Environmental Management System Manual
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Date: 16th Jan 2017
Version number: 0.13
Owner: Abigail Dombey, Environmental Manager
Approval route: Carbon Management Programme Board
Approval status: Draft
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Table of Contents
1. Introduction & Scope ....................................................................................................................................................... 4
1.1 Introduction ....................................................................................................................................................................... 4 1.2 Scope of Certification ..................................................................................................................................................... 5
2. Normative References ..................................................................................................................................................... 6
3. Terms and Definitions ..................................................................................................................................................... 7
4. Environmental Management System Requirements .......................................................................................... 9
4.1 General Requirements ................................................................................................................................................... 9 4.2 Environmental Policy ................................................................................................................................................. 10 4.3 Planning ............................................................................................................................................................................ 11
4.3.1 Environmental Aspects ................................................................................................................................................ 11
4.3.2 Legal and Other Requirements .............................................................................................................................. 14
4.3.3 Objectives, Targets & Programmes ....................................................................................................................... 15
4.4 Implementation & Operation .................................................................................................................................. 16 4.4.1 Resources, Roles, Responsibility & Authority .................................................................................................... 16
4.4.2 Competence, Training and Awareness ................................................................................................................. 22
4.4.3 Communication ............................................................................................................................................................... 23
4.4.4 Documentation ............................................................................................................................................................... 25
4.4.5 Control of Documents................................................................................................................................................... 26
4.4.6 Operational Control ...................................................................................................................................................... 27
4.4.7 Emergency Preparedness & Response .................................................................................................................. 28
4.5 Checking ........................................................................................................................................................................... 29 4.5.1 Monitoring & measurement ...................................................................................................................................... 29
4.5.2 Evaluation of Compliance .......................................................................................................................................... 33
4.5.3 Non Conformity, Corrective and Preventive Action ....................................................................................... 34
4.5.4 Control of Records ......................................................................................................................................................... 35
4.5.5 Internal Audit .................................................................................................................................................................. 36
Appendix A – Related EMS Documents ....................................................................................................................... 40
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1. INTRODUCTION & SCOPE
1.1 INTRODUCTION
The University of Brighton has adopted Sustainability as one of its four core values, set out in the
University Strategy (2016-2021). The university strives to be a centre of excellence for sustainability
research, work with local, regional and global communities and all of our teaching and learning, across all
subject areas. This work is all supported by a belief in creating learning and working environments that
embrace sustainability at their core.
The university makes a significant contribution to sustainability, not only in our role as a recognised
provider of research and teaching, but also the way we perform as a business and engage positively with
the local and wider community. If sustainability is to be achieved, economic, social and environmental
goals must be progressed simultaneously.
The aim of this Environmental Management System Manual (EMS Manual) is to explain the core elements
of the EMS and their interaction. The EMS Manual outlines how operational elements are managed, as
well as outlining the roles and responsibilities of key individuals with the EMS.
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1.2 SCOPE OF CERTIFICATION
The scope of certification for this Environmental Management System (EMS) is:
All areas of the University of Brighton Estate
The University Estate is defined as all areas under operational control by university member of staff. This
includes five main sites across the South East of England; three sites in Brighton, one in Eastbourne and
one in Hastings. The scope also stretches to the university managed Halls of Residences in Brighton, but
not those managed by third parties.
Centrally the EMS is held and continually managed by the Environment Team of the university based at
Exion 27, Crowhurst Road, Hollingdean, Brighton, BN1 8AF.
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2. NORMATIVE REFERENCES
All references are taken from the ISO14001:2015 international Standard.
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3. TERMS AND DEFINITIONS
Auditor: person with competence to conduct an audit.
Compliance Register: Register of applicable legal and other requirements relating to the activities
undertaken by the university.
Continual Improvement: recurring process of enhancing the Environmental Management System in
order to achieve improvements in overall Environmental performance consistent with the university’s
Environmental Policy.
Corrective Action: Reactive actions to eliminate the cause of Nonconformity.
Environmental Manager: Responsible for aspects of the EMS (see 4.4.1)
Document Register: Repository of information regarding the status of EMS documents and records.
Emissions: Any output from the firms’ operations that have an impact
EMS Documents: documents that are required by and form part of EMS including the Environmental
Policy, Environmental Objectives, Environmental Targets and EMS records.
Environment: surroundings in which the University of Brighton operates, including air, water, land,
natural resources, flora, fauna, humans, and their interrelation.
Environmental Aspect: element of the university’s activities that can interact with the Environment.
