General Policy
Estates, Facilities and Capital Services
Head of Estates
Estates Compliance Manager, Sector Estates Managers, H&S adviser
01 January 2006
09 July 2018
09 July 2021

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.


This policy is an integral part of NHS Fife’s approach to quality, safety and governance. The Health and Safety at Work Act etc (1974) and the Management of Health and Safety at Work Regulations (1999) place a duty on NHS Fife to publish issue and implement a Window Management Policy. This Policy outlines the principles to be adopted and implemented in order to achieve the objectives set out in the aforementioned legislation and other related legislative documents,specifically the Scottish Health Technical Memorandum 55: Windows, NHSScotland Hazard Notice HAZ (SC) 04/02 Window Security in the NHSScotland Estate and the Health and Safety Executive Health Services Information Sheet No 5: Falls from Windows or Balconies in Health and Social Care (Aug 2012).


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


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 may be delegated to an appropriate senior manager, but the Chief Executive remains accountable to the Board.

3.2 Head of Estates

The Head of Estates is responsible for ensuring:

  • The implementation and management of the Policy across NHS Fife
  • That NHS Fife staff are aware of and have access to the Policy.
  • That NHS Fife staff understand the importance of compliance with the procedures relating to the Policy.
  • That staff receive training commensurate with their role and responsibilities
  • That an approved window management structure is maintained within NHS Fife
  • Advice is provided on the potential areas of risk and identify where systems do not comply with current legislation and guidance
  • Advice is provided on the required procedures for the management of risk from windows.
  • Monitoring of the implementation and efficacy of procedures adopted to control risk.
  • Changes in policy or procedures are approved through the appropriate NHS Fife management group.
  • Adequate records are kept.

3.3 Individual Managers and Members Of Staff

  • NHS Fife Estates Managers must ensure that they and all relevant Estates staff undertake appropriate instructionin line with their role requirements and in relation to this policy document and related guidance documents. The maintenance and testing of window restrictors will be in accordance with the named guidance in these procedures.


4.1NHS Fife aims to comply with the legal requirements of current British Standards and Codes of Practice and should be read in conjunction with Appendix 1 – SOP 19

4.2 Windows in all parts of NHS Fife require being risk assessed to ensure adequate protection against individuals falling from, or leaving NHS premises from insecure windows, and to minimize the risk of illegal access. NHS Fife has a duty of care to protect (as far as reasonably practicable) patients, staff, and the general public from injury resulting from persons falling or exiting from insecure or unsafe windows.

4.3The aim will be achieved by the following objectives:

  • The security of all windows should be risk assessed to ensure that the appropriate duty of care is undertaken in respect of patients, staff & general public. The assessment should include looking at the use of, and access to, each area especially by patients, visitors and children, and should take account of patient category and physical capability, especially in psychiatric units
  • The elimination of incidents due to badly maintained or sub-standard windows. Windows should be replaced or modified if necessary
  • modifying or changing window openings by use of restrictors and fixings to British Standard BS6375-2, capable of withstanding 1000 N applied force
  • to ensure a comprehensive system of written risk assessments of all types of windows, and ensure suitability of existing windows and fittings
  • to ensure recommended cleaning frequencies in keeping with the Association of Domestic Management best practice document
  • to conduct an audit and survey review of windows within NHS Fife every two years, and address any detected deficiencies


The key risks involved in implementation of these procedures are:-

5.1 Lack of staff awareness of these procedures, resulting in non-compliance

5.2 Lack of robust organisational arrangements around implementation of these procedures.

5.3 Failure to implement and maintain the required procedures.


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

  • Appendix 1 - SOP 19 Window Management & Security
  • Scottish Health Technical Memorandum 55: Windows
  • NHSScotland Hazard Notice HAZ (SC) 04/02 Window Security in the NHSScotland Estate

  • Health and Safety Executive Health Services Information Sheet No 5: Falls from Windows or Balconies in Health and Social Care (Aug 2012)
  • NHS Fife Risk Register / Risk Assessment Policy (GP/R7) and Appendices.
  • NHSScotland Safety Action Notice SAN (SC) 02/23. Change of Use of Buildings to Accommodate Mental Illness Patients: Risk of Injury/Suicide


BS 6375-2:2009. Performance of Windows and Doors. Classification for operation and strength characteristics and guidance on selection and specification.

7.2 BS 6262-4:2005. Glazing for Buildings. Code of practice for safety related to human impact.

7.3 PAS 24:2016

Related Publications

Related Policies