HSPOL28 Asbestos Management Policy by Provide Community

Asbestos Management Policy

Version: V2

Ratified by: Financial and Investment Committee (FIC)

Date ratified: 06/12/2023

Job Title of author: Head of Health, Safety and Compliance

Reviewed by Committee or Expert Group Property Health and Safety Steering Group

Equality Impact Assessed by: Head of Health, Safety and Compliance

1. Introduction

Provide Community has a legal duty to manage the risk from asbestos or to co-operate with whoever manages this risk to ensure that persons are not exposed to contaminated airborne dust. Persons whose normal duties may bring them into contact with Asbestos Containing Materials (ACMs) will be trained to recognise asbestos products and work to approved safe procedures.

This document is based upon the following documents: ‘A Comprehensive Guide to Managing Asbestos’ (HSG 227); The Control of Asbestos Regulations 2012; Approved Code of Practice” (ACOP) “Managing and working with asbestos” (L143 Second Edition).

Control of Asbestos Regulations 2012 apply to all sites owned, occupied or operated from by Provide Community where there is a risk of any person being exposed to asbestos in any form.

The presence of asbestos containing materials (ACM’s) does not in itself constitute a danger. However, it is hazardous when disturbed or damaged and must be treated accordingly. Activities which give rise to airborne dust, e.g. abrasion, breaking, sawing, cutting, drilling or machining ACM’s, are most likely to present risks.

2. Purpose

The purpose of this policy is to provide a comprehensive safe management system for asbestos. Through a series of practical measures this will eliminate/minimise exposure so as far as is reasonably practicable to Asbestos Containing Materials (ACMs).

Asbestos is a natural material (a fibrous silicate) found in rocks all over the world. It has been commercially used for about 150 years because it is strong, flexible, stable and fireproof. The three main types of asbestos that were used in the UK are:

• Crocidolite (Blue asbestos)

• Amosite (Brown asbestos)

• Chrysotile (White asbestos)

These cannot be identified by their colour alone.

As part of the duty to manage, Provide Community will, for those premises it owns, occupies, manages or for which it has responsibility:

• Take reasonable steps to determine the location of materials likely to contain asbestos in premises.

• Presume materials contain asbestos unless there is strong evidence to the contrary.

• Make and keep up to date, a written record of the location and condition of presumed or confirmed asbestos containing materials.

• Monitor the condition of presumed or confirmed asbestos containing materials via annual reinspection’s

3. Definitions

Asbestos Containing Materials (referred to as ACM’s),

Materials which can contain any of the 3 common forms of asbestos fibre in any proportion. ACM’s fall into 2 distinct categories:

• Low density materials which can only be handled by a HSE approved licensed contractor.

• High density materials that do not require a licensed contractor.

Surveys

There are 2 types of survey that can be undertaken to identify ACM’s:

• Management Survey – this type of survey can be completed by presuming the presence of ACM’s, sampling suspect materials for confirmation or a combination of both and is the most commonly used method.

• Refurbishment/Demolition Survey (R&D) – this type of survey is fully intrusive which will include the identification and testing of concealed materials. This type of survey is likely to be undertaken where a structure is due to be substantially altered or demolished.

Management Plan

The Control of Asbestos Regulations 2012 require every non-domestic property to have an Asbestos Management Plan. This document is intended to explain how the person responsible for the building, the Duty Holder, intends to manage the asbestos present to prevent persons being exposed to the asbestos.

A Responsible Person for Asbestos (RPA)

Person formally appointed to be responsible for the day-to-day management of the Asbestos Register(s) and to carry out duties as detailed in this policy, (e.g. responsible for ensuring appointed asbestos consultants, surveyors, analysts and contractors undertake all instructions in accordance with current asbestos/health and safety legislation).

4. Duties

Chief Executive

The Chief Executive has the overall responsibility for health, safety and welfare of staff and others affected by the work activities of the organisation and for the effective implementation of asbestos management policies and procedures.