Environmental Auditor: person who has received appropriate auditor training and who is named in the
Internal Auditor List.
Environmental Impact: any change to the Environment, whether adverse or beneficial, wholly or
partially resulting from the university’s Environmental Aspects.
Environmental Management System (EMS): the University of Brighton’s management system used to
develop and implement its Environmental Policy and manage its Environmental Aspects.
Environmental Objective: overall environmental goal, consistent with the university’s Environmental
Policy, which the university sets itself to achieve.
Environmental Performance: results of the university’s management of its environmental aspects
measured against its Environmental Policy, Environmental Objectives, Environmental Targets and other
environmental performance requirements.
Environmental Policy: overall intentions and direction of the University of Brighton related to its’
Environmental Performance.
Environmental Target: detailed performance requirement, applicable to the University of Brighton or
parts thereof, that arise from the Environmental Objectives and that needs to be set and met in order to
achieve those objectives.
Interested Party: person or group concerned with or affected by the Environmental Performance of the
university.
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Internal Audit: systematic, independent and documented process for obtaining audit evidence and
evaluating it objectively to determine the extent to which the environmental management system audit
criteria set by the university are fulfilled.
Internal Auditors: persons nominated within EMS and with the requisite training to audit compliance
with EMS
Legal and Other Requirements: applicable legal requirements and other requirements to which the
University of Brighton subscribes related to its Environmental Aspects (including non-regulatory
guidelines and public commitments).
Management Programme: programme detailing responsibilities, activities, budget and timescale of
achievement for each Environmental Objective and related Environmental Target(s).
Major Incident: an accident or incident which is not contained within the site boundary and/or requires
the involvement of a regulatory authority.
Minor Incident: an accident or incident which is contained within the site boundary of the university and
which does not require the involvement of a regulatory authority.
Nonconformity: non-fulfilment of an EMS or ISO14001 requirement.
Preventive Action: Proactive action to eliminate the cause of an actual or potential Nonconformity.
Prevention of Pollution: use of processes, practices, techniques, materials, products, services or energy
to avoid, reduce or control (separately or in combination) the creation, emission or discharge of any type
of pollutant or waste in order to reduce adverse Environmental Impacts.
Procedure: specified way to carry out an activity or process.
Resources: any substance or material consumed or used by the firm that has an impact
Support Services Managers and Supervisors: those with specific responsibility for one or more
procedures under EMS.
University: term used when referring to the University of Brighton as a whole.
University of Brighton: All areas of the university estate, as outlined within the scope section of the
Environmental Management System.
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4. ENVIRONMENTAL MANAGEMENT SYSTEM REQUIREMENTS
4.1 GENERAL REQUIREMENTS
The University of Brighton has established, documented, implemented, maintains and strives to
continually improve our environmental management system in accordance with the requirements of BS
EN ISO14001 through adherence with the policies and procedures laid out in this manual.
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4.2 ENVIRONMENTAL POLICY
The University of Brighton has established its Environmental Policy and ensures that, within the defined
scope of our Environmental Management System, it is communicated to all staff and persons working for
or on behalf of the university and is publically available.
The University of Brighton's Senior Management Team, Sustainable Development Management Group
and the Carbon Management Programme Board, who all share responsibility for this policy, fully support
the commitment and objectives outlined. The final sign off of this policy is the responsibility of the Vice
Chancellor on behalf of the Board of Governors.
It is the responsibility of all staff, students, visitors and contractors to help embed this policy in the
everyday life of the university community.
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4.3 PLANNING
4.3.1 ENVIRONMENTAL ASPECTS
The University of Brighton has established this procedure to identify those environmental aspects of its
activities, over which it has control or influence, taking into account planned or new developments.
Environmental aspects are evaluated to determine those which are significant and therefore require
monitoring and, where possible, mitigation. This information is taken into account when maintaining the
EMS. The results of this identification and evaluation process are recorded in the register of
environmental aspects and regularly reviewed.
The process of accurately identifying environmental aspects and evaluating associated environmental
impacts is central to the success of the EMS. The process can be summarised as follows:
All significant environmental aspects must be monitored and, where possible, mitigated. The significance
of an environmental aspect is determined by reference to its likely frequency of occurrence and the
severity of the consequences of occurrence in accordance with the following table, based upon the
recorded normal, abnormal and emergency conditions outlined within the register of environmental
aspects:
*Can be positive or negative depending if the impact is positive or negative
Significance = Frequency of Occurrence x Potential Severity
A score of 9 (+ or -) or more indicates that an environmental aspect is significant. Environmental aspects
which do not score 9 (+ or -) or more but which are the subject of a legal requirement, or which have
significant potential to damage the reputation of the university, are automatically deemed significant.
