PGN-04… · E-PGN-04 1 Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust E-PGN-04 – Asbestos – V02 Oct 19 Part of CNTW(O)32 – Estates Operations and Maintenance Policy

1 Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust Appendix 1- Emergency Procedures E-PGN-04 – Asbestos – V02 Oct 19 Part of CNTW(O)32 – Estates Operations and Maintenance Policy

Estates Operations and Maintenance Practice Guidance Note

Management and Control Of Asbestos – V02

Date Issued

Issue 1 – Oct 19

Planned Review

Oct 2022

E–PGN-04 Part of CNTW (O)32 – Estates Operations and Maintenance Policy

Author / Designation Andrew Short Operations Estates Manager

Responsible Officer / Designation

Paul McCabe - Director of Estates and Facilities -

NTW Solutions Ltd

Contents

Section Description Page No

1 Introduction 1

2 Scope 1

3 Statement 1

4 Definitions 2

5 Responsibilities 3

6 Guidance 6

7 Training 7

8 Associated Documents 10

Appendices – listed separate to PGN

Document No:

Description

Appendix 1 Emergency Procedure for suspected damaged Asbestos containing materials

Appendix 2 Accessing the Asbestos Register

E-PGN-04

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust E-PGN-04 – Asbestos – V02 Oct 19 Part of CNTW(O)32 – Estates Operations and Maintenance Policy

1

1 Introduction 1.1 As Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust and

its subsidiaries including NTW Solutions Limited (CNTW) are owners and occupiers of various premises and have maintenance and repair responsibilities for those premises, there is a duty to assess them for the presence and condition of asbestos containing materials.

1.2 This duty is undertaken by Estates Department on behalf of the Trust. 1.3 Where asbestos is present the Estates Department must ensure that the

risk is assessed, that a written plan identifying where asbestos is located is prepared and that measures to manage the risks are set out in the plan and implemented.

2 Scope 2.1 This practice guidance note (PGN) together with any associated

procedures and guidance notes, shall be observed by all employees of CNTW.

3 Statement 3.1 CNTW is committed to effective management and control of asbestos in

order to reduce the risks to patients, staff, visitors and members of the public.

3.2 The Estates Department will put in place an operational and managerial

structure that accord with Legislative Standards, Approved Codes of Practice, National and Local Guidance and current Best Practice. In particular the Trust shall comply with:

Health and Safety legislation, including the Management of Health and Safety at Work regulations 1999 and the Workplace (Health, Safety and Welfare) Regulations 1992 (as amended)

The Control of Asbestos Regulations (CAR) 2012

The Management of asbestos in non-domestic premises, Approved Code of Practice and Guidance, L127 (HSE)

HSG 264: Asbestos The Survey Guide

HSG 210: Asbestos Essentials: A Task Manual for Building, Maintenance and Allied Trades of Non-Licensed Asbestos Work

3.3 The Trust will ensure that the Estates Department is supported by the

resources required to meet these objectives.

E-PGN-04


2

3.4 All work on the building fabric, services, plant or equipment, whether carried out by employees or external contractors, should be managed and conducted in a way that eliminates or at least minimises exposure to airborne asbestos fibres, so far as is reasonably practicable.

3.5 CNTW employees and its contractors are not expected to do any kind of

work with asbestos containing materials, as this will be contracted out to licensed asbestos removal contractors under the supervision of asbestos analysts.

