangements, security, infection control, data protection and

patient confidentially.

The contractor will also be expected to comply with all legislation, guidance and good working practices as embodied in published documents. Documentary evidence of compliance must be provided on request. 6.3 Thorough Examinations All lift installations and equipment are required to be examined in accordance with the

regulation.

A thorough examination should include the following:

landing and car doors and their interlocks;

worm and other gearing;

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main drive system components;

governors;

safety gear;

suspension ropes;

suspension chains;

overload detection devices;

electrical devices (including earthing, earth bonding, safety devices, selection of

fuses, etc.);

braking systems (including buffers and over speed devices); and hydraulics.

6.4 Role of the Duty Holder The duty holder is legally responsible for ensuring that the lift is safe to use

and that it is thoroughly examined. These responsibilities include:

maintaining the lift so that it is safe to use;

selecting and instructing the competent person;

ensuring that the lift is examined at statutory intervals (every 6 or 12 months) or

in accordance with an examination scheme drawn up by a competent person;

keeping the competent person informed of any changes in the lift operating

conditions which may affect the risk assessment;

making relevant documentation available to the competent person, e.g.

manufacturer’s instructions and maintenance records;

acting promptly to remedy any defects;

ensuring that all documentation complies with the Regulations; and record

keeping

6.5 The Law Requires That all lifts when in use should be thoroughly examined:

after substantial and significant changes have been made;

at least every six months if the lift is used at any time to carry people, every

12 months if it only carries loads, or in accordance with an examination

scheme; and

following ‘exceptional circumstances’ such as damage to, or failure of, the lift,

long periods out of use or a major change in operating conditions which is likely

to affect the integrity of the equipment.

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7 Safe Systems of Work 7.1 General Ensure that:

A Risk Assessment is required for ALL work to LV electrical systems,

Installations and equipment

Live working is not normally permitted [special controlled circumstances may

apply]

A ‘Dead’ working permit is required before work on any electrical installation

connected with a lift installation

All insulated hand tools must be inspected before use for cuts and damage to the insulation, if damaged remove out of use and report to your supervisor.

Ensure appropriate signage is posted at all times.

7.2 Lift Motor Room

Ensure that:

All safety rails and guards are in place. If rotating parts are not guarded, take particular care when hand winding.

All rotating parts are painted yellow (BS7255 1989 and the Provision and Use of Work Equipment Regulations (PUWER) 1998. Safe use of work equipment, Approved Code of Practice and guidance L22);

Lift motor room floor hatches have been tested and marked with the safe working load [SWL];

Suitable safety rails (edge protection) will be used if the hatch has to be open for any reason [see: ACOP ‘Safe use of Lifting Equipment’ L113.Regulation 3, Para 68 to82];

Rubber safety mats are in place at control panels / equipment. These should be tested and clean

Ensure appropriate signage is posted at all times.

7.3 Working on Lifts

Ensure that:

safety / caution signs must be posted at all point of lift car access (each landing) to warn that the lift is out of service

isolate and lock off all sources of supply in accordance with the lock of procedures before working on electrical equipment

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Ensure appropriate signage is posted at all times.

7.4 Working on/in Lift Pit Ensure that:

safety/caution signs must be posted to warn of the risk of falling

Safety barriers are to be used whenever work is required in the lift pit or at car

doors

safety/caution signs must be posted to warn of the danger of crushing by the car

or platform of a hydraulically operated lift

and be suitably propped and prevented from downward movement before any

work is undertaken beneath it

before any person enters a lift pit the electrical power supply shall be isolated

using the lift pit switch where provided and 'Caution' notices placed on points of

isolation

Ensure appropriate signage is posted at all times.

7.5 Working in a Lift Shaft Ensure that:

Safety/caution signs must be posted at all point of lift car access (each landing)

to warn that the lift is out of service.

isolate and lock off all sources of supply in accordance with the lock of

procedures before working on electrical equipment

Ensure appropriate signage is posted at all times.

7.6 Working on Car Tops Ensure that:

safety/caution signs must be posted at all point of lift car access (each landing) to

warn that the lift is out of service.

Keep clear of counter weight when riding on car top

all double lift installations should have the lift shaft totally screened - keep away

from that adjacent edge

Ensure appropriate signage is posted at all times.

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7.7 Hand Winding

Ensure that:

Staff must be trained to carry out hand-winding

isolate and lock off all sources of supply in accordance with the lock of procedures before working on electrical equipment

When hand winding has been carried out, any separate winding wheel and/or

brake release lever shall be removed before restoring the electrical supply.

