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General Policy
Estates, Facilities and Capital Services
Head of Estates
Estates Compliance Manager
Director of Property & Asset Management
01 January 2006
14 November 2023
14 November 2026


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.


1.1 This policy outlines the principles to be adopted and implemented in order to achieve the objectives set out in legislation and other related guidance documents, specifically the Scottish Health Technical Memorandum 55: Windows and the Health and Safety Executive Health Services Information Sheet No 5: Falls from Windows or Balconies in Health and Social Care.


2.1 This Policy is Applicable to all NHS Fife premises owned by, leased by or 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 has been delegated to an appropriate senior manager, The Director of Property and 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 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 this policy 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 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.
• The implementation and efficacy of procedures adopted to control risk.

3.4 Estates Managers

• Making sure that all staff are aware of this policy.
• Advice is provided on the required procedures for the management of risk from windows.
• Ensure that they and all relevant Estates staff undertake appropriate instruction in line with their roles and responsibilities with respect to this policy and associated procedure.
• Adequate records are kept.

3.5 Estates Supervisors

• Will have day to day responsibility for ensuring the effective implementation of this policy and associated procedures including checking of window restrictors and risk-assessments, as per the guidance provided (SOP 19 – Window Management & Security).

3.6 Members Of Staff

• Taking reasonable care of themselves and others who may be affected by their actions.
• Co-operating by following rules and procedures designed for safe window management.
• 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 window management.
• Taking part in training designed to meet the requirements of the policy.


4.1 NHS Fife aims to comply with the requirements of current British Standards and Codes of Practice and should be read in conjunction with SOP 19 – Window Management & Security.

4.2 All windows across 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 members of the public from injury resulting from persons falling or exiting from insecure or unsafe windows.

4.3 The 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 and members of the 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.
• 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.
• Ensuring a comprehensive system of written risk assessments of all types of windows and ensure suitability of existing windows and fittings.
• Ensuring recommended cleaning frequencies in keeping with the Association of Domestic Management best practice document.
• Conducting 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 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.


This section details the documentation relating to this Policy. It is recommended that this document is read in conjunction with the following:

SOP19 Window Management & Security
NHS Fife Risk Register and Risk Assessment Policy (GP/R7)


7.1 Statute, Legal and Guidance

Workplace (Health, Safety and Welfare) Regulations 1992 – Regulation 14

• Health and Safety Executive, Health Services Information Sheet No.5: Falls from windows or balconies in health and social care

BS 6375-2:2009 – Performance of windows and doors, Classification for operation and strength characteristics and guidance on selection and specification.

BS 6262-4:2018 – Glazing for buildings, Code of practice for safety related to human impact.

PAS 24:2022 – Enhanced security performance requirements for doorsets and windows in the UK.

7.2 NHS Requirements

NHS Scotland has published Scottish Health Technical Memoranda (SHTM) which contain policy and procedural guidance.

SHTM 55: Windows