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General Policy
Estates, Facilities and Capital Services
Estates Officers - Specialist Services & Compliance
Director of Estates and Facilities, Sector Estates Managers
Director of Estates, Facilities and Capital Services
01 January 2006
21 September 2020
21 September 2023

General Note

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

New policies/procedures will be subject to a review date of no more than 1 year from the date of 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 a policy/procedure 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 The Health and Safety at Work Act 1974, the Management of Health and Safety at Work Regulations 1999, and the Electricity at Work Regulations 1989 place a duty on NHS Fife to publish, issue and implement an Electrical Safety Policy which outlines the organisation and procedures required to achieve the objectives set out in those legislative documents.

1.2 NHS Fife regards Health and Safety as a matter of prime importance which is to be given an equal priority with other business and operating objectives and, so far as is reasonably practicable, will ensure that the electrical safety of employees at work, patients and other persons is not adversely affected by any of NHS Fife’s operational activities.

1.3 NHS Fife recognises that the lowest acceptable standards of electrical safety are contained in legislation and it is the aim of NHS Fife as an organisation committed to quality performance to improve upon these standards. This policy is to ensure the provision of safe electrical equipment which is insulated, earthed or otherwise suitably protected, thereby ensuring the safety of the user.

1.4 NHS Fife is committed to the safe operation of all the electrical systems for which it has a responsibility, by implementing the requirements of Scottish Health Technical Memorandum:-

06-01: Electrical services supply and distribution Part A: Design considerations
06-01: Electrical services supply and distribution Part B: Operational management
06-02: Electrical safety guidance for low voltage systems
08-03: Bedhead Services
08-02: Lifts

The above Technical Memorandums mentioned in 1.4 are managed by the Estates teams under the Estates Electrical Safety & Operation Procedure, in line with the SHTM’s. Other areas under control of Estates are PAT Testing, although some of the rules under the electricity at work regulations pass some responsibility onto the user of the equipment.

Lifts and Medical Equipment are covered under a separate Estates Procedure.

1.5 The Estates Department has detailed procedures on electrical operational management and safe systems of work, and is a much more in depth level of electrical management and safety, over and above this NHS Board policy. (See appendix 2).

1.6 NHS Fife regards electrical 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 NHS Fife’s interests. (See guidance in Appendix 1.)

1.7 NHS Fife proposes to continue to promote and develop a pro-active electrical safety regime by providing information, training and instruction for all employees together with safe workplace procedures and rigorous maintenance routines for all electrical equipment.

1.8 NHS Fife’s review procedures for health and safety matters, identification of hazards and elimination of risks shall also take account of the electrical systems, with the safety codes’ guidance, to ensure compliance with statutory legislation.

1.9 The effectiveness of the electrical safety policy and procedures depends to a large extent on the full co-operation and active participation of all employees to implement safe work practices and to report on any perceived risk of danger arising from the use of the electrical system and equipment.
This electrical safety policy will apply wherever any NHS Fife employees are working and to all electrical equipment belonging to NHS Fife, wherever it is located.


2.1 Applicable to all NHS Fife owned premises and those where NHS Fife services are delivered.


3.1 All users of electrical equipment within NHS Fife

3.2 Heads of Departments for keeping suitable records and management of personal electrical items

3.3 Each local Estates department has responsibility to manage the fixed electrical systems and equipment within NHS Fife premises.


4.1 Installation

All new fixed electrical systems and equipment must be checked and tested for electrical safety by a competent person before being taken into use. This may be carried out by an approved electrical contractor (those who are registered with the National Inspection Council for Electrical Installation Contracting or a member of the Electrical Contractors Association) or an electrician from the Estates Department (who has gained the City & Guild 2391 or 2394/2395 qualification).

4.2 Inspection and Testing

All fixed electrical plant and installation (s) must be routinely inspected and tested, in accordance with current legislation and good electrical practice. Testing of electrical installations will be the responsibility of the local Estates Department and only up to the point of isolation, e.g. specialist fixed and/or medical equipment, e.g. MRI scanners etc will not be tested, and the responsibility for the maintenance of this equipment will be with the user and managed under a service & maintenance contract with the manufacturer or suitably competent contractor.

