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General Policy
Estates, Facilities and Capital Services
Estates Services Manager (C&NEFife)
Estates Compliance Manager, Sector Estates Managers, Head of Estates
Director of Property & Asset Management
01 January 2006
14 November 2023
14 November 2026


NHS Fife acknowledges and agrees with the importance of regular and timely reviews of policy statements and aims to review policies within the timescale set out.

New policies will be subject to a review date of no more than 1 year from the date of the first issue. Reviewed policies will have a review date set that is relevant to the content (advised by the author) but will be no longer than 3 years.

If the policy is past its review date, then the content will remain extant until such time as the policy review is complete and the new version published.


1.1 NHS Fife takes the health, safety, and welfare of its entire staff seriously. This policy outlines the steps to be taken by NHS Fife to ensure that staff or others do not work in confined spaces where it can be avoided. Where this is not possible, a documented, suitable and sufficient risk assessment must be undertaken, and a safe system of work developed.

1.2 This policy is to enable NHS Fife to meet its obligation to protect staff and contractors from the risks of work in confined spaces, so far as is reasonably practicable.


2.1 This Policy is Applicable to all NHS Fife owned premises and those where NHS Fife services are delivered. Examples of confined spaces in such locations could be ducts, vessels, culverts, tunnels, boreholes, manholes, excavations, sumps, inspection pits, freight containers, tanks, building voids, some enclosed rooms (particularly plant rooms) and compartments within them, including some cellars, enclosures for the purpose of asbestos removal, interiors of machines, plant, or vehicles.


3.1 Chief Executive

The Chief Executive of NHS Fife has overall executive responsibility for ensuring that effective arrangements are in place to manage all safety, health and risk matters within NHS Fife. This responsibility has been delegated to an appropriate senior manager, the Director of Property & Asset Management, but the Chief Executive remains accountable to the Board.

3.2 The Director of Property & Asset Management is the Executive Lead for Health and Safety and is responsible for:

• Making sure that there are arrangements for identifying, evaluating, and managing risks associated with work in confined spaces.
• Making sure that the Board regularly reviews the effectiveness of the policy.

3.3 Director of Property & Asset Management

Through the Head of Estates is responsible for ensuring:

• The implementation and management of the policy and associated procedures across NHS Fife.
• That NHS Fife staff are aware of and have access to the policy and associated procedures.
• That NHS Fife staff understand the importance of compliance with the procedures associated with this policy.
• That staff receive training commensurate with their role and responsibilities.
• That risk assessments are carried out and reviewed regularly.
• Putting procedures and safe systems of work into practice which are designed to eliminate or reduce the risks associated with work in confined spaces.
• That staff groups and individuals identified as being at risk are given appropriate information, instruction, and training.

3.4 Departmental Managers

• Making sure that all staff are aware of this policy.
• Providing resources for putting the policy into practice.
• Making sure there are arrangements for monitoring incidents linked to work in confined spaces.
• Making sure that appropriate support is given to staff involved in any incident.
• Managing the effectiveness of preventative measures through an effective system of reporting, investigating, and recording incidents.
• Ensuring that staff are consulted through partnership arrangements, on matters relating to their Health and Safety.

3.3 Members of Staff

• Taking reasonable care of themselves and others who may be affected by their actions.
• Co-operating by following rules and procedures designed for safe work in confined spaces.

• Reporting all incidents that may affect the health and safety of themselves or others and asking for guidance as appropriate.
• Reporting any risks they identify or any concerns they might have in respect of work in confined spaces.
• Taking part in training designed to meet the requirements of the policy.


4.1 The aim of this policy is to minimise the risk of harm to all persons working in confined spaces. The operational components are listed below and are fully detailed in the NHS Fife Guidance on Management of Risks Associated with Work in Confined Spaces (GP/C1-1).

• Assessing the risks from entry.
• The definition of a Confined Space and the specified risks.
• Developing a safe system of work.
• Permit to work.
• Training requirements.


The key risks involved in implementation of this policy are:

• Lack of staff awareness of this policy, resulting in non-compliance.
• Lack of robust organisational arrangements around policy implementation.
• Failure to implement and maintain the required procedures associated with the policy.


This section details the documentation relating to this Confined Space Policy. It is recommended that this document is read in conjunction with the following:

• Guidance on Management of Risks Associated with Work in Confined Spaces.
• NHS Fife Risk Register and Risk Assessment Policy (GP/R7)


7.1 Statute, Legal and Guidance

Confined Spaces Regulations 1997, available online at

Safe work in confined spaces, Confined Spaces Regulations 1997, Approved Code of Practice, Regulations and Guidance. L101.
Workplace health, safety and welfare. Workplace (Health, Safety and Welfare) Regulations 1992, Approved Code of Practice and guidance. L24.
Confined spaces, A brief guide to working safely. INDG 258.

Available online at HSE: Information about health and safety at work

7.2 NHS Requirements

NHS Scotland has published Scottish Health Technical Memoranda (SHTM) which contain policy and procedural guidance.

SHTM 08-07: Confined Spaces policies, procedures and guidance