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Asbestos management plan_EF01_AMP_ November 2017

ASBESTOS MANAGEMENT PLAN NOVEMBER 2017

This Asbestos Management Plan supersedes all previous Asbestos Management Plans

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Policy title Asbestos Management Plan

Policy reference

EF01- AMP

Policy category Estates and Facilities

Relevant to All Staff and Contractors

Date published November 2017

Implementation date

November 2017

Date last reviewed

October 2017

Next review date

November 2018

Policy lead Jane Bonotto, Health and Safety Manager

Contact details Email: [email protected]

Telephone: 0203 3176775

Accountable director

D Wragg, Director of Finance

Approved by: Health, safety and Fire Committee -Sep 2017 Estates and Capital Planning Committee – Nov 2017)

Ratified by: Audit and Risk Committee

Document history

Date Version Summary of amendments

Jul 2016 2 Routine update

Nov 2017 3 Routine update

Membership of the policy development/ review team

Asbestos Management Group

Consultation TFM Contractor – Engie

Staff via Trust consultation process

RF & CNWL principal NHS tenants

mailto:[email protected]

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DO NOT AMEND THIS DOCUMENT

Further copies of this document can be found on the Foundation Trust intranet.

Contents

1 Introduction 5

2 Principles of the Plan 6

3 Aims and Objectives 8

4 Scope 8

5 Duties and responsibilities 8

6 Definitions 12

7 Asbestos management group 12

8 Surveys and re-inspections 13

9 Registers and Action Plans 13

10 Monitoring of ACM 14

11 Safe systems of work 14

12 Dissemination and implementation arrangements 16

13 Training requirements and competency 17

14 Monitoring and audit arrangements 17

15 Review of the management plan 19

16 References 19

17 Associated documents 19

18 Asbestos fixed term contracts 19

19 TFM contract 20

20 Documents and filing 20

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21 Emergency responses 20

22 St Pancras Hospital – ACM Restricted Areas 21

Appendix 1: Equality Impact Assessment Tool 22

Appendix 2: Professional Structure for Asbestos Management 23

Appendix 3: Register of Formal Appointments 24

Appendix 4: Emergency Contacts List 25

Appendix 5: Emergency Response Flow Diagrams 26

5.1 Discovery of Potential/Suspect ACM

5.2 Suspect Disturbance of ACM

5.3 Major Failure of Building Services within an ACM Zone

5.4 Fire involving ACM

Appendix 6: Asbestos Fixed Term Contract List 30

Appendix 7: File Structure – Master Register 31

Appendix 8: File Structure – Working Register 32

Appendix 9: Process Chart – Updating the ACM Registers 33

Appendix 10: Trust ACM Permit to Work Form 34

Appendix 11: Induction Pack Page (ACM) Trust Employees 37

Appendix 12: St Pancras Hospital – ACM Restricted Areas 39

Appendix 13: ACM Works Notifications 41

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1. Introduction

This Asbestos Management Plan will be implemented and maintained by the

Asbestos Management Group. The Terms Of Reference (TOR) for the

Asbestos Management Group and the reporting stream up will be to the

Estates & Capital Planning Committee (ECPC) which in turn reports to the

Resources Committee. It will be the function of Asbestos Management

Group to provide assurance to the ECPC that the asbestos management

arrangements are in place and adequate. Additionally failures, incidents or

exceptional circumstances will be reported upwards via the ECPC.

Additionally the outputs from the Asbestos Management Group will

communicated to the Health, Safety & Fire Committee for information only. It

is noted that the Health, Safety & Fire Committee reports to the Audit & Risk

Committee.

1.1 Executive Summary

This Asbestos Management Plan describes the details of how the Trust will

manage its ACMs within its premises including those which are leased, owned or informally occupied.

This Asbestos Management Plan is deemed to be implemented with

immediate effect and will be ratified by the Estates & Capital Planning Committee and will be reviewed and updated in the 4th Quarter or the business year 2017/18.This document has been produced to formalise the management plan in the Trust standard format. An emergency asbestos management plan was produced and adopted by the Asbestos Management Group on 15/09/17 and subsequently presented to the Estates & Capital Planning Committee.

This management plan is produce in accordance with the Trust‟s Asbestos

Management Policy and details how the Trust manages asbestos and asbestos containing materials which may be present in its premises. This management plan accords with the requirements of the Health & Safety Executive Approved Code of Practice with respect to the management of asbestos. In order to ensure the implementation of this management plan and the Asbestos Management Policy the Trust will keep in place a formal Asbestos Management Group.

