Asbestos containing materials policy

1 Introduction

This document contains the trust’s policy on the management of asbestos containing materials (ACM’s) in premises that are owned, occupied or maintained by the trust. It sets out the policy for the planned management and emergency actions involving ACM’s.

Asbestos is a generic term for a number of silicates of iron, magnesium, calcium, sodium and aluminium, which appear naturally in a fibrous form. The fibres are chemically inert, incombustible and insoluble in solvents and water, although some of them may be attacked by strong acids and alkalis. Combined with its fibrous nature these properties enabled its application in a wide variety of products. Its most common uses were as an asbestos insulation or coating used for:

thermal insulation of boilers, ancillary plant and pipework (often hidden under floors and ducts)
as a spray coating on steelwork, concrete walls and ceilings for fire protection and insulation
acoustic insulations of buildings
some textured coatings and paints (for example, Artex)

Insulating board which was used in a wide variety of places such as:

fire protection on doors, protected exits and structural steelwork
cladding on walls, ceilings (Asbestolux and marinite)
internal walls and partitions
ceiling tiles in a suspended ceiling

Asbestos cement which is found as:

corrugated sheets (roofing and cladding for buildings).
flat sheeting for partitioning, cladding and door facing, and
rainwater goods (gutters, down pipes).
roof tiles, cold water tanks

As ropes and fabrics, used for:

insulation and gaskets
fire blankets
protective clothing

The presence of asbestos containing materials does not in itself constitute a risk, however they may become hazardous when disturbed or damaged and must be treated accordingly. Activities that give rise to airborne dust, for example, abrasion, breaking, cutting, drilling or machining are likely to present a risk. The use of asbestos insulation and most types of asbestos is banned in the United Kingdom, but many thousands of tonnes of asbestos were used in buildings in the past. Much of this asbestos is still in place and it cannot easily be identified from its appearance.

The trust has a duty, so far as is reasonably practicable; to ensure that there is a regime for the management of asbestos. There are a number of Regulations that place a duty on an employer with regard to asbestos. These include:

the Health and Safety at Work Act (1974). This Act requires an employer to conduct their work in such a way that their employees will not be exposed to health and safety risks, and to provide information to other people about their workplace which might affect their health and safety
the Construction (Design and Management) Regulations (2015). These regulations require the trust to pass on information about the state or condition of any premises (including the presence of hazardous materials such as asbestos) to the principal designer before any work begins and to ensure that a health and safety file is available for inspection by any person who needs the information
the Control of Asbestos Regulations (2012) requires employers to prevent the exposure of their employees to asbestos, or where this is not practicable, to reduce the exposure to the lowest possible level. This includes a regulation placing a duty on those who have repair and maintenance responsibilities for premises, due to a contract or tenancy, to manage the risk from asbestos in those premises. Where there is no contract or tenancy the person in control of the building will be the duty holder. There is also a duty of cooperation on other parties

2 Purpose

The purpose of this policy is to identify how the trust manages the ongoing risks to persons from potential exposure to asbestos containing materials. This policy applies to all buildings owned or occupied by the trust, and other buildings where trust employees may carry out work, including residential and non-domestic lettings.

The purpose of this policy and any supporting documents are intended to ensure that the trust meets the requirements of the Health and Safety at Work Act (1974) in relation to ACM’s and complies with the requirements of the Control of Asbestos Regulations (2012). These requirements include:

to reduce exposure to ACM’s to a reasonably practicable minimum
promoting awareness through appropriate training courses on the hazards of ACM’s together with awareness of the trust’s policy, surveys and procedures
ensuring that all properties are surveyed to determine if ACM’s are present
maintaining a written record and site plans detailing asbestos locations, presumed locations and areas not accessed
providing and maintaining an up-to-date asbestos register. Reviewing the register on an annual basis. To make this information available to all persons who are liable to disturb an ACM’s or are potentially at risk from ACM’s
assessing the risk of potential exposure to all identified ACM’s. Factors include location, condition and frequency of access. This will determine the action required, for example, repair, physical protection or removal
implementing an effective management plan so that appropriate measures, such as monitoring, encapsulation, sealing, labelling, inspection or removal of the ACM’s are undertaken
information from the up-to-date asbestos register shall be made available to the trust employees, consultants and contractors appointed to undertake building related projects, including maintenance contractors and any other persons (including emergency services) who may be undertaking activities which by their very nature may have an impact on identified or suspected asbestos materials
ensuring that all work undertaken on ACM’s is carried out in accordance with current legislation