When determining the potential severity of an environmental impact consideration must be given to the
scale of the university’s activities giving rise to that impact.
Frequency of occurrence Factor Potential severity Factor*
Unlikely (less than once a year) 1 Minimal 1 or -1
Common (monthly/ more than once a
year) 2 Low 2 or -2
Frequent (daily/weekly) 3 Moderate 3 or -3
High 6 or -6
Severe 10 or -10
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Our approach to identifying environmental aspects considers the following:
Emissions to air;
Releases to water;
Releases to Land;
Waste and by products;
Energy Use;
Energy Emitted (e.g. heat);
Use of raw materials and natural resources;
Physical attributes (e.g. size, shape, colour, appearance)
University’s core activities (e.g. teaching and learning)
The results of the environmental aspect identification and evaluation process are recorded in the register
of environmental aspects.
The register contains the following information:
A list of all university’s activities within the scope of the EMS that generate environmental
aspects under normal, abnormal and emergency conditions;
A list of related environmental impacts;
An evaluation of the significance of each identified environmental aspect;
Supporting information to lend evidence to the evaluation of significance; and
The university documents and committees relevant to each impact.
The process of identifying and evaluating the significance of environmental aspects arising from our
activities is on-going and the responsibility for keeping the register up to date will be with the
Environmental Team, with the overall responsibility being the role of the Environmental Manager.
In order to ensure that the EMS continues to address priority issues we will review our register of
environmental aspects annually as part of the annual review process.
The register will also be reviewed in the following circumstances:
As a consequence of any significant changes to the organisation’s activities or services;
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As a consequence of any relevant changes to the Compliance Register;
As a consequence of feedback from environmental incidents, complaints and/or non-
conformances identified during the internal or external audit process; and
In response to stakeholders’ reported and documented concerns.
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4.3.2 LEGAL AND OTHER REQUIREMENTS
The University of Brighton has established this procedure to identify and enable access to all applicable
legal and other requirements to which the university subscribes and which relate to its environmental
aspects. A list of identified legal and other requirements is recorded in our compliance register and this
information is taken into account in maintaining the Environmental Management System (EMS).
All legal and other requirements relevant to the university’s environmental aspects at the launch of the
EMS were identified. The results of the legal review are recorded in the compliance register. New legal
and other requirements are screened for their relevance to the university and the compliance register
amended as appropriate.
The introduction of new or amended legal and other requirements is principally monitored by the regular
review of resources such as Cedrec Environmental, the Environment Agency and the Health and Safety
Index.
The introduction of new or amended legal and other requirements that are considered by the
Environmental Manager, or nominated representative, to be of particular relevance and importance to
the university are cascaded to relevant employees as quickly as practicable. Communication may be via
email, intranet, oral communication or internal mail.
The Environmental Manager or nominated representative will review the subscription and other
resources to which s/he has access on a monthly basis to determine any changes to legal and other
requirements.
The Environmental Manager will appoint a competent person to review the compliance register on a
twice annual basis and update the compliance register after identification of any relevant changes to legal
and other requirements and following management review (if necessary).
The Environmental Manager will also identify and amend any elements of the EMS affected by changes to
legal and other requirements as necessary and communicate those changes to relevant employees as
quickly as practicable.
Awareness of and compliance with legal and other requirements will be assessed during the programme
of internal environmental audits, by those competent to do so.
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4.3.3 OBJECTIVES, TARGETS & PROGRAMMES
The University of Brighton has developed this procedure in order to establish, implement and maintain
environmental objectives and environmental targets consistent with our Environmental Policy, legal and
other requirements, significant environmental aspects and other considerations as appropriate.
In establishing our environmental objectives targets we have given consideration to many areas. These
include; the university’s Strategic Plan; past Environmental Policies; legal and other requirements; the
significant environmental aspects and environmental impacts of all our operations; technological and
financial options; operational and business requirements; and the views of various interested parties as
appropriate.
Specific and measurable environmental targets are set in order to help us to achieve our environmental
objectives within a specified time frame. Responsibility for specific environmental objectives and related
environmental target(s) is assigned by the Environmental Manager. The final sign off of each strategy will
lie with the relevant Board or Committee of the university. These groups include; the Carbon
Management Programme Board, Estates Committee, Learning and Teaching Committee, Sustainable
Development Policy Co-ordination Group, Finance and Audit Committee, with the final decision on all
strategies lying with the Board of Governors of the university.