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2. Principles of the Plan The implementation of The Control of Asbestos Regulations 2012 (CAR 2012) has resulted in the need for the “Duty Holder”, as defined in Regulation 4, to manage the risk associated with Asbestos Containing Materials (ACMs) in buildings. CAR2012 Regulation 4 – „the Duty Holder‟ means (a) every person who has, by virtue of a contract or tenancy, an obligation of any extent in relation to the maintenance or repair of non-domestic premises or any means of access to or from those premises; or (b) in relation to any part of a non-domestic premises where there is no such contract or tenancy, every person who has , to any extent, control of that part of the premises or any means of access or egress to or from those premises, and where there is more than one such duty holder, the relative contribution to be made by each such person in complying with the requirements of this regulation will be determined by the nature and extent of the maintenance and repair obligation owed by that person. Asbestos surveys are to be carried out on buildings and areas owned, managed and occupied by the Trust and asbestos location and condition reports have been issued. It should be noted that Trust premises include a mixture of leasehold, freehold and informed occupations. Where the Trust owns, controls or maintains the buildings or any part, the Trust is the Duty Holder and has to ensure compliance with CAR 2012. There may also be other Duty Holders who occupy or manage or maintain or own Trust premises; if so, the Trust must work together with and cooperate with any other Duty Holder. To ensure that personnel within the buildings, who work on the structure or services within it, are not exposed to the hazards associated with asbestos it is recommended that the following management plan be adopted. The Trust will manage its premises and building fabric on the presumption that asbestos is or could be present until proven that materials do not contain asbestos.

Any identified Asbestos Containing Materials (ACMs) or presumed ACMs that are in good condition and remain in place are to be entered on the Asbestos Register which is to be held on site at St Pancras Hospital, Estates & Facilities Office. Any person who is likely to come into contact with the ACMs must be alerted to its presence. Warning labels shall be applied to known or presumed ACMs where appropriate, such as in plant

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rooms and service areas. It is not intended to identify low risk ACMs in areas frequented by operational staff, patients or visitors.

To ensure that everyone who carries out work on the premises is made aware of the location of ACMs and the location of non-asbestos materials, which could be mistaken for asbestos, they will be given access to the Asbestos Register for the particular building. Access to this register by contractors will be monitored to ensure that that they have studied the Asbestos Register and Surveys.

Should it be necessary for any work to be carried out which would interfere with ACMs the Trust must ensure that the ACMs are removed by a licensed contractor before any work is carried out if these cannot effectively be repaired or protected

The Management Plan should be reviewed on a regular basis to ensure that it is still effective and to check on the condition of any ACMs which remain in place on a regular basis, preferably not exceeding 2 years.

TO ALL STAFF, CONTRACTORS AND THIRD PARTIES

Any work on the fabric of the building cannot start without the relevant parts of the asbestos register being checked – available of the Trusts MiCAD system which can be accessed via the TFM service provider or the Trust’s Estates & Facilities team. No tenant, contractor or member of staff will effect or allow others to effect disturbance to any materials within the buildings managed by the Trust at any time. If works need to be undertaken to any part of the building or plant and services within the buildings then these activities must be notified to the Trust estates & Facilities Department before any planning is undertaken, to ensure that correct procedures can be undertaken where there is potential contamination from hazardous materials or ACMs. This management plan only relates to areas of buildings occupied or managed by the Trust. Under the Control of Asbestos Regulations 2012 there is a need for the duty holder to provide a management plan for ACMs within their demised areas of buildings.

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3. Aims and Objectives

Camden & Islington NHS Foundation Trust is committed to providing a safe

and healthy workplace for everybody. To achieve this, asbestos will be managed and exposure to it prevented, as far as reasonably practicable by ensuring that:

An effective management structure is in place

An effective asbestos management plan is implemented

There is promotion of asbestos awareness through training and communication

4. Scope The Control of Asbestos Regulations 2012 applies to all premises owned,

occupied or operated by Camden & Islington NHS Foundation Trust:

This applies to all Trust areas

This applies to all staff groups

This applies to all contractors and sub-contractors

This applies to all third parties including volunteers It should be noted that no identified exceptions exist with respect to this plan

as it is a statutory requirement to manage ACMs in accordance with CAR 2012 and its associated statutory instruments.

6. Duties and responsibilities

The Chief Executive has ultimate responsibility for ensuring that mechanisms are in place for the overall implementation, monitoring and revision of policy. The Associate Director, Governance and Quality Assurance, via the Clinical and Corporate Policy Manager, is responsible for ensuring:

In conjunction with the Policy Lead identifies resource implications to facilitate implementation and compliance.

Training and monitoring systems are in place.

Regular review of the policy takes place. Associate Divisional Directors are responsible for implementation of the policy within their own spheres of management and must ensure that:

All new and existing staff have access to and are informed of the policy

Ensure that local written procedures support and comply with the policy

Ensure the policy is reviewed regularly

Staff training needs are identified and met to enable implementation of the

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policy. All Trust staff are responsible for ensuring that they:

Are familiar with the content of the relevant policy and follow its requirements

Work within, and do not exceed, their own sphere of competence.