Where the surveys identify that remedial works may be required the trust shall appoint a competent United Kingdom accreditation service (U.K.A.S) approved consultant to manage the works. Independent consultants, who may undertake testing, sampling, monitoring and supervision, shall have in place the relevant level of U.K.A.S accreditation issued by an appropriate body complying with ISO17025. In addition to this and for the supervisory facet of their services the consultant shall also have in place a licence issued by the health and safety executive.

3 Scope

This policy shall apply to all trust staff, contractors and others who may be affected by ACM’s. The trust has many different arrangements in relation to the properties that are occupied by its staff and service users. The accountability for the management of asbestos is the organisation with the overall control of the building. These other host organisations may have their own policies in relation to the management of asbestos.

Trust managers in these buildings should follow any local policies and procedures that may apply in addition to those outlined in this policy and trust managers should also determine that appropriate measures are in place for the management of asbestos.

Some of the activities associated with the management of ACM’s overlap with those of other policies and procedures. Specific Regulations and guidance cover the hazards of these other activities and the precautions to be taken in relation to these. It is not the intention of this policy to provide details of the overlapping Regulations and guidance or the related hazards and precautions to be taken.

4 Responsibilities, accountabilities and duties

The trust has many differing arrangements in relation to the properties that are occupied by its service users and staff. The accountability for the management of ACM’s may be the responsibility of the organisation with the overall control of the building.

For buildings where the trust has overall control of the building, the accountability for the management of ACM’s remains with the trust.

4.1 The chief executive

The chief executive has the overall accountability for ensuring compliance with statutory regulations. The responsibility for the management of ACM’s is devolved to directors, managers, heads of department and to all trust staff.

4.2 Director of finance

For buildings that are maintained by the trust the responsibility for the overall management ACM’s is given to the director of finance who further devolves responsibility to the head of estates and facilities and to officers of the estates department.

4.3 Head of estates and facilities

The head of estates and facilities is responsible for the management of ACMs who devolves this responsibility to officers of the estates department.

The head of estates and facilities shall ensure that suitable and sufficient arrangements are in place for the assessment of risk and to develop a management plan for ACM’s in the areas of his control. This includes setting a suitable and sufficient policy for management of ACM’s in accordance with the control of asbestos regulations and to develop and monitor procedures for effective implementation. Some of these duties are delegated to the estates operations manager.

4.4 Estates operations manager

The estates operations manager has the delegated responsibility for the management of ACM’s in the areas of his control. The estates operations manager has the delegated responsibility for ensuring that all Statutory Instruments and guidance relating to the management of ACM’s in the areas of his control are implemented and maintained where resource allows and that adequate resources are available for staff training and the management of asbestos within trust agreed financial limits. This responsibility is further delegated to other managers and officers in the estates department.

The estates operations manager should ensure that suitable and sufficient arrangements are in place for implementing the procedures necessary for compliance with the control of asbestos regulations in areas of his control. In particular this will include:

implementing a pro-active management action plan for managing ACM’s for the premises controlled by the trust
ensuring that advice and information on ACM’s is available to employees, contractors and others. Ensuring that all staff under his control are given appropriate training
ensuring that any person organising work in the trust under his control, who may disturb ACM’s has access to up-to-date information and understands the requirement to avoid disturbing the material
advising and assisting other trust employees of their duty in relation to the Control of Asbestos at Work Regulations (2012). Maintaining a record of ACM’s and ensuring that up-to-date risk assessments are available
ensuring that a regular review of the asbestos register and risk assessments are carried out. Where asbestos exists in a public accessible area, discreet labelling will be used to ensure that persons undertaking any work which may increase the risk of exposure are warned appropriately but not so as to cause public concern. When it is not possible to label asbestos, for example, external items and floor tiles, the survey should state this
implementing emergency procedures in the event that any ACM’s or suspect ACM’s are disturbed in an uncontrolled manner
ensuring that records relating to asbestos are kept permanently

