Health & Safety
Health & Safety Manager
Health & Safety Team
Director of Property and Asset Management
01 January 2006
01 January 2021
01 January 2023

General Note

NHS Fife acknowledges and agrees with the importance of regular and timely review of procedure statements and aims to review policies within the timescales set out.

New procedures will be subject to a review date of no more than 1 year from the date of first issue.
Reviewed 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 procedure is past its review date then the content will remain extant until such time as the procedure review is complete and the new version published, or there are national policy or legislative changes.


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. Location

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. Scope

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 height;
• 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. Staff

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)