ACM Specific Duties and Responsibilities The Trust will keep in place a formal professional structure for asbestos management including formal appointments in writing by exchange of letters. Please refer to the appendices for the formal professional management structure chart and to the Asbestos Management Policy for duties and responsibilities. The specific roles and responsibility for ACMs management are as follows: ○Duty Holder, Chief Executive ○Executive Director for Asbestos Management, Director of Finance ○Board Delegated Designated Person, Associate Director of Estates &Facilities ○Responsible Person (Asbestos) ○Authorising Engineer / Specialist Adviser for asbestos ○Competent Persons / Contractors for asbestos The Trust has a formal duty to manage the performance of the TFM provider with respect to the contacted services provided for asbestos management. The TFM contractor has contractual duties with respect to ACMs management on behalf of the Trust. This formal duty is implemented by the Associate Director of Estates & Facilities who has management control of the TFM contract. The Associate Director of Estates and Facilities will be supported in managing the TFM contract by the follow Trust staff: ○Head of Facilities ○Head of Hard Facilities Management ○Trust Health & Safety Manager ○Trust Property Manager

Capital Projects

The Capital Programme Manager will ensure that projects and works under his control are appropriately managed in accordance with Trust policy and this management plan. The Trust officer or Project Manager who has management control of the scheme must ensure appropriate steps are taken to identify any ACMs present by carrying out a risk assessment, with reference to the Asbestos Register and any relevant Management Surveys. Before work commences, in an area where asbestos is suspected or has not been surveyed or identified a,

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Refurbishment and Development survey must be completed as a minimum, and any identified asbestos removed by a suitably qualified contractor. On completion they must ensure that the registers and files are updated accordingly. Additionally those Trust officers / staff undertaking capital schemes and works not under the control of the Capital Programme Manager have the same responsibility to ensure that the works are undertaken in accordance with Trust policy and this management plan.

Landlords & Tenants

It is the Trust Property Managers responsibility to ensure the appropriate documentation and information is exchanged between the Trust, its landlords and its tenants. Landlords – formal written request for Asbestos Register and Management Plan and appropriate follow up and on-going communications. This will include periodic due diligence check to ensure that existing ACM is being managed and re-inspected in accordance with the landlords management plan. Tenants – formal communication identifying ACMs and Asbestos Register and informing them of the location of the Management Plan and how to obtain further information. Additionally a copy of the Asbestos Management Policy should be made available. All to be conducted in writing and supplemented via Email as required All communication regarding ACMs with both landlords and tenants will form part of the documentation retained with the asbestos files.

I. C. T. and Telecommunications

The Associate Director of ICT will ensure that projects and works under his/her control are appropriately managed in accordance Trust policy and this management plan. The Trust officer or Project Manager who has management control of the scheme will ensure appropriate steps are taken to not to disturb any ACMs. As a minimum this will include a Refurbishment and Development surveys and communications. Additionally ensure that the registers and files are updated accordingly. All surveys, works and communications will be conducted with the agreement of the Estates & Facilities team.

Third Parties

All organisations / individuals not forming part of Camden and Islington NHS Foundation Trust but who reside or visit the Trusts premises have a duty to follow the Trusts Asbestos Management Policy and this management plan. These

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duties form part of the requirements of the Health and Safety at Work Act and as such are mandatory.

Due Diligence

Trust officers / staff that engage contractors will be responsible for carrying out due diligence checks with respect to works on ACMs. Additionally they have a responsibility to inform contractors of any ACMs which they may come into contact with whilst on Trust premises. The instructing officer / manager will be responsible for ensuring that all contractors/staff are inducted and instructed to an appropriate level for the works being undertaken. Asbestos Contractors Where the Trust arranges for the removal or remediation works to be carried out on ACM then they will arrange for the removal or encapsulation to be completed in accordance with the HSE guidance by an appropriate licensed contractor. Where the asbestos contractors are engaged for works on Trust properties the following due diligence checks should be made by the Trust officer with management responsibilities for the works e. g. capital project manager, hard FM manager or the responsible person: ○Competency and experience ○Training Records ○Health & Safety Records e. g. H&S policy, face fit tests ○Systems of accreditation e. g. ISO 9001 minimum ○HSE License (including checking the HSE web site for period license has been granted) ○Insurances Please refer to the appendices for guidance on what works need to be notified to the HSE. Also refer to the HSE guidance document for further information. Analytical Services When remediation/removal works are being undertaken or works close to ACM which may allow people to come into contact with ACM, as a direct result of their work activities. Then adequate analytical services must be procured independent of the contract. Usually this will be a direct appointment by the Trust and not a sub-contractor. The analytical company should have the following, which the Trust officer should check:

Competency

Training certificates

Insurances

UKAS accreditation for the services being provided to ISO 17025

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The analytical services may include the following depending on the nature of the works being undertaken, which is the Trust officers‟ responsibility to define:

Re-assurance air testing/monitoring

4-stage certification of re-occupation

monitoring of works against specification

Witnessing and inspection enclosure integrity

6. Definitions and nomenclature ACOP Approved Cope of Practice usually issued by the HSE

ACM Asbestos Containing Materials

AE/SA (Asbestos) Authorising Engineer / Specialist Advisor for Asbestos

AIB Asbestos Insulating Board

CAR 2012 The Control of Asbestos Regulations 2012

CP (Asbestos) CP (Asbestos) Competent Persons / Contractors for asbestos

DP Trust Board Delegated Designated Person

HSG 264 HSE Asbestos Publication, The Survey Guide

HSAWA Health and Safety at Work etc. Act 1974

HSE Health and Safety Executive

L143 HSE ACOP, Managing &Working with Asbestos 2013

MMMF Man Made Mineral Fibre

RP (Asbestos) Responsible Person for Asbestos Management RPE Respiratory Protective Equipment

RAMS Risk Assessment & Method Statement

PPE Personal Protective Equipment

TFM Total Facilities Management

Trust Camden and Islington NHS Foundation Trust

UKAS United Kingdom Accreditation Service. The United

Kingdom Accreditation Service

PPM Planned Preventative Maintenance

SOP Standard Operating Procedures

7. Asbestos Management Group

The function of the Asbestos Management Group is to deliver a compliant management system for all ACMs within the Trusts premises. It will be chaired by the Associate Director of Estates & Facilities with governance of reporting duty to the Estates & Capital Planning Committee.