4.5 Estates officers or managers

Estates officers or capital project managers or contract administrators, or estates managers responsible for organising works in buildings, particularly those works which may affect the fabric of the structure or equipment within it, shall have regard to the possibility of disturbing ACM’s. In particular they shall:

ensure that all project specifications and works comply with the requirements of any relevant legislation, guidance and approved codes of practice
assess areas of potential disturbance at the planning stage to identify any known risk from asbestos by interrogating the asbestos register and, if appropriate, arranging for a survey for refurbishment or demolition is carried out. This will apply to all refurbishment work and demolition and is requirement of the Construction Design and Management Regulations (2015)
inform appropriate staff and liaise with managers and department heads in relation to asbestos containing materials
if necessary, halt work and inform staff if suspected asbestos material is discovered during the course of any works and seek advice from an asbestos consultant
implement emergency procedures in the event that any ACM’s or suspect ACM’s are disturbed in an uncontrolled manner

4.6 Care group directors or heads of departments or service managers

Trust managers have a key responsibility for ensuring that there is a proactive approach to organising, planning, controlling and reviewing health and safety. They have a responsibility to ensure that staff under their control are provided with suitable information, instruction and training in relation to all relevant health and safety matters which includes ACM’s.

Trust Managers should ensure that they have a copy of the asbestos register for all buildings where the trust provide services from. Estates can provide a register for all buildings that are in control of the trust. The register should be made available to staff.

Trust managers may challenge any person carrying out work on building fabric to determine if the area of work has been checked for the presence of asbestos. Estates personnel can provide advice and assistance in this matter.

4.7 Head of information technology

The head of information technology (IT) 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 either trust or contract staff the estates department have been contacted and advice sought

If suspected asbestos containing materials are found the work must be halted and advice sought from estates personnel.

4.8 Contractors

All contractors responsible for organising works in buildings, which may affect the fabric of the structure, or equipment within it, should have regard to the possibility of disturbing ACM’s. In particular they should:

consider at the initial outset of the project, the possibility of disturbing ACM’s. Dependent upon the nature of the work to be completed, consider whether additional surveys may be required
consult with the trust’s estates department with specific regard to the review of the existing asbestos of ACM’s

They should ensure that all their employees receive suitable and sufficient information, instruction and training including supervision relevant to the task they are to undertake, and including any specific procedures relative to the presence of known or suspected ACM’s.

Evidence of such training and subsequent refresher training usually every 3 years must be provided prior to the commencement of any work.

4.9 All staff

With specific reference to ACM’s all trust staff should be aware of the following:

should any employee accidentally disturb identified ACM’s they are to report the incident immediately to their direct line manager, who shall report to the person in control of the building and to the trust estates department, so that any emergency procedures can be initiated as soon as is practicable. An incident report must be submitted if this occurs
all trust staff have a responsibility not to disturb, or commission any other person such as a contractor to disturb any part of the fabric of any building without consultation with the organisation in control of the building or the trust’s estates department, for example, drilling walls, windowsills, ceilings, installing telephone or data cables in ducts and voids
staff may wish to see the asbestos register for the buildings that they occupy. This should be made freely available

5 Procedure or Implementation

5.1 Safety of staff, patients, contractors and others

The trust should provide adequate information, instruction and training (including supervision) for all staff and others who are involved in the management and maintenance of properties or who are liable to be exposed to ACMs during the course of their work. All contractors who may carry out works in areas where asbestos containing materials have been previously identified shall be required to provide evidence of similar information, instruction and training (including supervision) to their staff.

Guidance for staff, contractors and others on the safety aspects related to ACM’s is set out in this policy and the references therein. Advice from the trust’s asbestos consultant must always be sought on asbestos related matters. The trust has many differing arrangements in relation to the properties that are occupied by its patients and staff. The responsibility for the management of asbestos containing materials is the organisation with the overall control of the building; however the trust owes a duty of care to all staff, contractors, patients and others which includes as far as is reasonably practicable, preventing exposure to asbestos fibres.

