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General Policy
Estates, Facilities and Capital Services
Estates Compliance Manager
Director of Estates, Sector Estates Manager
Director of Estates, Facilities & Capital Services, Director of Workforce
09 August 2019
20 September 2020
20 September 2024

General Note

NHS Fife acknowledges and agrees with the importance of regular and timely review of policy/procedure 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/procedures 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/procedure review is complete and the new version published, or there are national policy or legislative changes.


1.1 The Health and Safety at Work Act 1974, the Control of Substances Hazardous Regulations 2002 (COSHH) and the Management of Health and Safety at Work Regulations 1999, place a duty on NHS Fife to publish, issue and implement a Ventilation Systems 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 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 Ventilation Systems 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 correct management of Ventilation Systems and the associated safe methods of work for Estates staff and Contractors.

1.4 NHS Fife is committed to the safe operation of all the Ventilation systems for which it has a responsibility, by implementing the requirements of the Provision and use of Work Equipment Regulations (PUWER) and the Scottish Health Technical Memorandum (SHTM): -

SHTM 03-01: Ventilation Systems – Procedure & Guidance

Compliance with the above Technical Memorandum is managed by the Estates teams under the Estates SOP for Ventilation Systems.

1.5 The Estates Department has detailed procedures on Ventilation systems management and safe systems of work and is a much more in-depth level of management and safety, over and above this NHS Board policy. (See appendix 1).

1.6 Any amendments to existing ventilation systems, or any new installations, must be designed and installed in line with SHTM and other relevant technical standards. If a deviation is required from any of these standards, this must be clearly documented and only signed off by the relevant technical person(s), including an NHS Fife representative.

1.7 NHS Fife proposes to continue to promote and develop a pro-active Ventilation systems safety regime by providing information, training and instruction for all Estates employees together with safe workplace procedures and rigorous maintenance routines for all 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 Ventilation systems, with the safety codes’ guidance, to ensure compliance with statutory legislation.

1.9 The effectiveness of this safety policy and procedures depends to a large extent on the full co-operation and active participation of all Estates employees to implement safe work practices, under the control of a suitably appointed authorised person.


Applicable to all NHS Fife owned premises.


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 on Ventilation Systems
• Making sure that the Board regularly reviews the effectiveness of the policy

3.3 Head of Estates

3.3.1 The Head of Estates is responsible for ensuring:
• Implementation and management of the policy and associated procedures across NHS Fife
• NHS Fife staff are aware of and have access to the policy and associated procedures
• NHS Fife staff understand the importance of compliance with the procedures associated with this policy
• Staff receive training commensurate with their role and responsibilities.
• That risk assessments are carried out and reviewed regularly
• That putting procedures and safe systems of work into practice which are designed to eliminate or reduce the risks associated with work on Ventilation Systems
• 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

3.3.2 The Estates Manager and/or the Authorised Person are responsible for:
• 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 on Ventilation Systems
• 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
• 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 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 in respect of work on Ventilation Systems
• Taking part in training designed to meet the requirements of the policy
• The authorised person has responsibility for implementation of the requirements of the SHTM
• Implementing safe systems of work.
• Coordinating and managing all contracts on critical ventilation systems ensuring they are verified as per guidelines.


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 Ventilation Systems

4.2 Managers must make sure that staff are not exposed to the risks associated with work on Ventilation Systems or, if that is not reasonably practicable, that the risks are adequately controlled.

4.3 This policy should be read in conjunction with Appendix 1 – SOP 03 Ventilation Systems and Procedures


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

Appendix 1 - SOP 03 Ventilation Systems and Procedures


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

7.2 Management of Health and Safety at Work Regulations 1999

7.3 Personal Protective Equipment at Work Regulations 1992

7.4 Provision and Use of Work Equipment Regulations 1998

7.5 Lifting Operations and Lifting Equipment Regulations 1998

7.6 Construction (Design Management) Regulations 2015

7.7 Control of Substances Hazardous to Health

7.8 SHTM 03-01 Ventilation Systems

Related Publications
• GP/V1 – Ventilation Systems - EQIA