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8. Surveys and Re-inspections

Only appropriately accredited and competent staff / contractors are to be used for surveying and re-inspections, as outlined below: ○Management Surveys ○Refurbishment and Development Surveys ○Demolition Surveys ○Re-inspections All Surveys and re-inspections will be procured in accordance with industry best practice e.g. HSG264 (details below).Unless specifically stated in the instruction/commission all surveys should include a ACM risk assessment in accordance with HSG 264 guide, material assessment algorithm. HSE Asbestos: The Survey Guide second edition published 2012 ISBN: 978 0 7176 6502 0 Series: Code HSG264 Free to down load at: www.hse.gov.uk/pubns/books/hsg264.htm Re-inspection frequencies will be determined by the nature and location of the ACM however, as a minimum checks will be carried out every 12months.

9. Registers & Action Plans

The main mechanism for informing on the location and status of ACMs will be in the form of a Working Register stored on MiCAD including spread sheets and drawings. Those who will access the working register will be Trust staff, Trust appointed contractors, TFM staff and contractors along with other third party organisations such as building tenants and volunteers for example. Direct access to the MiCAD based Working Register will be via the TFM contractor or via the Estates & Facilities team. Please refer to the appendices for the formal structure of the registers and action plans. Working Asbestos Register will contain: ○ACMs drawings ○Register Spread Sheets ○Action Plan Spread Sheets ○Policies, Procedures, Safe Systems of Work and standard operating procedures The asbestos register/plan will be 1 spread sheet containing 2 pages for each building:

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○ACMs Register page ○ACMs Action Plan page 9.1 Register Updating Mechanism The asbestos registers will be maintained and updated by the E&F Department as part of the Responsible Persons duties. Please refer to the appendix for the process chart for updating the asbestos registers 9.2 Re-inspection Mechanism Re-inspections will be conducted in accordance with the ACMs Action Plan, see above. The preferred option for re-inspection is via a suitably competent contractor via the TFM contract.

10. Monitoring of ACM

The Trust is responsible for monitoring the condition of ACM, recording the results and carrying remedial works to ensure asbestos fibres cannot become airborne or pose a hazard people. The Responsible Person will ensure that adequate arrangements are in place to maintain the ACM in a safe state. Any ACM remaining within the Trusts premises will be regularly monitored to ensure that they have not deteriorated or been damaged and then any records relating to them will be updated. Re-inspection frequencies will be determined by the nature and location of the ACM however, as a minimum checks will be carried out every 12 months.

11. Safe Systems of Work

The Trust, its contractors and third parties working in or around Trust premises or areas will maintain safe systems of work to prevent the disturbance of ACMs. This will include but not be limited to: ○Specifications for ACM removal / remediation ○RAMS – Risk Assessments & Method Statements ○SOP – Standard Operating Procedures ○Permit to Work on ACM ○Audit of works as required 11.1 Specifications The Trust officers, or in some cases its contractors, will produce a briefing document outlining the requirements for works on ACM. Specialist advice will be sought when producing specifications for works. In most cases this will be for

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larger removals / remediation works. As routine works would normally be covered under the SOP section below. 11.2 RAMS The Trust officers, or in some cases its contractors, will ensure that adequate RAMS are in place including a specific section on how to deal with ACM where the works may disturb asbestos or ACM. 11.3 SOP The Trust officers, or in some cases its contractors, will ensure that where applicable industry standard operating procedures are used for carrying out works which may disturb asbestos or ACM. Please refer to HSE task manual detailed below: HSE Asbestos Essentials dated 2012 ISBN: 9780717665037 Series: Code HSG210 Free to down load at: www.hse.gov.uk/pubns/books/hsg210.htm This task manual is aimed at all workers who may come into contact with asbestos, including electricians, plumbers, carpenters etc. It will be useful to employees, the self-employed and managers. Most maintenance (PPM and Reactive) tasks are covered by this guidance from the HSE. Note Where the works are not covered by this HSE guidance then a specific set of RAMS must be produced and agreed prior to a permit being issued. 11.4 Permit to Work on ACM The Trust officers, or in some cases its contractors, will ensure that a permit to work is issued to control the works which may disturb asbestos or ACM. A permit to work will only be produce once an adequate safe system of work has been agreed. All staff, contractors, sub-contractors and other third party organisations will ensure they have a valid permit to work to cover the works being conducted. No works which may disturb asbestos or ACM will be started without a valid ACM permit to work underpinned by appropriate RAMS and SOP. 11.5 Audit of Works

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The Trust officers, or in some cases its contractors, will ensure that periodic/ad-hoc audits are conducted to ensure that works are being carried out in accordance with the identified safe system of work and permit. The audit can be documented separately and annotated on the permit to work.