Chief Finance Officer

The Chief Finance Officer isthe lead Board Director forthe implementationof the policy and is responsible for promoting the policy and supporting those managers tasked with implementing the policy. The Executive Finance Director has nominated the Director of Estates & Facilities as Duty Holder to carry the specific responsibility for the effective implementation of asbestos management policies and procedures in writing.

Director – Estates & Facilities (including H&S)

The Director of Estates & Facilities (including H&S) has the legal responsibilities of the management of asbestos in writing. This individual will ensure that the operational requirements of both the policy and The Asbestos Management Plan are adhered to by all who could come into direct contact with the Asbestos Containing materials. They will devolve the management duties but not the legal responsibilities to a Responsible Person for Asbestos (RPA) and deputy within the Estate and Facilities Directorate.

The Director - Estates & Facilities (including H&S) will ensure

• HSG 264 asbestos surveys by UKAS accredited surveyors, to find and record the location and condition of known or suspected ACMs.

• Undertake an assessment of the risk of all known or suspected ACMs on all its owned/controlled buildings or co-operate with those undertaking such an assessment where the building is shared, let or rented.

• Hold all conclusions and findings of all asbestos assessments, all surveys commissioned and all other relevant information in a central and accessible location. This information will be updated regularly, and all updates recorded in each site’s asbestos management plan.

• Ensure that all relevant personnel will undertake initial training and, if required, refresher training to ensure they are kept updated on new developments in the management and control of asbestos to ensure competent performance of their specific duties. Attendance will be recorded and maintained ready for inspection if required.

Responsible Person Asbestos (RPA)

• To ensure that their colleagues and contractors implement any procedures deemed necessary by the Head of Safety and Resilience.

• To ensure departmental staff, patients or visitors are not at risk of exposure to hazardous asbestos materials.

• To ensure any work likely to affect asbestos materials is carried out after consultation with, and in agreement with, the Head of Safety and Resilience in accordance with Control of Asbestos (CAR) 2012.

• To ensure new equipment or apparatus erected, installed, purchased or gifted are free of asbestos material.

• To receive and be aware of asbestos in their area of influence and ensure others in their control are aware of the location of the Asbestos Policy and the location of asbestos containing materials.

• Ensure all contractors working within Provides premises, before they start work, are aware of the nature and extend of any known or suspected ACMs which may affect their work; where all asbestos information is kept and what to do should they suspect asbestos has been disturbed

Estates and Facilities Staff

The Estates Team will:

• Compile and maintain a record (Asbestos Register) of all known or suspected Asbestos Containing Materials (ACMs) within of all premises owned or controlled by the organisation. Ensuring annual Re-Inspection Surveys are undertaken by a UKAS accredited surveyor.

• Ensure that an Asbestos Management Plan for all buildings that Provide staff occupy is kept up to date, implemented and reviewed on an annual basis as in accordance with Regulation 4 of the Control of Asbestos Regulations 2012.

• Be responsible for actively working with colleagues to maintain services that could compromise the service provision, ensuring safe accesses to suspected areas by relevant contractors when needed.

• Involve the operational staff responsible for the building.

• Actively lead and advise on the removal of any contaminants that could compromise access to areas, plant and or equipment within any of the organisation’s buildings.

• Project manage all asbestos remedial/ removal work with assistance from a UKAS accredited consultancy and using removal contractors licensed by the HSE for all work with asbestos, including review of all risk assessments and method statements (RAMS) as required.

• Ensure that prior to any project works (refurbishment, demolition, etc.) liaise with the Estates Team Project Manager and Head of Safety and Resilience to ensure a specific asbestos assessment and take steps to mitigate the risk posed by any potential asbestos present in areas affected by the planned works.

• Undertake all necessary steps to ensure asbestos information is made available to all parties who may be affected by the presence of ACMs.

• Ensure, as far as reasonably practicable, that anyone who may come into contact with known or suspected asbestos within any of its owned or controlled premises is made aware of all current information held regarding asbestos which may affect their activities.

• Develop, implement and monitor safe systems of work to protect the safety, health and welfare of employees, building users and third-party contractors.

