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 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 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, or if national policy or legislative changes are made
1. FUNCTION
1.1 NHS Fife takes the health, safety, and welfare of its entire staff seriously and is of prime importance, which is to be given equal priority with other business and operating objectives and will, so far as is reasonably practicable, ensure that the safety of employees, patients and other persons is not adversely affected by any of NHS Fife’s operational activities associated with our pressure systems.
1.2 NHS Fife recognises that the lowest acceptable standards of pressure system safety are contained in legislation, and it is the aim of NHS Fife to improve upon these standards. This policy is to ensure the correct management of pressure systems and the associated safe methods of work ensuring the safety of estates staff, contractors, users of the systems and others within the vicinity of use.
1.3 NHS Fife proposes to continue to promote and develop a pro-active pressure systems safety regime by providing information, training and instruction for all employees, together with safe workplace procedures and rigorous maintenance routines for all equipment.
1.4 The effectiveness of this safety policy and associated procedures depends largely 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 maintenance, repair or use of the pressure systems or equipment.
2. LOCATION
2.1 This policy is applicable to all NHS Fife owned premises, those where NHS Fife services are delivered or where pressure systems, belonging to NHS Fife, are being used.
2.2 The management and maintenance of Decontamination Equipment are out with the scope of this policy or the associated procedures.
3. RESPONSIBILITY
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 and 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 on Pressure Systems;
- Making sure that the Board regularly reviews the effectiveness of this policy and by considering NHS guidance, that the policy continues to meet legislative requirements.
3.3 Director of Property and 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 appropriate information, instruction and training, including training at induction, updates and refresher training as necessary, commensurate with their role and responsibilities.
- Procedures and safe systems of work are put in place which are designed to eliminate or reduce the risks associated with work on pressure systems.
- That staff groups and individuals identified as being at risk are given
3.4 The Estates Manager is responsible for:
- Providing resources for putting the policy into practice
- 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
- Making sure that all staff are aware of this policy
- Making sure there are arrangements for monitoring incidents linked to work on Pressure Systems
- 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 on Pressure Systems
- 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 on Pressure Systems.
- Taking part in training designed to meet the requirements of the policy
3.5 Authorised Person (Pressure Systems)
The Authorised Person (Pressure Systems) is responsible for ensuring:
- The implementation of the requirements of the Scottish Health Technical Memorandum (SHTM 08-08).
- Implementing safe systems of work and the Safe Operating Procedures.
- Coordinating and managing all contracts on critical pressure systems ensuring they are maintained and operating within the Safe Operating Procedures.
3.6 Members Of Staff
NHS Fife regards pressure system safety as a responsibility of every employee, to safeguard themselves, their colleagues, and other persons within the sphere of NHS Fife’s interests. They are responsible for:
- Taking reasonable care of themselves and others who may be affected by their actions.
- Co-operating by following rules and procedures designed for safe working with ventilation systems.
- 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 with ventilation systems, plant or equipment or work tasks associated with the systems, plant or equipment.
- Taking part in training designed to meet the requirements of the policy.
4. OPERATIONAL SYSTEM
4.1 The Management of Health and Safety at Work Regulations 1999 create a duty to assess significant risks in the workplace. This duty extends to those risks associated with Pressure Systems. The Pressure Systems Safety Regulations 2000 further refers.
4.2 Managers must make sure that staff are not exposed to the risks associated with work on Pressure Systems or, if that is not reasonably practicable, that the risks are adequately controlled.
4.3 The safe operation of all pressure systems for which NHS Fife has responsibility for will be operated and managed by implementing the requirements of Scottish Health Technical Memorandum 08-08: Pressure Systems – Procedure & Guidance (SHTM 08-08)
4.4 The Technical Memorandum mentioned in 4.3 is managed by the Estates Department under Appendix 1 – SOP 15 Pressure Systems Safety Rules & Procedures.
4.5 Training
4.5.1 Training is an essential element of safe working practice, and all staff must be appropriately trained, prior to being appointed or instructed to undertake any of the defined operational roles and responsibilities detailed in the Scottish Health Technical Memorandum 08-08 Pressure Systems.
4.5.2 The training of an individual, which can be by formal education and by on-the-job tuition, as appropriate. The trained individual is to be assessed for suitability by the person responsible for the appointment of the individual to a particular duty.
4.5 Incident Reporting
4.5.1 Any incident which involves pressure systems, and which compromises safety must be reported, in the first instance to the Estates Department, who will inform the Authorised Person for the system. The Authorised Person for the system will determine what action is to be taken to prevent any risk or danger arising from the reported equipment.
4.5.2 All reported incidents are to be investigated, and a written record of the incident and action taken is to be entered into Datix.
4.5.3 The reporting of injuries or dangerous occurrences under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR), will be acted upon, by the Health and Safety Department upon completion of the required Datix notification.
4.6 Review
4.6.1 This Pressure Systems Policy and associated Procedures are to be formally reviewed periodically by the NHS Fife Pressure Systems Safety Group and an agreed minute of the review is to be retained.
5. RISK MANAGEMENT
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.
6. RELATED DOCUMENTS
This section details the documentation relating to this Policy. It is recommended that this document is read in conjunction with the following:
- Appendix 1 – SOP 15 Pressure Systems Safety Rules & Procedures.
- GP/I9 – NHS Fife Adverse Events Policy
- GP/H1 - NHS Fife Health and Safety Policy
- GP/P4 – Personal Protective Equipment Policy
7. REFERENCES
7.1 Statute, Legal and Guidance
Management of Health and Safety at Work Regulations
Personal Protective Equipment at Work Regulations
Provision and Use of Work Equipment Regulations
Construction (Design Management) Regulations
Control of Substances Hazardous to Health
PSSR 2000 (Pressure Systems Safety Regulations 2000)
Available online at www.legislation.gov.uk
Pressure Systems Safety Regulations 2000. Approved Code of Practice and guidance on Regulations. L122.
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.
8. RELATED PUBLICATIONS
- GP/P9 – Pressure Systems - EQIA