3.6 CNTW acknowledges the health hazards arising from exposure to airborne

asbestos fibres and accepts its responsibility in managing that risk. CNTW will manage this risk by ensuring the following control measures are in place:

An up-to-date ‘Asbestos Register’ will be kept for all CNTW premises

All areas known to contain asbestos will be risk assessed annually

Any maintenance work carried out in areas known to contain asbestos will only be allowed after a satisfactory Risk Assessment

Only Health and Safety Executive (HSE) licensed contractors will be used for asbestos work

Only United Kingdom Accreditation Service (UKAS) accredited analysts will be used for asbestos sampling and monitoring asbestos removal work

Following asbestos removal or treatment, areas may only be reoccupied if the area is visually clean and the air level is less than 0.01 fibres per ml

CNTW Employees will be given adequate training in respect of their duties associated with this PGN

An ‘Asbestos Group’ will be set up, comprising of Designated Officer (chair) Responsible and Deputy Officers, and Estates Staff representatives. Other specialists may be co–opted as required

4 Definitions 4.1 CAR 4.1.1 The Control of Asbestos Regulations 2012.

E-PGN-04


3

4.2 ACMs 4.2.1 Asbestos Containing Materials; any substance or material that contains

asbestos. 4.3 Airborne Asbestos Fibres 4.3.1 Microscopic fibres released from various types of asbestos into the air can

be breathed in and lead to disease. Asbestos is normally mixed with other building materials to form a finished product. The risk of a building product releasing asbestos fibres greatly depends upon the other materials with which the fibres are mixed. The easier the material which contains the asbestos fibre disintegrates, the higher the risk of airborne fibres being released.

4.4 Licensed Asbestos Removal Contractor (LARC) 4.4.1 A contractor licensed by the Health and Safety Executive under the Control

of Asbestos Regulations (CAR) 2012 and normally a member of ARCA or ACAD Division of TICA.

5 Responsibilities 5.1 Chief Executive 5.1.1 The Chief Executive has overall accountability for ensuring that the

Management and Control of Asbestos is implemented. This responsibility will be delegated to the Director of Estates and Facilities, for implementation. The Trust’s Estates Department will be instructed to comply with the requirements of this PGN and implement the work as detailed.

5.2 Head of Estates 5.2.1 The Head of Estates shall act as Duty Holder under the CAR and will be

responsible for managing the day-to-day arrangements made under this PGN.

5.3 Estates Operational Managers 5.3.1 The Estates Operational Managers will be appointed as the Deputy Duty

Holders and will be responsible for assembling and maintaining a suitably qualified Asbestos Team, consisting of staff and retained consultants/contractors, chairing the Asbestos Policy Group, the development of day-to-day operational PGN for asbestos issues within the Trust, including the receipt of papers by the Estates ‘Responsible Officer’ (Asbestos) to support improvements.

E-PGN-04


4

5.4 Responsible Officer (Estates) 5.4.1 The ‘Responsible Officer’ will have accountability for ensuring the

requirements of this PGN are met and to specifically ensure that the following is undertaken.

5.4.2 The ‘Responsible Officer’ shall carry out the following duties:

Liaise regularly with Estates colleagues to ensure that they are fully aware of any planned developments which potentially involve Asbestos containing Materials (ACM) dust generation or release

Ensuring current knowledge of best practice in the control of asbestos and ensuring all polices are kept up-to-date

Maintaining records relating to known asbestos locations

Arranging and monitoring regular inspections of known asbestos locations

Training Estates personnel with regard to risks and associated precautions relating to Asbestos

Monitoring of Estates staff and Contractors to ensure their compliance with this guidance and procedures

Maintain their own knowledge and appropriate level of training 5.4.3 The ‘Responsible Officers’ are as follows:

Central Sector: Senior Estates Officer (Building)

North Sector: Estates Officer (Building)

South Sector: Estates Officer (Building)

Cumbria Sector: Estates Officer (Property)

5.5 Estates Maintenance Staff 5.5.1 All Estates Trade Staff must:

Follow the requirements of this PGN

Comply with their legal duty to take care of their own health and safety and that of others affected by what they do and do not do

E-PGN-04


5

Make full use of control measures put into place by the Trust, and co-operate with them so that they can comply with any legal duties placed on them

Not disturb Asbestos Containing Materials (ACM’s) and immediately report any damage to Asbestos Containing Materials so that appropriate action can be urgently taken. Should, during the course of work, suspected Asbestos Containing Materials be encountered, the work must stop immediately and follow the procedure in Appendix 1.