Ensure appropriate signage is posted at all times.

7.8 Access Controls Ensure that:

Only authorised persons are permitted to enter a lift motor room

No entry signs to be fitted to all lift motor room doors as indicated in the current

Safety documents pertaining to lift management.

Before plant, equipment, electrical and pressure (Hydraulic) systems are worked

on, they must be safely isolated from all sources of danger. Safe isolation

methods include permits, locks and caution notices.

Safety Lock-offs will be controlled using special locking devices to allow the use

of safety locks. The keys to safety locks is to be retained by the Competent

Person who applied them

Each competent person will be issued with a personal locks(s). The issue will be

recorded. A spare key will be locked in a safe where access can only be

obtained in an emergency.

If an Authorised Person applies the safety lock before the permit-to-work is

issued, the key must be placed in a key safe – one key to the key safe being

retained by the Authorised Person, and the other being issued to the person in

receipt of the permit

8 Maintenance and Test Records Records will be kept of

the thorough examination report

all maintenance, service and repairs

The thorough examination report - by law should:

identify the equipment examined (serial number, make, etc), the employer and

the premises;

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give the date of the last thorough examination and specify when the next one

should take place;

specify the safe working load of the lift;

give the reason for the thorough examination (i.e. following installation, according

to an examination scheme, statutory interval, etc.);

identify any defect which is or may become a danger to people;

give the details of any repair, renewal or alteration required to remedy the defect

and the date by which it should be undertaken;

give details of any tests carried out;

give details of the person carrying out the report and the person validating the

9 Competence

Any individual working on lift equipment should have documented competence in lift works as identified in HTM 08-02 and noted previously in this policy. Those required to monitor and control lift specialist contractors and oversee lift stewards and wardens will be suitably trained by having attended appropriate courses including specialist lift manufacturer courses. A training needs analysis will be conducted in order to identify the staff that require training and the level of that training.

10 Training – Emergency Release of Passengers The emergency release of lift passengers and using the hand winding procedure will be

only carried out be trained people - those who have received training from the lift

manufacturer or approved courses e.g. Eastwood Park Training, which will include:

Instruction in the safety skills and knowledge common to the safe operation of

lifts

The dangers arising from inappropriate actions

hazardous areas (e.g. beneath lift cars.)

The main causes of accidents and relevant safe working practices, including the

correct use of barriers

Slips trips and falls

Information and instructions

Approved staff groups who have been trained to release those trapped in a lift are

Estates Personnel designated as Lift wardens

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The Fire, Health and Safety Course is part of the Trust Training Plan, this includes elements of electrical safety which all staff members must undertake on an annual basis. Completion of this course is recorded. 11 Equality and Diversity On completion of the impact assessment form the strategy/policy/procedure can contain the following statement: “The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This document has been appropriately assessed.” 12 Monitoring Compliance

The Estates and Facilities Department will have the overall responsibility to ensure this policy for lift installations is adhered to. Aspects of the policy where user involvement is identified should be adopted and promoted by the relevant mangers as identified above.

Standard / process / issue

Monitoring and audit

Method By Committee Frequency

Monitoring for effective implementation and compliance to statutory standards will use audit check sheets which compares key milestones for compliance

Annual Audits

Authorising Engineer

Director of Estates & Facilities

Quarterly report to H&S Committee

Compliance to standards

will be monitored at a six-

monthly frequency. Any

perceived lapse in

standards of the

application of the Trust

policy will be reported to

the Estates & Facilities

Department Head

Annual Tests Authorising Engineer

Director of Estates & Facilities

Quarterly report to H&S Committee

Audits, random in nature

will be carried out and will

consider the following

minimum requirements.

the work is being done

Testing in line with current Regulations

Estates Operational Manager & Risk Manager

Health & Safety Committee

5-yearly

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correctly

agreed work practices

are being used

any agreed site rules (if

relevant) are been

followed

training or information

requirements have

been passed on,

taking into account staff

churn of changes in

work teams /

individuals

working practises are

relevant to the task in

hand

13 Consultation and review This electrical safety policy is to be reviewed every 2 years or subject to changes in legislation or practice. 14 Implementation (including raising awareness)

The Policy will be made available to all on the NUTH document database. Policy

awareness will be communicated through the relevant committee’s and training for

specific staff as specified within the training section of this policy.