• Ensure all contractors and staff working in buildings for maintenance and refurbishment have appropriate asbestos awareness training.

Assistant Director IT and Systems

Assistant Director IT and Systems and other staff within the service may arrange for IT cabling or infrastructure work to be carried out in areas where ACM’s are present. These staff should have due regard to the possibility of disturbing ACM’s and must ensure that prior to any work being carried out the by approval is sought from the Estates and Facilities team.

If suspected asbestos containing materials are found the work must be halted and advice sought from the Estates and Facilities team.

Contractors

• Actively cooperate with Provide as an organisation in all matters of Health and Safety and proactively identify potential hazards that may affect themselves or other building users.

• Estate manuals are located in the reception of each building and contractors need to sign that they have read the policy and attach their documentation when they attend to do work.

• Refrain from any activities which may disturb known or suspected asbestos containing materials; undertake any refurbishment or demolition works prior to consultation with the Head of Safety and Resilience

• Work together with the organisation to prevent the spread or exposure to asbestos.

• To report any incidents of exposure to asbestos or risk of harm due to failing to follow this policy onto the organisations incident reporting system.

All Staff

• Taking care of their own health and safety and that of others who may be affected by their acts or omissions at work.

• Ensure that the Estates Team, is informed immediately when asbestos is identified or suspected so that assessments can be made and the appropriate action taker.

• Ensure that their department implements any procedures deemed necessary by the Estates Team.

• Ensure departmental staff, patients or visitors are not at risk of exposure to hazardous asbestos materials.

• Ensure any work likely to affect asbestos materials is carried out after consultation with, and in agreement with, the Estates Team.

• Ensure new equipment or apparatus erected, installed, purchased or gifted on behalf of the organisation is free of asbestos material.

• Receive and be aware of asbestos in their area of influence and ensure others in their control are aware of the location of the Asbestos Policy and the location of asbestos containing materials.

5. Consultation and Communication

The development of this policy was with the Estates and Facilities staff and Health, Safety, Fire and Security Manager.

6. Monitoring

This policy will be monitored by the Responsible Person Asbestos and reviewed annually or sooner if circumstances deem it necessary.

7. Training

Provide Community will ensure that adequate instruction, information and training is given to all relevant employees who are liable to disturb ACM’s within the course of their normal working activities, and the protective and preventive measures to be employed.

Contractors who regularly access areas, which may contain asbestos, will be requested to demonstrate that they have in date asbestos awareness training by producing a copy of their certificate. The certificate must be in date i.e. less than 1 year old and must have been issued by a qualified, competent asbestos trainer/consultant.

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 Demolition Surveys

• Re-inspections

All Surveys and re-inspections should include an ACM risk assessment in accordance with HSG 264 guide, material assessment algorithm.

Re-inspection frequencies will be determined by the nature and location of the ACM however, as a minimum check will be carried out every 12 months.

9. Asbestos Management Plan

An asbestos Management Plan describes the details of how Provide Community will manage its ACMs within its premises including those which are leased, owned or informally occupied.

An Asbestos Management Plan (Appendix: 1) will be kept at each site within the Estates folder with the Management Survey and latest reinspection. The management Plan will detail:

• who is responsible for managing asbestos in the building

• the asbestos register (the asbestos survey information)

• plans for work on asbestos materials (if any)

• the schedule for monitoring the asbestos materials' condition

• telling people who might disturb the asbestos about your decisions

• emergency response on disturbing asbestos

10.Removal and Encapsulation

Only Approved Licensed Asbestos Contractors will be allowed to work on asbestos containing materials. Planned removal will be carried out in full compliance with HSE approved methods. Such approval by the HSE takes 14 days for Licensable work and may require prior notification for Notifiable non-license work, and should be planned accordingly when preparing project timescales.

11.Emergency Procedure

Anyone suspecting asbestos containing materials has been disturbed the following action should be taken immediately:

• Evacuate the area immediately, without causing alarm. Any clothing which is contaminated with suspected asbestos fibres should be removed and left in the ‘contaminated area’.