5.6 Contractors 5.6.1 Contractors are responsible for compliance with this PGN and relevant

procedures, and where acting as sole, main or principal contractor to have a thorough understanding of these procedures.

5.6.2 Contractors must have membership of the Asbestos Aware Contractors

Scheme (AACS), or an equivalent commitment to training. 5.6.3 Contractors must ensure that all sub-contractors are informed of this PGN

and relevant procedures, in particular the location of ACMs within the project area.

5.6.4 Contractors need to co-operate with the Estates ‘Responsible Officer’

(Asbestos) and any Licensed Asbestos removal contractors or associated contractors working within or adjacent the known or intended project area.

5.6.5 Contractors must ensure that emergency measures are in place for any

suspected or known exposure to Asbestos Containing Materials, and that these are in line with CNTW procedures.

5.7 Capital Projects Team 5.7.1 Estates Project staff have responsibilities as outlined in this PGN. A

significant responsibility is the requirement to undertake a ‘Refurbishment

and Demolition’ survey of the area before a project starts, where the work

will entail demolition or exposure of parts of the structure or fabric that could not be seen during the ‘Management Survey’. Recommendations made by the Analyst or ‘Responsible Officer’ for Asbestos for any remedial action should be incorporated into the project works. If suspect materials are discovered during the course of project works the Project Manager shall halt the work, inform the ‘Responsible Officer’ or the relevant Deputy Responsible Officer (Asbestos) and take any necessary or recommended action, which may include informing staff and building occupants and clearing the site. The Project Manager shall arrange for any necessary analytical works and seek advice from the Asbestos Works Co-ordinator on the most appropriate remedial action.

5.7.2 All relevant documentation should be retained with the Project File/Health

and Safety File with a copy sent to the ’Responsible Officer’ for Asbestos.

E-PGN-04


6

5.8 Staff 5.8.1 Staff are responsible for ensuring that any work that may disturb or

damage asbestos insulation or asbestos products is avoided. 5.8.2 They are responsible for contacting the Estates ‘Responsible Officer’

(Asbestos) and ensuring the Trust asbestos management procedures are abided by, when work cannot be completed without disturbing asbestos.

5.8.3 They are responsible for reporting to their supervisor or manager any

material suspected to contain asbestos, and where the material has been disturbed or damaged, or where staff are likely to undertake work which may affect such material.

5.8.4 Line Managers, whose staff could disturb Asbestos Containing Materials

as a result of their work should ensure that they attend an asbestos awareness course and understand this PGN as it applies to them, and ensure that their staff use the facilities operated by Estates Department for managing Asbestos Containing Materials to avoid exposure as a result of their work.

6 Guidance 6.1 The scope of this PGN requires the full co-operation of management and

staff at all levels across the organisation. 6.2 This guidance outlines the nature and extent of the risks associated with

asbestos and gives details of on-going control methods and precautionary measures, which are to be employed on all Estates related works. In addition to the application of this guidance, other rules, Policies and Procedures issued by management or by other authorities shall be complied with in accordance with management instructions.

6.3 Where employees are required to work in areas not owned or controlled by

CNTW, this guidance and its operational Procedures will be used as a guide to safe working, where there is a risk of exposure to asbestos.

6.4 The ‘Control of Asbestos Regulations (CAR) 2012’ introduced an explicit

duty to manage asbestos in non-domestic premises. The duty to manage requires those in control of premises to:

Take reasonable steps to find materials likely to contain asbestos and check their condition

Presume materials contain asbestos unless there is strong evidence to suppose they do not

Make a written record of the location and condition of asbestos and presumed asbestos – containing materials and keep a record up-to-date

E-PGN-04


7

Assess the risk of the likelihood of anyone being exposed to fibres from these materials

Prepare a plan to manage that risk and put it into effect to ensure that:

o Any material known or presumed to contain asbestos is kept in a good state of repair

o Any material that contains or is presumed to contain asbestos is,

because of the risks associated with its location or condition, repaired or if necessary removed; and

o Information on the location and condition of the material is given to

anyone potentially at risk 7 Training 7.1 It is acknowledged that effective management of Asbestos Containing

Materials requires knowledge of a specialised area of health, safety and construction works.