For each objective a strategy is outlined, or under development, which also details the activities required
to meet objectives and targets, the time frame (including any significant milestones) for achievement, and
related budget information. The strategies do not need to be exactly followed, as they constitute a guide,
so long as the objectives and targets are met.
Where the achievement of an environmental objective or environmental target is, or is likely to be,
delayed or cancelled for any reason the responsible manager should report this to the Environmental
Manager.
The responsible manager and the Environmental Manager will then collaborate to revise the
environmental target and/or related environmental objective as appropriate.
Our environmental objectives and environmental targets will be reviewed as follows:
On an annual basis as part of the management review process;
As and when changes are made to the compliance register;
In response to other changed circumstances;
When failure to meet an environmental objective or environmental target is highlighted through
audit; and
As a consequence of documented and reported stakeholder concerns.
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4.4 IMPLEMENTATION & OPERATION
4.4.1 RESOURCES, ROLES, RESPONSIBILITY & AUTHORITY
The University of Brighton has established this procedure to ensure the availability of resources essential
to establish, implement, maintain and improve the EMS.
Resources include human resources and specialised skills, organisational infrastructure, technology and
financial resources.
Organisation
The overall organisational structure of the EMS is set out in the appended EMS Organisation Chart. The
chart illustrates the relationship between the Carbon Management Programme Board, Environment
Team and all university staff with respect to the EMS.
The Environmental Manager has been nominated as the management representative and reports on the
performance of the EMS to management at Management Review as a basis for improvement of the EMS.
EMS Organisation Chart
Board of Governors
Management Group
Carbon Management Programme Board
Environment Team
Environmental Manager
Support Service Managers and
Supervisors
All University Staff
Management Review Group
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Responsibilities
Board of Governors and Management Group are responsible for:
Sign off of all relevant EMS documents.
The Carbon Management Programme Board is responsible for:
Approving and endorsing Environmental Objectives and Targets for the university.
Ensuring that the resources essential to the implementation and control of the EMS are made
available.
Co-ordinating any review of the Environment Policy.
Conducting a Management Review Meeting to discuss the implementation of the EMS.
The Management Review Group is responsible for:
Ensuring appropriate mechanisms are in place to ensure legal compliance in all business activities
at the university.
Secure the resources required to maintain the EMS.
Ensure the EMS is established, implemented and maintained.
Monitor the performance of the EMS.
Establish, review and revise the institution’s environmental policy, objectives and other elements
of the EMS.
Report on the EMS to the Carbon Management Programme Board.
The Environment Team comprises the Environmental Manager, the Energy Management Engineer, the
Environment Officer, Assistant Environment Officer, Assistant Environmental Communications Officer
and the Sustainable Behaviour Assistant. The Environment Team can also call upon any other competent
persons deemed necessary to assist in implementing and maintaining the EMS. The Environment Team is
responsible for:
Ensuring that sufficient and appropriate measures are adopted and employed throughout the
university to prevent the occurrence and/or mitigate the effects of emergency environmental
situations or accidents.
Ensuring that the decisions and actions adopted at Management Review and Internal Audits are
implemented as appropriate.
Ensuring all documents in the Document Control Register are up to date with the correct version
number.
Devise and promote initiatives to inform interested parties about the EMS.
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Help the EMS Manager to regularly audit the EMS.
The Environmental Manager is responsible for:
Represents all environmentally related work carried out at the university, at the EMS
Management Review Group meetings.
The establishment and maintenance of the Register of Environmental Aspects.
Evaluating the significance of the identified Environmental Aspects.
To ensure day to day compliance with the Compliance Register and, in consultation with Support
Services Managers and Supervisors, and any other relevant parties, to modify procedures, and
document changes to procedures, to ensure compliance.
Monitoring progress against the Environmental Objectives and Environmental Targets and
reporting periodically to the Carbon Management Programme Board.
Compiling information with respect to progress towards Environmental Objectives and
Environmental Targets and communicating this internally.
Assigns Roles, Responsibilities and authority and informs individuals about their obligations
including suppliers and contractors.
Maintaining a record of official correspondence relating to the EMS and related issues and for
maintaining a Register of Environmental Complaints.
Ensuring that actual and potential Nonconformities are resolved quickly and efficiently.
Authorising, issuing and maintaining EMS Documents (in consultation with related personnel
where appropriate).
Ensuring that the EMS is established implemented and maintained in accordance with the
requirements of EcoCampus and ISO14001.