• Cordon/lock off the area until a full assessment has been completed.

• Contact the Estates and Facilities team who will then arrange for a U.K.A.S approved analyst to attend site.

• The asbestos Register for the building may assist in identifying the type of material that has been disturbed as it may have previously been sampled for asbestos containing material.

• Background air sampling may be required depending on the extent of the damage. This will determine the correct procedurefor making safe the damage.

• Any staff who may have been exposed to asbestos may be referred to Occupational Health. In all circumstances an individual’s line manager or the Trust manager engaging a contractor is to complete a Datix incident report.

Refer to the HSE guidance document EM1 for further advice.

12.References

Key legislative requirements with regards to asbestos management include:

• The Control of Asbestos Regulations 2012

• Managing and Working with Asbestos ACoP L14

• Hazardous Waste Regulations

• Construction (Design and Management) Regulations (CDM)

• Health and Safety at Work Act (1974)

• Management of Health and Safety at Work Regulations

• Control of Substances Hazardous to Health (COSHH) Regulation

• HSPOL08 Health and Safety Policy

• HSPOL01 Managing Contractors on Site Policy

• Health and Safety at Work Act, 1974

• Control of Asbestos Regulations 2012 and all associated Approved Codes of Practice

• HSG 227 A comprehensive guide to managing asbestos in premises

• HSG 247 Asbestos: The licensed contractors' guide

• HSG 248 Asbestos: The analysts' guide for sampling, analysis and clearance procedures

• HSG 264 Asbestos: The survey guide

• HSG 210 Asbestos essentials: A task manual for building, maintenance and allied trades of non-licensed asbestos work

1. Introduction

This Asbestos Management Plan sets out the actions taken within Provide Community premises to manage Asbestos Containing Materials (ACMs) in accordance with the Control of Asbestos Regulations (CAR) and Provide Community Asbestos Policy (HSPOL28)

To ensure employees, patients, residents’ contractors and visitors to the premises do not disturb ACMs and are safe from potential exposure, the following effective asbestos management procedures are in place:

• A designated person/s responsible for the management of asbestos in Provide Community premises (referred to as the Responsible Person Asbestos); including the updating of existing records

• Provision of asbestos awareness training to relevant employees and third parties as deemed necessary (including the keeping of appropriate training records)

• Annual reviews of Asbestos Management Surveys and Management Plans

• Ensure that where necessary, a refurbishment or demolition survey (R&D) is undertaken when any intrusive cabling/construction works are carried out

• Seek advice and guidance from suitably qualified and experienced UKAS accredited Competent Person/s, consultant or contractor on any asbestos related work activities that are to be undertaken (this may include, but is not limited to: re-inspections, asbestos removal works, environmental cleans, encapsulation works & air-monitoring)

• Report any instances of exposure to ACMs to the Estates and Facilities team and complete a Datix

2. Plan prepared by:

Name:

Position/job title

Email:

Mobile phone:

Date: Version

3. Reviewing/Revising this plan

Provide Community Estates and facilities Team must review and (if necessary) revise this Asbestos Management Plan annually or if any significant changes are identified:

• an asbestos control measure is reviewed

• asbestos is removed, disturbed, sealed or enclosed

• the plan is no longer adequate for managing the asbestos risks, for example, if new asbestos is identified or a previously inaccessible area is now accessible

Date of review

Name/job title

Date of review

Name/job title

Date of review

Name/job title

Date of review

Name/job title

Date of review

Name/job title

Date of review

Name/job title

Date of review

Name/job title

4. Duty Holder

Name:

Position/job title

Email:

Mobile phone:

Date of training (Asbestos management)

5. Responsible Person Asbestos (RPA)

Name:

Position/job title

Email:

Mobile phone: Date of training (Asbestos management)

Name: Position/job title

Email: Mobile phone: Date of training (Asbestos management)

6. Location of Asbestos Survey and Asbestos Register

The Asbestos Survey provides accurate information on the location, amount and condition of ACMs. The information in the survey report will be used to form the asbestos register which is a key component of the management plan for the premises. The Estates and Facilities team will ensure that an up-to-date copy of the asbestos survey/register will be available on the premises.