7.2 The Head of Estates will ensure that a suitable level of expertise is

available for the Trust, either by training of employees, using external training courses or resources, or by establishing a relationship with a specialist external organisation such as a UKAS accredited Consultancy.

7.3 Information will be sought from specialist consultancies and publications,

including HSE documents. Information will be made available to employees, contractors, visitors, etc., by means of specific notice boards, local intranet, Trust web-site, tool-box talks etc.

7.4 Instruction 7.4.1 The Operational Estates Manager will arrange for adequate instruction to

be given to all necessary personnel and organisations. Instruction may be in the form of in-house training seminars, distribution of information by letter, leaflets or electronic communication etc.

7.5 Training/Information 7.5.1 The Operational Estates Manager will assess training requirements and

co-ordinate its provision. The intention is to provide an open and responsive culture where individuals have an awareness of the risks and an appreciation of the effectiveness, suitability and requirement for management procedures.

E-PGN-04


8

7.5.2 The key purposes of asbestos awareness/training is to ensure that the location of, or the means to locate, the Asbestos Register and AMP is known by all who may require such information.

Arrangements for safe systems of work/controls on buildings works are known to all relevant parties

7.5.3 It is acknowledged that risk groups, such as new employees, newly appointed contractors etc., may require asbestos awareness training or similar as part of their induction process.

7.6 Training of Non-employees 7.6.1 Employers have a duty under Regulation 3(4)(a) of the Asbestos

Regulations to ensure, so far as is reasonably practicable, that adequate information, instruction and training is given to non-employees who are on the premises and could be affected by the work, as well as their own employees.

7.6.2 The training/information agenda will be as follows and as shown in the

training chart:

Group Description: A Employees (non-estates) B Estates maintenance / building operatives C Employees with extra responsibilities, e.g. Estates ‘Responsible

Officer’ (Asbestos) and Deputies D Visitors E Contractors F Consultants engaged on capital projects

E-PGN-04


9

Item Group

A B C D E F

Asbestos health risks

Fibres have to be airborne to cause exposure/entry into lungs

Good condition ACM’s are best left in place

Avoid exposure – one-off accidental exposure has negligible effect regarding increasing health risks, however, risk will increase if level, frequency or duration increases

Responsibilities

Trust responsibilities and key contact people

Individual responsibilities

Procedures

Location and purpose of EOP

Key personnel – contact details

Procedures when damaged or suspect ACM found

Procedures to be followed by maintenance or external contractors

ACM’s in buildings – general uses

Range and location of ACM’s within the Trust

Before working on any building materials

(Procedures to avoid exposure to ACM’s)

Check whether it is an ACM

Ensure Trust and company procedures are being complied with (e.g. identify ACM’s materials, take advice from the Estates ‘Responsible Officer’ (Asbestos); be aware of emergency measures)

Know what work you are allowed to do on an ACM If relevant, know how to work safely on ACM’s and how others, (e.g. Licensed Contractors) may work safely

Advanced knowledge

CAR, HSG 227

P405 Management of Asbestos in Buildings

ARCA/ACAD Asbestos Management courses

E-PGN-04


10

7.7 Training Review 7.7.1 The Operational Estates Manager will review the training arrangements, as

minimum, annually to assess if:

All individuals/department/groups requiring training have been identified

Re-training requirements are adequate

Trust induction arrangements are adequate

Course content is appropriate

Review records will be kept 7.8 Training Providers 7.8.1 Where in-house expertise is not available specialist providers may be

considered. The Operational Estates Manager will arrange for external trainers from specialist consultancies or training organisations.