If asbestos containing materials are identified (or area liable to be present) and are found to be in good condition, sealed and unlikely to be disturbed or damaged, the assessment may show that it is safe to leave in-situ. The person responsible for the management of the premises must identify and introduce the measures to manage the risk. This will include making the relevant section of the asbestos register available for inspection, as and when applicable, checking the labels identifying asbestos containing materials are in place, and monitoring the condition of the identified or presumed asbestos containing material. Where the trust is in control of premises, where asbestos containing materials are present or liable to be present, the following measures shall be carried out:

an asbestos register is compiled identifying the location of all ACM’s. The condition and historical data pertaining to any completed remedial works shall be retained. The register shall be subject to periodical inspection and review, which shall include inspections of asbestos containing materials remaining in-situ. As far as reasonably practical the register and accompanying reports shall remain unambiguous and up to date. A risk register should be in place which assesses the risk of potential exposure to all identified ACM’s. Priorities identified with the register should be reviewed on a regular basis

The trust aims to prevent exposure to asbestos to a reasonably practicable minimum of anyone who may be affected by the trust’s activities by utilising the information available from the asbestos register. Where this is not reasonably practicable, the trust will reduce exposure to the lowest level reasonably practicable, by measures other than the use of personal protective equipment. The trust will also reduce the numbers of people exposed to as low as reasonably practicable.

5.2 Records of asbestos containing materials and risk assessments

Surveys of buildings may identify asbestos which has a high material risk score which provides information on how readily the material will release airborne fibres should it be disturbed. A high material risk score does not follow that these materials should be given priority for remedial action. A risk assessment should also be carried out which takes into account other additional factors listed below:

the likelihood of the condition of the asbestos to deteriorate over time and release fibres
maintenance and other activities which are carried out in the area and are likely to disturb the asbestos
occupant activity which is likely to disturb the asbestos, determined by the amount of the ACM and its accessibility and vulnerability to disturbance
human exposure potential if the asbestos is disturbed, including the number of occupants, the frequency of use of the area and the time spent in each area

The risk assessments form the basis of the trust’s management plan. It is recognised that there is a need to balance the resources that are available to the risk that is presented by asbestos. The trust therefore operates a risk based approach in relation to asbestos.

An example of a low risk situation is asbestos cement products such as soffit boards, roof tiles, edging strips which are outdoors and are generally inaccessible without the use of ladders or scaffolding, so are unlikely to be disturbed and if disturbed then any fibres are less likely to be inhaled due to natural factors such as wind and rain. Another example is friable asbestos in a boiler room, which is unoccupied unless planned checks on equipment are carried out, which may only be for a few minutes every week. The potential for exposure in such circumstances is low, however if any work is carried out in the boiler room which may disturb the asbestos, this could lead to exposure to asbestos fibres. In such circumstances a survey for refurbishment will be required.

Where the trust has responsibility for a building, records of surveys, re-inspections, test results and previous asbestos removal schemes are available from the estates electronic database. Where the trust does not have responsibility for a building, the asbestos register or a statement from the organisation in control of the building should be held by the service manager and should be available to all staff.

6 Training implications

Estates staff should receive training by an appropriate competent person. This should include the following:

a basic introduction as to the type of materials and products, which may contain asbestos and typical locations within buildings
that the main risk associated with asbestos exposure relates to the inhalation of airborne fibres
that any exposure to asbestos should be avoided and the risk increases as the level duration, and frequency of exposure increases
what emergency procedures should be followed if materials suspected to contain asbestos are disturbed

6.1 All estates staff asbestos awareness training

How often should this be undertaken: Every 2 to 3 years.
Length of training: 2 hours.
Delivery method: Classroom based.
Training delivered by whom: Specialist consultant.
Where are the records of attendance held: Personal file plus ESR.

All trust staff should be made aware of the key points within this policy. This will be achieved by team brief or daily email

7 Monitoring arrangements

7.1 Compliance with policy

How: Audit.
Who by: Health and safety lead.
Reported to: Head of estates and facilities.
Frequency: Yearly.

7.2 Policy remains up-to-date

How: Monitoring of regulations and guidance.
Who by: Estates operations manager.
Reported to: Head of estates and facilities.
Frequency: On-going.

8 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

8.1 Privacy, dignity and respect

The NHS constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

8.2 Mental capacity act 2005

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

8.2.1 How this will be met

The mental capacity act is not relevant to this policy.

9 Links to any associated documents

10 References

Refer to the HSE guidance document EM1 (opens in new window) for further advice.

11 Appendices

11.1 Appendix A Asbestos 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 or lock off the area until a full assessment has been completed
contact an estates manager 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 procedure for 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 an incident report