15 References Health and Safety at Work etc. Act 1974 HTM 06 - 01 Electrical services supply and distribution Part B: Operational management. HTM 06 - 02 'Electrical services supply and distribution' Electrical Safety Guidance for low voltage systems. The Management of Health and Safety at Work Regulations 1999 The Provision and Use of Work Equipment Regulations 1998. The Working at Height Regulations 2005.

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The Control of Substances Hazardous to Health Regulations 2002. The Electricity at Work Regulations 1989. Memorandum of guidance in the Electricity at Work Regulations 199 Electrical Equipment (Safety) Regulations 1994. Guidance on safe isolation procedures GS38. Electrical test equipment for use by electricians. INDG354 (rev1): Safety in electrical Testing. HSG85: Electricity at work: safe working practices. The Health and Safety (Safety Signs and Signals) Regulations 1996. ACOP L22 PUWER - Safe use of work equipment.

Personal protective equipment at work 2nd edition INDG402: Safe use of ladders. INDG405: Top tips for ladder and stepladder safety. INDG73 (rev): Working Alone in safety. Thorough examination and testing of lifts, Simple guidance for lift owners 16 Associated documentation Appendix 1 – Visual User Check Appendix 2 – Live Working Permit Appendix 3 – Safe to Work Permit

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Appendix 1A

Audit record form part 1: Lifts - Organisation Control

Date of Audit...…………………….

Signed by Estates Operational and Manager ……...………… Print Name.………………………………………………………………………..………….. Signed by Risk Manager.………………………………………………….…… Print Name…………………………………………………………………………………….. Comments to be expanded in a full report

Organisation controls

Yes No Comments

1.1

Has the organisation appointed a Designated Person (Lifts) in writing specifically to be responsible and who has overall authority and responsibility for lifts and their safe operation (HTM 08-02 Lifts)

1.2

Has the organisation appointed staff in writing for the practical implementation and safe operation and maintenance of lifts as: Authorising Engineer (Lifts) Authorised Person (Lifts Competent Person (Lifts) Lift Steward Lift Release Wardens (HTM 08-02 Lifts

1.3

Is an annual programme of training in place for lift release (lift wardens) (HTM 08-02 Lifts)

1.4

Are suitable and effective training records maintained for each member of staff? (Management of H&S at Work: Reg 13)

1.5

Is evidence available to demonstrate that contractors and other external organisations who work on lifts are carrying out their duties in accordance with the regulations? (The Electricity at Work Regulations 1989 Reg 16) (HTM 08-02 Lifts)

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Organisation controls

Yes No Comments

1.6

Are specifically designed lift car / opening barriers available for use when working on lifts (Management of H&S at Work: Reg 3

1.7

Has an assessment of risk been prepared, documented and recorded for all electrical tasks as appropriate in accordance with the required criteria? (Management of H&S at Work: Reg 3

1.8

Are risk assessments freely available with the ranking identified for all work carried out? (M of H&S W: Reg 3)

1.9

Are records of maintenance and statutory inspection current and up-top date

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Appendix 1B

Audit record form part 2: Lifts - working environment compliance

Date of Audit...…………………….

Signed by Estates Operational and Manager ……...………… Print Name.………………………………………………………………………..………….. Signed by Risk Manager.………………………………………………….…… Print Name……………………………………………………………………………………..

Comments to be expanded in a full report

Review

Period Reviewer Comments

Completion of permit authorisation and safe systems of work implementation

At occurrences of work requiring a permit - random selection

Estates Officer, Operations and Maintenance

Inspection of the working area

At occurrences of work - random selection

Supervisor

Inspection of tools, equipment and access equipment

At 6 monthly intervals

Risk Manager

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Appendix 1C

Audit record form part 3: Lifts - Policy and SOP compliance

Date of Audit...…………………….

Signed by Estates Operational and Manager ……...………… Print Name.………………………………………………………………………..………….. Signed by Risk Manager.………………………………………………….…… Print Name……………………………………………………………………………………..