8 Associated Documents

CNTW(O)32 – Estates Operations and Maintenance Policy

E-PGN-04

Appendix 1


Emergency Procedures Emergency situations considered within this guidance relate to when:

Asbestos Containing Materials are damaged

Suspect Asbestos Containing Materials are encountered

Remedial works result in release of elevated airborne fibre levels

Non-Licensed personnel require urgent access to asbestos remedial works area.

In all cases the Estates Help Desk should be contacted immediately, they will then notify the Estates ‘Responsible Officer’ (Asbestos) or a local Deputy Responsible Estates Officer (Asbestos). The measures taken should prevent or minimise the exposure of personnel to airborne asbestos fibre. Damaged Asbestos Containing Materials The Estates Helpdesk should be contacted immediately, they will then notify the Estates ‘Responsible Officer’ (Asbestos) or the local Deputy ‘Responsible Officer’ (Asbestos) whose advice must be followed and if either of the afore mentioned Officers cannot be contacted immediately.

All persons in the area must stop work immediately and the area closed to access

Prevent people from entering the area

If any person has got dust or debris on their clothing or overalls, they should remove these and place them in a plastic bag, find facilities to wash or shower as soon as possible, and leave the shower / washroom in a clean state

The incident must to be reported immediately to Estates Supervising Officer, so a licensed contractor can be appointed to facilitate decontamination

The Estates ‘Responsible Officer’ (Asbestos) will take appropriate action to prevent exposure of personnel – for example using the services of a UKAS accredited consultancy

E-PGN-04

Appendix 1

12

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust Appendix 1 – Emergency Procedures – V02 Oct 19 Part of CNTW(O)32 – Estates Operations and Maintenance Policy

and a Licensed Asbestos Removal Contractor for remedial works

Suspect Asbestos Containing Materials Training on the recognition of suspect Asbestos Containing Materials is offered through the Asbestos Awareness Training courses. If suspect materials are discovered:

Contact the Estates Helpdesk immediately; they will then notify the Estates ‘Responsible Officer’ (Asbestos) or the local Deputy Responsible Officer (Asbestos);

If either of the afore mentioned Officers cannot be immediately contacted; Do not disturb the material;

Inform others that material should remain undisturbed – if possible, use appropriate warning signage. Estates Helpdesk will carry appropriate stock.

The Estates ‘Responsible Officer’ (Asbestos) will take appropriate action to prevent exposure of personnel – for example using the services of a UKAS accredited consultancy and a Licensed Asbestos Removal Contractor for remedial works.

Projects For those engaged in project work the Site Manager should immediately inform the Estates Helpdesk, together with the Estates ‘Responsible Officer’ (Asbestos) and the Project Manager. The Site Manager should halt all local works and take any necessary or recommended action. Such action may include informing staff and building occupants, clearing the site, etc. He shall inform the Project Manager of all developments. General Health and Safety reporting procedures may be prompted, for example, completion of Accident or Dangerous Occurrence Reports which may require submission to the Trust Safety Department. The contractor’s own Health and Safety reporting procedures may also be triggered by such events. The Estates ‘Responsible Officer’ (Asbestos) or the Deputy Estates Officer (Asbestos) shall arrange for any necessary analytical works and advise on the most appropriate remedial action. It is probable that removal of the materials would be recommended in the majority of projects.

Urgent access to an Asbestos Work Area In the case of an emergency (medical, services, safety etc.) only those who have received training, are properly protected, and are under the supervision of the Estates ‘Responsible Officer’ (Asbestos) or local Deputy Responsible Estates Officer

E-PGN-04

Appendix 1

13

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust Appendix 1 – Emergency Procedures – V02 Oct 19 Part of CNTW(O)32 – Estates Operations and Maintenance Policy

(Asbestos), Licensed Asbestos Contractor or Analytical Consultancy, will be allowed entry into an asbestos enclosure.