12. Dissemination and implementation arrangements

All Trust staff will be informed about asbestos and where information can be found on the subject at formal inductions sessions conducted by the Learning & Development team. It should be noted that where non-Trust staff may come into contact with ACM then the Trust manager responsible for the area and control of these staff will have a duty to inform these individuals companies or groups. 12.1 Methods of Communication Verbally in induction, training sessions, team meetings/briefings and tool box talks Labelling and signage on or close to the ACMs, a standard asbestos warning label will be implemented by the Trust please refer to the appendix for an example. Writing training and instruction and contract documents, Emails, Trust intranet Policies, Management Plans and Registers freely available to staff, contractors and third parties 12.2 A specific communications plans will be implemented for the following: ○Trust wide all staff (including trade union representatives) ○Staff/Contractors working with Trust properties e.g. maintenance / refurbishment ○SPH site ○HMHC site ○Remaining sites ○Tenants within C&I Trust facilities ○Requirements of Landlords ○Press and Media ○Other interested parties Formal communications will be conducted with trade union representative and other similar interested organisations or group e.g. volunteers or emergency services.

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13. Training requirements and competency

The Trust will train its staff to a level appropriate to their role within the Trust and potential for them to come into contact with ACMs. Additionally staff that supervise or procure works which potentially could come into contact with ACMs will be appropriately trained. The Responsible Person for Asbestos will be responsible for ensuring the necessary training is in place and for checking competency of those involved in asbestos management. All staff will be given basic instructions with respect to ACMs at formal induction, this will include as a minimum: ○State all staff have duties in accordance with Trust policies and HASAWA ○Where to find the Asbestos Management Policy ○The fact that asbestos may be present in the premises were they work ○How to find out more information regard ACMs in their area ○What to do if they have a concern or believe ACMs has been damaged or disturbed The Trust employees who are deemed to require formal asbestos awareness training will receive this on an annual basis. All estates & facilities staff directly employed by the Trust will be required to undertake asbestos awareness training. The Trust managers with „on-call‟ management duties will be briefed on the management plan and receive asbestos awareness training.

14. Monitoring and audit arrangements

Please see below the monitoring table for asbestos management for the

Trust.

Asbestos management plan_EF01_AMP_ November 2017

Elements to be monitored

Lead How Trust will monitor compliance

Frequency Reporting Which committee or group will the monitoring report go to?

Acting on recommendations and Lead(s) Which committee or group will act on recommendations?

Change in practice and lessons to be shared How will changes be implemented and lessons learnt/ shared?

Up to date policy

DP Review by AMG

Annual ECPC ECPC & Resources Report to ECPC then Resources. Inform H&S Committee

Up to date formal appointments including AE/SA

DP Review by AMG

6 months ECPC ECPC & Resources Report to ECPC then Resources. Inform H&S Committee

AMG functioning DP AE/SA report


Up to date management plan

RP Review by AMG


Annual AE/SA report finding action signed off

RP Review by AMG

ECPC & Resources

ECPC & Resources Report to ECPC then Resources. Inform H&S Committee

Up to date ACM registers, action plans and drawing

RP AE/SA report


Re-inspections in date

RP AE/SA report


Robust SSOW in place & audited

RP & TFMC

AE/SA report


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15. Review of the management plan

This management plan will be reviewed on the following occasions: ○June 2016 ○December 2016 Then annually or at significant change of operations or legislation It will be the duty of the Responsible Persons to update the management plan and approval will be at the Asbestos Management Group.

16. References

Health & Safety at Work Act 1974 Control of Asbestos Regulations 2012 HSG 264 Asbestos: The surveyors guide L143 HSE ACOP Managing and Working with Asbestos Management of Health & Safety at Work Regulations 1999 Workplace (Health, Safety & Welfare) Regulations 1992

17. Associated documents

The following Trust policies are noteworthy for the subject of asbestos management: Health & Safety Policy Asbestos Management Policy

18. Asbestos Fixed Term Contracts

The Trust and/or the TFM contractor will appoint a fixed term contractor to carry works on ACMs including small surveys, small scales notifiable, non-notifiable and licensed works. This contract will reviewed and re-let on an annual basis. The asbestos contracts will be split into distinct work streams utilising specialists from each field of expertise, as follows: ○Surveying and Re-inspections ○Removals and Remediation ○Analytical and Clearance Services ○ Project Management for Asbestos Works

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ASBESTOS MANAGEMENT PLAN, FEBRUARY 2016

19. TFM Contract

The Trust has contracted out the operation and maintenance of its premises/facilities to a TFM (Total Facilities Management) contractor. The TFM contractor will ensure that it has appropriate safe systems of work in place to manage its activities and risks associated with its activities and ACMs. The TFM contractor and the Trust will work to together to provide assurance and conduct audits as part of the routine management of the ACMs. The Responsible Person for Asbestos will ensure that systems and working practices align between the TFM service provide and the Trust.

