Health & Safety Manager
Health & Safety Team
Director of Estates, Facilities and Capital Services
01 January 2006
01 May 2019
01 January 2021


1.1.This procedure has been developed to allow NHS Fife to comply with the requirements of The Work at Height Regulations 2005 (as amended) and the Management of Health and Safety at Work Regulations 1999 (as amended).

1.2.Work at height, is work in any place, including a place at, above or below ground level where a person could be injured if they fell from that place.  This can also include means of access and egress to a place of work. It includes work on or from step stools and step ladders.



2.1.1.The procedure applies across all areas of NHS Fife and the Fife Health and Social Care Partnership including domiciliary settings.


2.2.1.The procedure applies to all NHS Fife and Fife Health and Social Care Partnership staff including agency and contracted personnel, and any other person who is not an NHS Fife employee, but who is working under the supervision and direction of an NHS Fife employee.


3.1.Senior and Line Managers

3.1.1.Any work at height needs to be properly planned in advance of the work activity, appropriately supervised and carried out in a safe manner.  Careful consideration should be given to the selection and use of work equipment.

3.1.2.Senior and line managers are responsible for:

  • ensuring that every effort is made to avoid working at height;

  • ensuring that, where working at height cannot be avoided, a suitable and sufficient risk assessment is carried out;

  • ensuring employees and their representatives are consulted when assessing the risks connected with working at heights;

  • ensuring that all staff who work at height receive appropriate information, instruction, training or supervision;

  • ensuring all equipment used while work at height is being carried out is appropriately inspected and maintained; and

  • ensuring that all staff involved in working at height are aware of this procedure, understand its content and comply with local procedures and safe systems of work.

3.1.3. Where the consequences of a fall from height are assessed as significant, Senior and Line Managers must also;

  • provide suitable work equipment or other measures to prevent falls where work at height cannot be avoided;

  • ensure that prior to working at height, a written safe system of work, including emergency and rescue procedures, has been developed and where necessary, a permit to work issued;

  • ensure that all staff who work at height are fit to do so;

  • ensure that all staff who issue permits to work, have appropriate information, instruction, training and supervision; and

  • ensure that all contractors employed are competent to work at height and are appropriately managed when on site.

3.1.4.Managers and Supervisors who issue permits to work, are responsible for

  • assessing all associated risks involved in working at height, see Appendix 1 for risk factors associated with working at height [Ref 6.1 Appendix 1];

  • developing a safe system of work [Ref 6.2 Appendix 2];

  • ensuring all necessary precautions, including emergency procedures, are taken;

  • checking safety at each stage of the work;

  • acting upon any report of an activity or defect likely to endanger safety;

  • checking the workplace before it is used;

  • checking work equipment installed or assembled prior to use;

  • the issue of the permit to work and its cancellation;

  • managing contractors while they are on site.


3.2.1.Staff are responsible for:

  • assisting with the assessment of risks;

  • complying with any safe system of work developed through risk assessment and any requirements of a permit to work;

  • using any safety equipment supplied;

  • following training and instruction;

  • informing their managers if they suspect that the system of work in place is ineffective or inadequate;

  • reporting any activity or defect likely to endanger safety; and

  • reporting all incidents (including near misses).and any defects in equipment using the DATIX Incident Reporting System.


4.1.Where work at height cannot be avoided, a suitable and sufficient risk assessment must be carried out.

4.2.Where work at height poses significant risks a written safe system of work must be developed including emergency procedures.

4.3.A permit to work will be necessary where the work at height is assessed as posing significant risks to health.

4.4.Training will be required for all staff required to work at height and for the managers or supervisors who issue permits to work. 


5.1.This procedure is a part of NHS Fife’s system for managing risk as described in the NHS Fife Risk Register and Risk Assessment Policy & NHS Fife Adverse Events Policy. 


6.1.Appendix 1: Work at Height Risk Assessment Guidance

6.2.Appendix 2: Developing a Safe System of Work

6.3.GP/I9 Adverse Events Policy.

6.4.GP/R7 - Risk Register and Risk Assessment

6.5.GP/C4 - Control of Contractors (Equipment & Building Maintenance)


7.1.The Work at Height Regulations 2005

7.2.Health and Safety in Roof work (HSG33)

7.3.Working on roofs (INDG284)

7.4.Safe use of ladders and stepladders (INDG455)

7.5.Safe use of work equipment - Provision and Use of Work Equipment Regulations 1998 (L22)

7.6.Personal protective equipment at work -Personal Protective Equipment at Work Regulations 1992 (L25)

8.Appendix 1: Work at Height Risk Assessment Guidance

When assessing the risks, use must be made of all the information available about the work to be carried out.  All foreseeable hazards and risks must be considered in advance and the following issues may need consideration.

Work at height can include, but is not exclusively limited to:

  • working at ground level adjacent to an excavation;
  • working on roofs;
  • working from a ladder;

Specific guidance on ladders and stepladders can be found in the Health and Safety Executive document Safe use of Ladders and Stepladders (INDG455)

Specific guidance on working at height can be found in the Health and Safety Executive document Working at height (INDG401)

Issues for consideration in the risk assessment include:

  • the work activity being carried out;
  • frequency of access;
  • the duration of the work;
  • the location in relation to the presence of hazards such as open excavations, overhead services, asbestos etc;
  • the working environment with regard to weather or lighting;
  • Working within public areas, high footfall traffic etc.;
  • safe means of access and egress;
  • lone working;
  • condition and stability of work surfaces such as fragile materials, slippery surfaces etc;
  • physical capabilities of the workers such as pregnancy or vertigo sufferers;
  • the equipment to be used and its inspection;
  • falling objects; and
  • prevention of access by unauthorised persons;

Information on work at heights is available from the HSE website at  http://www.hse.gov.uk/work-at-height/index.htm or from the Health and Safety Team.

9.Appendix 2: Developing a Safe System of Work

In the development a written safe system of work, the information gathered during the risk assessment will be used to construct a document which will give information and instruction to the employees who are to carry out the work.

This will include all of the risk control measures and the reasons for their application.  e.g. the need to use ladder fixing points.

It will also detail, where necessary:-

  • the means for preventing unauthorised access to the area underneath the work being carried out.
  • any supervision that may be necessary
  • any weather conditions that workers may be exposed to e.g. icy roofs, slippery surfaces in the rain, wind
  • any emergency or rescue conditions e.g. it is not acceptable just to rely on the emergency services, this needs to be covered in the risk assessment and planned prior to the work being carried out.

Fall arrest equipment should be the last in the hierarchy of control.

Collective protection measures, e.g. guard rails, should be deployed in the first instance rather than personal protection.