Comments to be expanded in a full report

Section Review

Yes No Comments

Introduction Accuracy of text against ‘Trust’

and legislative requirements

Definitions Accuracy of text against legislative

requirements

Duties Accuracy of text against legislative

requirements

Safety rules and

procedures

Accuracy of text against legislative

requirements and current

arrangements

Records Accuracy of text against legislative

requirements

Application Accuracy of text against legislative

requirements

Accidents and

incidents

Accuracy of text against current

arrangements

Training Accuracy of text against current

arrangements

Process of

monitoring

Accuracy of text against current

arrangements

References Accuracy of references and dates

Version control

sheet

Accuracy of text against current

version number

Appendices Accuracy of text against legislative

requirements and current

arrangements

The Newcastle upon Tyne Hospitals NHS Foundation Trust

Equality Analysis Form A

This form must be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval.

PART 1 1. Assessment Date: 2. Name of policy / strategy / service:

Lift Safety Policy

3. Name and designation of Author:

Doug Ward, Director of Estates

4. Names & designations of those involved in the impact analysis screening process:

Samantha Grainger, Estates Officer, Rob Sanderson, Chief Building Officer

5. Is this a: Policy X Strategy Service

Is this: New X Revised

Who is affected Employees X Service Users X Wider Community

6. What are the main aims, objectives of the policy, strategy, or service and the intended outcomes? (These can be cut and pasted from your policy)

The aim of this policy is to ensure the provision of safe lift equipment, thereby ensuring the safety of the user.

7. Does this policy, strategy, or service have any equality implications? Yes No X

If No, state reasons and the information used to make this decision, please refer to paragraph 2.3 of the Equality Analysis Guidance before providing reasons:

The Trust, accepts its responsibility under the Health and Safety at Work Act 1974 (HSAWA), the Management of Health

and Safety at Work Regulations 1999 (MHSW), the Lifting Operations and Lifting Equipment Regulations (LOLER) 1998,

the Testing and assessment of lifts 1998 LG1, the Safety Assessment Federation Ltd and of BS7255 (1989), the Code of

practice for safe working on lifts, ACOP L113, Safe use of lifting equipment, HTM 08 02 – lifts, the Electricity at Work

22.12.2015

Regulations 1989 (EAWR), IEE 17th Edition Regulations (BS 7671), place a duty on Newcastle upon Tyne NHS Foundation

Trust (NUTH) to publish, issue and implement a lift safety policy, which outlines the organisation and procedures required to

achieve the objectives set out in those legislative documents.

The Trust recognises that the lowest acceptable standards of lift safety are contained in legislation and it is the aim of the Trust, as an organisation committed to quality performance, to improve upon these standards.

8. Summary of evidence related to protected characteristics Protected Characteristic Evidence, i.e. What evidence do

you have that the Trust is meeting the needs of people in various protected Groups

Does evidence/engagement highlight areas of direct or indirect discrimination? If yes describe steps to be taken to address (by whom, completion date and review date)

Does the evidence highlight any areas to advance opportunities or foster good relations. If yes what steps will be taken? (by whom, completion date and review date)

Race / Ethnic origin (including gypsies and travellers)

This policy does not differentiate race or ethnic origin

No NA

Sex (male/ female) This policy does not differentiate between male and female

No NA

Religion and Belief This policy does not differentiate between religions and beliefs

No NA

Sexual orientation including lesbian, gay and bisexual people

This policy does not differentiate between sexual orientation

No NA

Age This policy does not differentiate between age

No NA

Disability – learning difficulties, physical disability, sensory impairment and mental health. Consider the needs of carers in this section

This policy does not differentiate against any disability; all individuals involved in working on ventilation systems must be appropriately qualified or supervised.

No NA

Gender Re-assignment This policy does not differentiate against gender re-assignment

No NA

Marriage and Civil Partnership This policy does not differentiate on this

No NA

Maternity / Pregnancy This policy does not differentiate on this

No NA

9. Are there any gaps in the evidence outlined above? If ‘yes’ how will these be rectified?

No

10. Engagement has taken place with people who have protected characteristics and will continue through the Equality Delivery System and the Equality Diversity and Human Rights Group. Please note you may require further engagement in respect of any significant changes to policies, new developments and or changes to service delivery. In such circumstances please contact the Equality and Diversity Lead or the Involvement and Equalities Officer.

Do you require further engagement? Yes No X

11. Could the policy, strategy or service have a negative impact on human rights? (E.g. the right to respect for private and family

life, the right to a fair hearing and the right to education?

No

PART 2 Name:

Samantha Grainger

Date of completion:

22.12.2015

(If any reader of this procedural document identifies a potential discriminatory impact that has not been identified, please refer to the Policy Author identified above, together with any suggestions for action required to avoid/reduce the impact.)