20. Documentation and Filing

All documentation regarding ACMs is to be retained for at least 40 years. The Trust has decided to maintain a Working Register containing all information to operate and maintain its premises and a Master Register containing the Working Register and all other relevant information regarding asbestos and its management. It is the Responsible Person duty to ensure the registers are accurate and fit for purpose. At present the Trust has decided to use as the MiCAD platform to hold its Working Asbestos Register which the TFM provider will use to disseminated information to staff, contractors and other interested parties. The TFM service provider will provide the Trust with information and data for updating the working and master registers. The MiCAD Working Register will be administered on MiCAD by the E&F team. The Master Register contain the working register and will hold all the drawings, information, files and documentation regarding current ACMs and all historical information regarding ACMs and its management. This Master Register will be owned and operated by the E&F team and held on the Trusts intranet.

21. Emergency Responses

In the event of an emergency involving ACMs, presumed or suspect ACMs follow the emergency response flow diagrams located in the appendices. Additionally there is an emergency contacts list in the same section. ○Discovery of potential/suspect ACMs ○Disturbance of ACMs ○Emergency Response to a failure of building services in a ACMs area ○Fire in a building containing ACMs

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The Responsible Person for Asbestos will ensure that relevant authorities are updated on matters and surveys relating to asbestos and ACMs. Where potential exposure has occurred the Responsible Person will be informed so that appropriate actions can be undertaken, including under RIDDOR. Where service users (patients) or visitors may have been exposure to asbestos then the same procedures will be followed as if they were staff. However they will need to be assisted and guided by Trust staff. A Datix form will be completed for all potential exposures to asbestos. Additionally the Trusts Emergency Planning Officer will be informed of any potential exposures involving services users, staff or visitors to site. This will normally be achieved via the Datix system.

22. St Pancras Hospital – ACM Restricted Areas

A number of areas at St Pancras hospital have been identified as having asbestos debris present which may cause danger and as such these areas have had access restricted and the following has been put in place: ○Restrict access by installing additional security to exclude people (padlocks) ○Apply warning signs ○Communicate the closure of the areas ○Implement procedures for access should the need arise ○Log all access to these areas whilst restrictions are in place ○Inform people that have been into these areas of the presence of ACM Please refer to the appendices for details of the documentation regarding these areas.

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Appendix 1 Equality Impact Assessment Tool

Yes/No Comments

1. Does the policy/guidance affect one group less or more favourably than another on the basis of:

Race No

Ethnic origins (including gypsies and travellers) No

Nationality No

Gender No

Culture No

Religion or belief No

Sexual orientation including lesbian, gay and bisexual people

No

Age No

Disability - learning disabilities, physical disability, sensory impairment and mental health problems

No

2. Is there any evidence that some groups are affected differently?

No

3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?

N/A

4. Is the impact of the policy/guidance likely to be negative?

No

5. If so can the impact be avoided? N/A

6. What alternatives are there to achieving the policy/guidance without the impact?

N/A

7. Can we reduce the impact by taking different action?

N/A

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Appendix 2 Professional Structure for Asbestos Management

Executive Director With Responsibility For Asbestos Management

Director of Finance

Board Delegated Designated Person (DP)

Associate Director of E&F

E&F Managers H&S Manager

Head of FM Head of Hard FM

Capital Programme Manager Property Manager

Specialist Advisor or Authorising Engineer (AE)

Trust Appointment Appointed by DP

TFM Contract Manager

Authorised / Competent Persons (AP) TFM

Contractor

Specialist Advisor Authorising Engineer (AE) c (TFM contractor formal AE)

Responsible Person (RP)

Duty Holder

Chief Executive

Other Directors

Trust Board

Other Directors

Trust Board

TFM Contractor

External Appointment

Non-E&F Managers IT &Telecomms

Clinical Operations Emergency Planning

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Appendix 3 Register of Formal Appointments

Role Trust Office or Appointment

Duty Holder

Chief Executive

Executive Director with duties relating asbestos management

Director or Finance Formal Appointment Date Re-appointment Date

Trust Board Delegated Person with duties relating to asbestos management

Associate Director of Estates & Facilities Formal Appointment Date Re-appointment Date

Responsible Person for Asbestos

Health & Safety Manager Formal Appointment Date Re-appointment Date

Authorising Engineer / Specialist Advisor Asbestos

External Appointment (contracted) Formal Appointment Date Re-appointment Date

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Appendix 4 Emergency Contacts List

TFM service provider Including access to on-call managers

Engie 24/7 Help Desk 020 3317 3484

Fixed Term Contractor (Asbestos) Including 24/7 response

Insert once contract awarded

Trust on-call Manager Duty Executive

Access via Switchboard 020 3317 3500

Authorising Engineer / Specialist Advisor AE/SA for ACM

Please refer to the appendix containing the Register of Formal Appointments within this appendix

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Appendix 5.1 Emergency Response Flow Diagram

Discovery of Potential/Suspect ACMs

STOP ISOLATE EXCLUDE COMMUNICATE

Stop Work

Isolate the suspect ACM (if possible)

Replace the cover, close Distribution Board door etc

Remove people from the area

Close door of the room Lock/secure room

During Works

If you believe you have found asbestos

Inform your manager or supervisor

Inform TFM provider Inform Responsible Person

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Suspect Disturbance of ACMs

STOP DECONTAMINATE EXCLUDE COMMUNICATE SPECIALIST WORKS Exposure to Service Users / Visitors Same processes as for staff

ACM Disturbed or Damaged?