4.3 Portable Appliance Testing

All ‘portable’ equipment i.e. that is connected to the electricity supply with a plug, must be inspected and\or tested at installation and thereafter at appropriate intervals (frequency determined by a process of risk assessment based on its type of use and its environment). Records of the inspection and\or tests must be made and kept. See Appendix 1 with frequencies for testing portable equipment. Each local Estates department will manage this service for NHS Fife owned equipment.

4.3.1 In between recorded checks, users must regularly carry out a visual inspection and report any perceived defect. See Appendix 1 on guidance for user checking

4.3.2 After the recorded check, and repair if necessary, the checker must attach to the equipment a label saying Tested for Electrical Safety and insert the date that it was tested and next test date.

4.3.3 The appropriate manager from each area of NHS Fife must ensure that a comprehensive list of portable electrical equipment is kept, updated and available at time of inspection and that staff which they are responsible for, do not bring in personal items of electrical equipment.

4.3.4 No person shall use an item of electrical equipment unless it bears a label indicating a current pass status of safety inspection as issued by the Estates Department, its nominated contractor, or in the case of specialist medical electrical equipment, Medical Physics Staff.

4.3.5 Equipment found with no label or is over its test date as per Appendix 1, should not under normal circumstances be used. Should the need arise to use such an item of equipment in an emergency situation; the user of the equipment will determine if the risk is acceptable. This will include a visual check of the equipment by the user. The Department Manager must then contact the Estates Help Desk and arrange to have the equipment tested at the earliest opportunity.

4.4 Use (General)

4.4.1 Those in charge of work involving the use of electricity must ensure that the equipment is safe to use and adequately maintained.

4.4.2 They must ensure that those under their supervision are fully informed, instructed and, if necessary, trained in the safe operation of the equipment.

4.4.3 They must ensure that measures are in place to prevent the use of defective equipment.

4.5 Training

4.5.1 Training is an essential element of safe work practices and all staff must be appropriately trained, prior to being appointed or instructed to undertake duties under the safety procedures.

4.5.2 The training of an individual, which can be by formal education and by on-the-job tuition, as appropriate, is to be assessed for suitability by the person responsible for the appointment of the individual to a particular duty.

4.5.3 Examination of each person’s training record is to be included in the procedures review process and where necessary, periodic retraining is to be arranged to cover the technical aspects, electrical safety and first aid matters, as appropriate for each individual’s duties.

4.6 Incident Reporting

4.6.1 Any incident which involves the electrical system and which compromises safety must be reported, in the first instance to the Estates Services Department, who will inform the Authorised Person for the system and who in turn will determine what action is to be taken to prevent any risk or danger arising from the reported equipment.

All reported incidents are to be investigated by the Designated Person and a written record of the incident and action taken is to be filed in the system log book and the operational procedures manual. A Datix Entry will also be required.

4.6.2 The reporting of injuries or dangerous occurrences under the Reporting of Injuries, Diseases and Dangerous Occurrence Regulations 2013 (RIDDOR), will be acted upon, as required, by the Designated Person.

4.7 Review

4.7.1 This Electrical Safety Policy and Procedures are to be formally reviewed periodically by the Designated Person and the Authorising Engineer and an agreed minute of the review meeting is to be retained in the Operational Procedures manual and copies passed to all Authorised Persons


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

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

5.2 Lack of robust organisational arrangements around policy implementation

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


6.1 Appendix 1 – User checks as detailed in HSG 107 & NHS Fife Estates Risk assessment for PAT frequencies

6.2 Appendix 2 – SOP 13 – NHS Fife Estates - Electrical Safety & Operation Procedures


7.1 Health and Safety at Work Act 1974

7.2 Electricity at Work Regulations 1989

7.3 SHTM 06-02 & 03 - Electrical safety guidance for low voltage systems

7.4 HSG107 - Maintaining portable electrical equipment (PAT)

7.5 SHTM 08-02 - Lifts

7.6 SHTM 08-02 – Bedhead Services