Summary of asbestos on site in (see management Survey for further details)

In summary, there is asbestos known to be in the following location and structures:

Example

• Ground floor - vinyl tiles

• External – Cloaking

• Boiler room - gaskets

What documents are to be found on premises

(Management survey date) (Reinspection date) (R&D survey date) (Management Plan date) (Contractor review signing document)

Location of any surveys and their location on site

Where are the documents kept on the premises

7. Training

List staff that have had training, date - (details of training Company/content available from L&D team)

8. Contractors

Everyone attending a provide Community Premises to carry out any works will be required to access and review the asbestos survey, register and plan before undertaking any work.

All contractors undertaking any work will be required to sign that they have reviewed the asbestos survey, (Appendix 2)

Where there are ACMs that are to be worked on or nearby, no work will take place until an appropriate risk assessments and method statements (RAMS) of work is produced by a specialist UKAS licenced asbestos removal contractor and all HSE notification procedures given within the time scales for the HSE to authorise prior to works commencing.

All clean air tests must be taken and certificated that the area/s are safe to enter on completion of the works.

9. Asbestos Works and Removals

Provide Community will ensure that any works undertaken involving ACMs will be carried out within the requirements of the Control of Asbestos Regulations 2012. Control measures will be detailed in the risk assessments and method statements provided by the contractor.

10. Maintenance, Refurbishment or Demolition works

If any maintenance, refurbishment or demolishing works are required that are intrusive a Refurbishment and Demolition (R&D) survey will be undertaken as necessary to locate and describe, as far as is reasonably practicable, all ACMs in the area where the work will take place. This will be undertaken in accordance with the requirements of the Health and Safety Executive guidance HSG264.

11. IT Cabling

If any new IT cabling works are to be undertaken, it will need confirmation from the Estates and Facilities team whether a Refurbishment and Demolition (R&D) survey is required. This will be undertaken in accordance with the requirements of the Health and Safety Executive guidance HSG264 and instructed via Estates and Facilities.

12. Emergency Procedures

Anyone suspecting asbestos containing materials has been disturbed the following action should be taken immediately:

• Evacuate the area immediately, without causing alarm. Any clothing which is contaminated with suspected asbestos fibres should be removed and left in the ‘contaminated area’.

• Cordon/lock off the area until a full assessment has been completed.

• Contact the Estates and Facilities team who will then arrange for a U.K.A.S approved analyst to attend site.

• The asbestos Register for the building may assist in identifying the type of material that has been disturbed as it may have previously been sampled for asbestos containing material.

• Background air sampling may be required depending on the extent of the damage. This will determine the correct procedurefor making safe the damage.

Contact Estates and Facilities 0300 303 9964

Refer to the HSE guidance document EM1 for further advice (Appendix: 1)

13. Emergency Services – Fire

Emergency Services personnel attending site must be given access to the asbestos survey, register and plan on arrival, if requested.

Appendix 1: HSE Emergency Guidance

Appendix 2: Contractor Signing in sheet

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 1: ‘Screening’

Name of project/policy/strategy (hereafter referred to as “initiative”):

Asbestos Management Plan

Provide a brief summary (bullet points) of the aims of the initiative and main activities:

To protect staff, contractors and visitors with a comprehensive safe management system for asbestos. Through a series of practical measures this will eliminate/minimise exposure so as far as is reasonably practicable to Asbestos Containing Materials (ACMs).

Project/Policy Manager: Head of Health, Safety and Compliance Date: July 2023

This stage establishes whether a proposed initiative will have an impact from an equality perspective on any particular group of people or community – i.e. on the grounds of race (incl. religion/faith), gender (incl. sexual orientation), age, disability, or whether it is “equality neutral” (i.e. have no effect either positive or negative). In the case of gender, consider whether men and women are affected differently.

Q1. Who will benefit from this initiative? Is there likely to be a positive impact on specific groups/communities (whether or not they are the intended beneficiaries), and if so, how? Or is it clear at this stage that it will be equality “neutral”? i.e. will have no particular effect on any group.