Specialist Asbestos Contractor to carry out removal/encapsulation

within restricted are

Responsible Person to review

Responsible Person Identify extent of

disturbance and any contamination

Seek advice from AE / SA Asbestos

Document that no action for ACM required

Consult AE / SA Asbestos

Inform TFM Provider

NO

YES

Independent Analyst Certificate of Re-occupation

Stop Work

If needed and possible, decontaminate yourself so the ACM is not spread to

others in the s area

Remove people from the area

Close door of the room Lock/secure room

During Works

If you believe you have disturbed asbestos

Inform your manager or supervisor

Inform TFM provider Inform Responsible Person

28


Appendix 5.3 Emergency Flow Diagram

Major Failure of Building Services within an ACM Restricted Area

INFORM ISOLATE MITIGATE SPECIALIST WORKS COMMUNICATE REVIEW IMPLEMENT UPDATE

Inform TFM Provider

Inform Responsible Person

Specialist Asbestos Contractor to carry out

repairs within restricted are

Responsible Person to review and identify lessons

learnt

Failure Building Service e. g. major steam leak

electrical power outage


TFM Provider ‘make safe’ Isolate from outside the

restricted area

TFM Provider ‘mitigate’ failure e. g. provide temporary heaters

Responsible Person to implement changes and

works as required

29



Fire Involving ACMs

INFORM ISOLATE COMMUNICATE SPECIALIST WORKS COMMUNICATE REVIEW IMPLEMENT UPDATE Exposure to Service Users / Visitors Same processes as for staff

ACM Disturbed or Damaged?

Specialist Asbestos Contractor to carry out removal/encapsulation

within restricted are

Responsible Person to review

Fire Establish if ACM has been

disturbed or damaged


Document that no action for ACM required

‘Make Good’ Contractors instructed to carry out remedial works

Consult Emergency Services With respect to ACM

Inform TFM Provider

NO

YES

Establish extent and restrict access as required

Independent Analyst Certificate of Re-occupation

30


Appendix 6 Fixed Term Contractor Contact List A 6.1 Surveying

Contractor


Contract Administrator


Contract Quantity Surveyor


Location of Contract Documents


A6.2 Removals/Remediation/Restricted Areas Works

Contractor








A6.3 Analytical Services

Analyst








31


Appendix 7 File Structure – Master Register (Trust Intranet) The Master Asbestos Register will contain: The master documents for the Working Asbestos Register with current copies loaded onto MiCAD for access by all. Specific Master Asbestos Register Documentation will also contain: Air Testing Asbestos MTC Audit and DD (Due Diligence)

Communications

Document Archive (Old Iterations) e.g. old versions of working register, prior

policy, plans

Formal Appointments

Historical Information e.g. old surveys, removals documentation and 4-stage

clearance

Incidents & Datix (including RIDDOR notifications)

Management Group e.g. TOR, Agendas, Minutes & Action Logs

Risk Management e.g. high level risk assessments, risk registers

Significant Issues e.g. SPH 2015 16 and Tottenham Mews 2003

Surveys & Re-inspections

TFM for Asbestos e.g. details of the specific contractual duties

Training & Competency

Archived / Historical Documents / Information

Master Asbestos Register Trust Intranet

Master Documents which are not part of the

working register

Working Asbestos Register Master Documents

Working Asbestos Register Documents Downloaded

MiCAD

32


Appendix 8 File Structure – Working Register (MiCAD) The Working Asbestos Register will contain: Trust wide documentation ○ Policy, Management Plan, Procedures Specific Information on AMCs ○ ACMs drawings ○ Register Spread Sheets ○ Action Plan Spread Sheets - Remediation – removals, encapsulations, labelling/signage, update register - Re-inspections – schedules, results, action log from results, update register

Buildings

Levels

Document Library

Sites

Trust Wide Documents ○ Policy ○ Management Plan ○ Procedures

○ Drawings ○ Surveys ○ Registers ○ Action Plans

Areas / Zones Room Numbers

33


Appendix 9Process Chart – Updating the ACM Registers

Capital Project Team Schemes / Works

TFM Contractor Schemes / Works

ICT Team Schemes / Works

Trust E&F Team Controlling / Updating

Registers & Files

Landlord / Third Parties Scheme / Works

Landlord information

Working Asbestos Register MiCAD

UPDATED

Master Asbestos Register Trust Intranet

UPDATED

Working Register Updated and Accessible

34


Appendix 10 Trust Permit to Work ACM Asbestos Permit to Work v1

Location of Works(site/building/level/room):

Permit Serial Number:

Summary or Works:

*Works on ACM / Works near ACM Will the work disturb ACM *Yes/No

Instructing Officer/Manager Name:

Person/Contractor carrying out the works Name:

Details of ACM *in/close to work area, Register Reference etc.