In all cases where access may be required, contact the Estates ‘Responsible Officer’ (Asbestos) or the Deputy Estates Officer (Asbestos) and follow their advice. Copies of Incident Reports generated by site contractors are to go to the Estates ‘Responsible Officer’ (Asbestos) and the Safety Unit.

Notification Where exposure occurs above the CAR Regulations, Control Limits reporting of the incident to the HSE under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR) will be assessed and generally carried out by the Safety Director. Where the incident area is under the control of a Principal Contractor the reporting requirement is likely to be part of his responsibilities.

E-PGN-04

Appendix 2


Asbestos Register Surveys Existing information regarding the location and condition of asbestos containing materials at a given site within CNTW is held by the Estates Department. This information is contained within the Asbestos Register. The Trust has had a number of “Management” Surveys, carried out by UKAS accredited consultants, whose surveyors have attended P402 / P405 / S301 BOHS courses, in accordance with HSE guidance MDHS 100. The ‘Responsible Officer’ will review existing Registers to ascertain their currency and to ensure that they comply with the standards laid down in this guidance. Where they do not comply or are not current, new Surveys will be commissioned.

The Asbestos Register should contain the Asbestos Survey information that is specific to the premises on which it is held and should consist of:

A scale Site Plan which identifies the buildings

A Layout Plan for all buildings that identify unique room numbers

Survey Data Sheets which must be cross referenced with the plans referred to above

Supporting photographs to identify specific elements on the survey

The Risk Assessment Matrix and individual Risk Assessments relative to any identified Asbestos Containing Materials

Recommendations for each identified risk within the premise and supporting statements of action taken to contain or remove the Asbestos Containing Materials

Correspondence that is specific to the premises on which it is held, e.g. sample certificates

Clearance certificates, project works correspondence, Plans and Drawings.

E-PGN-04

Appendix 2

15

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust Appendix 2 – Asbestos Register – V02 Oct 19 Part of CNTW(O)32 – Estates Operations and Maintenance Policy

The Asbestos Register and plans for:

Hopewood Park and Community Premises is held by M Kirby

Monkwearmouth Hospital is held by M Kirby

Northgate Hospital and Community Premises is held by P Gair

St. Nicholas Hospital and Community Premises is held by K Scott

Carleton Clinic, Cumbria premises is held by TBA Role of Analysts Analysts conducting Asbestos Surveys must also take into account the following contributory factors to assessment of the condition of Asbestos Containing Materials and its future maintenance:

Location (rooms, corridors, external, etc.)

Frequency of use (High, Medium, Low)

Vulnerability to damage (likely, some risk, unlikely)

Entries on the Asbestos Survey information include a quantified Risk Assessment. This has been undertaken by applying numeric values to the following factors:

Type of product (plastics, cement, insulation or boarding)

Condition (good, fair, poor)

State (sealed, unsealed, friable)

Type of asbestos

Using the Asbestos Survey Information Periodically, and at least on an annual basis, the condition of materials identified in the Survey as Asbestos Containing Materials, should be visually inspected by either a trained Estates Officer, the ‘Responsible Officer’ or an Analyst, to determine whether its risk rating has changed. Particular attention shall be paid to those areas reaching higher scores, 10 and above, on the Asbestos Register.

E-PGN-04

Appendix 2

16

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust Appendix 2 – Asbestos Register – V02 Oct 19 Part of CNTW(O)32 – Estates Operations and Maintenance Policy

When assessing the condition and treatment of asbestos materials, it is the release of fibres into the air, which requires careful consideration. Fibre release may arise when:

The material is being disturbed (for example, if it is in a prominent position and prone to accidental damage)

The surface of the material is damaged, frayed or scratched

The surface sealant is peeling or breaking off

The material is becoming detached from its base (this is a particular problem with pipe and boiler lagging and sprayed coatings)

Coverings designed to protect the asbestos are missing, removed or damaged