N/A

Q2. Is there likely to be an adverse impact on one or more minority/under-represented or community groups as a result of this initiative? If so, who may be affected and why? Or is it clear at this stage that it will be equality “neutral”?

N/A

Q3. Is the impact of the initiative – whether positive or negative - significant enough to warrant a more detailed assessment (Stage 2 – see guidance)? If not, will there be monitoring and review to assess the impact over a period time? Briefly (bullet points) give reasons for your answer and any steps you are taking to address particular issues, including any consultation with staff or external groups/agencies.

N/A

Guidelines: Things to consider

Equality impact assessments at Provide take account of relevant equality legislation and include age, (i.e. young and old,); race and ethnicity, gender, disability, religion and faith, and sexual orientation.

The initiative may have a positive, negative or neutral impact, i.e. have no particular effect on the group/community.

Where a negative (i.e. adverse) impact is identified, it may be appropriate to make a more detailed EIA (see Stage 2), or, as important, take early action to redress this – e.g. by abandoning or modifying the initiative. NB: If the initiative contravenes equality legislation, it must be abandoned or modified.

Where an initiative has a positive impact on groups/community relations, the EIA should make this explicit, to enable the outcomes to be monitored over its lifespan.

Where there is a positive impact on particular groups does this mean there could be an adverse impact on others, and if so can this be justified? - e.g. are there other existing or planned initiatives which redress this?

It may not be possible to provide detailed answers to some of these questions at the start of the initiative. The EIA may identify a lack of relevant data, and that data-gathering is a specific action required to inform the initiative as it develops, and also to form part of a continuing evaluation and review process.

It is envisaged that it will be relatively rare for full impact assessments to be carried out at Provide. Usually, where there are particular problems identified in the screening stage, it is envisaged that the approach will be amended at this stage, and/or setting up a monitoring/evaluation system to review a policy’s impact over time.

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 2:

(To be used where the ‘screening phase has identified a substantial problem/concern)

This stage examines the initiative in more detail in order to obtain further information where required about its potential adverse or positive impact from an equality perspective. It will help inform whether any action needs to be taken and may form part of a continuing assessment framework as the initiative develops.

Q1. What data/information is there on the target beneficiary groups/communities? Are any of these groups under- or over-represented? Do they have access to the same resources? What are your sources of data and are there any gaps?

None

Q2. Is there a potential for this initiative to have a positive impact, such as tackling discrimination, promoting equality of opportunity and good community relations? If yes, how? Which are the main groups it will have an impact on?

Q3. Will the initiative have an adverse impact on any particular group or community/community relations? If yes, in what way? Will the impact be different for different groups – e.g. men and women?

Q4. Has there been consultation/is consultation planned with stakeholders/ beneficiaries/ staff who will be affected by the initiative? Summarise (bullet points) any important issues arising from the consultation.

N/A

Q5. Given your answers to the previous questions, how will your plans be revised to reduce/eliminate negative impact or enhance positive impact? Are there specific factors which need to be taken into account?

N/A

Q6. How will the initiative continue to be monitored and evaluated, including its impact on particular groups/ improving community relations? Where appropriate, identify any additional data that will be required.

N/A

Guidelines: Things to consider

An initiative may have a positive impact on some sectors of the community but leave others excluded or feeling they are excluded. Consideration should be given to how this can be tackled or minimised.

It is important to ensure that relevant groups/communities are identified who should be consulted. This may require taking positive action to engage with those groups who are traditionally less likely to respond to consultations, and could form a specific part of the initiative.

The consultation process should form a meaningful part of the initiative as it develops, and help inform any future action.

If the EIA shows an adverse impact, is this because it contravenes any equality legislation? If so, the initiative must be modified or abandoned. There may be another way to meet the objective(s) of the initiative.

Further information:

Useful Websites www.equalityhumanrights.com Website for new Equality agency www.employers-forum.co.uk – Employers forum on disability www.efa.org.uk – Employers forum on age