Person/Contractor has viewed the Asbestos Register for the area: *Yes/No Sign for Yes Print Name Date

Works to be Notified to HSE *Yes/No HSE reference - Works does not require HSE notification *Yes/No

Associated non-ACM works

Safe Systems/Methods of Work / Signage RAMS references:

SOP References:

Other Permits:

Isolations:

Other Hazards Hazards – Electrical / Mechanical / Building / Environmental

Mitigations

Electrical Systems

Mechanical Systems

35


Building (e.g. falls from height, confined space etc.)

Environmental (e.g. heat, weather etc.)

Other (e.g. security, traffic etc.)

Communications Local Operational Staff Informed *Yes/No Who

TFM Service Provider Informed *Yes/No Who

E&F Team Member Informed *Yes/No Who

Responsible Person Informed *Yes/No Who

Non-E&F Team Informed *Yes/No Who

Other *Yes/No (please specify) Who

Acceptance of Permit to Work Planned start of works Date Time

Planned completion of works Date Time

Trust Officer (Issuing Permit) Signed:

Print Name: Job Title / Function: Date: Time:

Acceptance of Permit to Work ACM *Person carrying work or *Person in control of work Signed:

Print Name Job Title / Function Date: Time:

Completion / Cancellation of Permit to Work Person in control of the works *Completion/Cancellation Signed:


Trust Officer (Closing Permit) Signed:


Analytical details Certificate of Re-occupation 4 Stage Clearance References:

Re-assurance Air Testing References:

Witnessing & Inspection Enclosure Integrity:

Other

36


Additional Information

RAMS = Risk Assessment / Method Statement; SOP = Standard Operating Procedures ACM = Asbestos Containing Material Delete as applicable*

37


Appendix 11 Induction Pack Page (ACM) Trust Employees

E&F Page for Induction Pack November 2015 v2 TFM Service Provider It should be noted that the Trust delivers its estates and facilities services via a TFM (Total Facilities Management) contract. This service provides a comprehensive estates and facilities management service including the operation and maintenance of the Trusts premises. Estates Maintenance & Works Examples of this are - electrical and lighting; plumbing and heating; building repairs and technical questions regarding the Trusts premises. Facilities Services Examples of this are – cleaning, catering, portering, postal services, security, grounds & gardens, linen provision The Trust retains a small management team to oversee the TFM contract and to provide management of areas such as health &safety, capital refurbishments, property management and fire safety. Asbestos in Trust Premises The Trust premises comprise a mix of old building from circa 1900 to more modern premises. Some of these buildings contain materials which may have asbestos in them. The Trust together the TFM service provider carefully manages the asbestos containing materials so as to avoid people coming into contact with it. You may see signage around the Trusts premises relating to asbestos – please don‟t interfere with the signage or area and report any concerns. All Trust employees need to understand and comply with the following with respect to asbestos and to the wider health and safety requirements of the Trust: ○ Staff have duties in accordance with the Health & Safety at Work Act

38


○ Staff have a contractual obligation comply with Trust Asbestos Management Policy ○ The Asbestos Management Policy is available on the Trust intranet ○ Staff should be aware that asbestos may be present in the building where they work ○ Where to find information regarding asbestos in the building where you work From your line manager, from the TFM provider or from the Estates & Facilities team ○What to do if they have a concern or they believe asbestos has been damaged/disturbed. Contact the TFM provider and your line manager Our TFM Service Provider is Engie contact details below:

FTM 24/7 Telephone Contact 020 3317 3484 FTM Email [email protected]

mailto:[email protected]

39


Appendix 12 St Pancras Hospital ACM Restricted Areas A12.1 Log Table of SPH ACM Restricted Areas

Area Location

Start Date

Notes End Date

Boiler House including Pump Room

11/09/15 Planned 09/03/16

Subways/Tunnels Including All Building Under-crofts

11/09/15 1 Access under controlled conditions for inspections only. 2 Consult RP (Asbestos) for any works. Maintenance limited to statutory and emergency works only.

TBA

South Wing Basement Plant Room

11/09/15 .

Planned 15/02/16

North Wing Basement including Plant Area


TBA

West Wing Basement Plant Room


TBA

South Wing Ground Floor Access to Old Theatre Plant Room

13/01/16 1 Access under controlled conditions for inspections only.

TBA

South Wing Ground Floor Old Store Room

13/01/16 1 Access under controlled conditions for inspections only.

TBA

A12.2 Access to Restricted Areas Pad Lock Key Holder = Responsible Person (Asbestos)

40

A12.3 Access Log Table – ACM Restricted Areas

Area / Location

Name (Please Print)

Department or Contractor

Date Time In Time Out

1

2

3

4

5

6

7

8

9

10

11

12

41

Appendix 13 ACM Works Notifications Please refer to the HSE guidance on managing and working with asbestos for details of which products and ACM are to be notified to the HSE. Further guidance can be sort from the AE/SA Asbestos for the Trust. All enquiries should be discussed with the (RP Asbestos) in the first instance.

Refer to: L143 HSE ACOP Managing and Working with Asbestos