General Policy
Estates, Facilities and Capital Services
Estates Services Manager (G&NEF)
Compliance Manager, Head of Estates, Sector Estates Managers, Compliance Officer
Director of Estates, Facilities & Capital Services
01 January 2006
18 May 2020
18 May 2022


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 written 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.


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 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 Estates, Facilities & Capital Services but the Chief Executive remains accountable to the Board.

3.2 The Director of Estates, Facilities and Capital Services 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 Estates, Facilities and Capital Services
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

• Making sure 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;
• Making sure that staff groups and individuals identified as being at risk are given appropriate information, instruction and training, including training at induction, updates and refresher training as necessary;

3.4 Individual 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;

3.5 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;


The key risks involved in implementation of this policy are:-

4.1 Lack of staff awareness of this policy, resulting in non-compliance

4.2 Lack of robust organisational arrangements around policy implementation

4.3 Failure to implement and maintain the required procedures associated with the policy


5.1 It is recommended that this document is read in conjunction with the following:

Guidance on Management of Risks Associated with Work in Confined Spaces


6.1 Safe work in confined spaces, Confined Spaces Regulations 1997, Approved Code of Practice, Regulations and guidance. L101, published by HSE.

6.2 NHS Fife Risk Register and Risk Assessment Policy (GP/R7)