GENERAL NOTE
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. FUNCTION
- 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.
- 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.
- 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.
- 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
- 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)
- 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
- 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.
- 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.
- 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.
2. LOCATION
2.1 This Policy is applicable to all NHS Fife owned premises
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 & Asset Management is the Executive Lead for Health and Safety and is responsible for:
- Making sure that there are arrangements in 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
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 risk 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.
3.4 Estates Manager
The Estates manager is responsible for ensuring:
- 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
3.4 Authorised Person (Ventilation)
The Authorised Person (Ventilation) is responsible for ensuring:
- The 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.
3.5 Members of Staff
NHS Fife regards ventilation 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 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
4.4 Training
4.4.1 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 03-01 Specialised ventilation for healthcare premises.
4.4.2 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 the ventilation systema, 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 Ventilation Systems Policy and associated Procedures are to be formally reviewed periodically by the NHS Fife Ventilation 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 Electrical Safety Policy. It is recommended that this document is read in conjunction with the following:
- Appendix 1 SOP 03 – Ventilation Systems and Procedures
- GP/I9 – NHS Fife Adverse Events 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
Lifting Operations and Lifting Equipment Regulations
Construction (Design Management) Regulations
Control of Substances Hazardous to Health
Available online at www.legislation.gov.uk
Safe use of work equipment, Provision and Use of Work Equipment Regulations, Approved Code of Practice, Regulations and Guidance. L22.
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.