Reporting to the Carbon Management Programme Board on the performance of the EMS for
review, including recommendations for improvement.
Ensuring that all relevant personnel are informed about EMS Documents which impact on their
duties.
Ensuring that controlled EMS Documents are current and available at the point of use, and is also
responsible the maintenance of the Document Control Register.
Organises the programme of Internal Audits and EMS Management Reviews.
Auditing the EMS in accordance with the requirements of EcoCampus and ISO14001 and to report
the results to the EMS Management Review Group.
Appointing an accredited external auditor to ensure that external audits are conducted at a
frequency appropriate to the maintenance of both EcoCampus and ISO14001 certification.
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Preparing the EMS Management Review agenda and co-ordinating the provision of information
necessary to complete the Management Review to attendees.
Arranging for minutes of the EMS Management Review Meeting to be taken and for retaining
these records.
Communications on the EMS or related issues with regulatory bodies, local authorities or the
emergency services.
Compiling an annual report on the implementation of the EMS across the university.
The Environmental Officer is responsible for:
Establishing and maintaining the Compliance Register.
Appraising the Carbon Management Programme Board Members, Auditors, Site, Departmental
and Line Managers, of the Compliance Register and specifically any changes that are made.
Identification of training needs across the University.
Development and implementation of an environmental training plan (which includes a schedule
of training).
The Assistant Environmental Communications Officer is responsible for:
Maintaining one full controlled copy of the EMS in hard copy.
External communication of certain environmental information via media as appropriate.
Communicating to partners and staff important aspects of the EMS and maintaining a log of
internal communications.
The Assistant Director of Estate and Facilities Management (Facilities) is responsible for:
Working with Safety Committee to investigate all emergency incidents and, where there is an
environmental impact, to report to the Environmental Manager, the Carbon Management
Programme Board and to the Board of Governors where appropriate on:
o Causes of accidents, including any non-conformities,
o Arrangements taken to prevent or mitigate any further environmental impact,
o Arrangements, if necessary, to make good any damage to property,
o Action plan to prevent recurrence of the incident (including modification of those parts of
the EMS as required)
Coordinating the response to an emergency environmental situation or accident.
Ensuring that spill kits are available and maintained at appropriate locations across the
university.
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Ensuring that individuals who may be called upon to respond to an emergency environmental
situation or accident have had appropriate training and instruction, and where possible follow
documented procedures to minimise the environmental impact of an incident.
Individual managers are responsible for:
Allocating responsibility for managing the achievement of Environmental Objectives and
Environmental Targets relating to their activities, and reporting on progress to the Environment
Team.
Ensuring that personnel (including external contractors) under their control are appropriately
trained to complete their tasks.
Ensuring that the Environmental Policy and relevant elements of the EMS are communicated to
employees and/or contractors within their line management function prior to commencement of
work.
Reporting environmental performance information to the Environmental Manager.
Ensuring that any contractors operating under their authority in or around the university are
made aware of, and comply with, these requirements.
Ensuring that corrective and/or preventive actions are properly implemented within the specified
time frame.
All managers and staff are responsible for:
Notifying the Environmental Manager of any incidents or accidents.
Notifying the Environmental Manager of any known changes to their activities that are likely to
affect the Register of Environmental Aspects.
Advising the Environmental Manager if they become aware of changes to current or proposed
Legal and Other Requirements which may impact on their duties or related activities.
Proposing Environmental Objectives and Environmental Targets for the University, through
contacting the Environmental Manager.
Contributing to the achievement of the University of Brighton’s Environmental Objectives and
Environmental Targets.
Ensuring that they comply with the provisions of this procedure to the extent that it relates to
matters within their control.
Communicating any issues which may affect the Environmental Policy or EMS to the
Environmental Manager.
Cooperating with internal and/or external auditors.
Ensuring that they are familiar with the current versions of documents as required.
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Providing feedback on the continuing suitability of EMS Documents which impact on their duties
to the Environmental Manager.
Bringing suspected, potential or actual Nonconformities to the attention of the Environmental
Manager as soon as practicable.
Any other duties specified in the EMS in which specific responsibility has been allocated to them.
Internal Auditors are responsible for:
Ensuring that Internal Audits are carried out in accordance with the requirements of ISO14001.
Familiarising themselves with the activity or element of the EMS to be audited and prepare an
Internal Audit Checklist prior to Internal Audit.
Follow-up on any Nonconformity identified in the course of an Internal Audit and ensure that
agreed Corrective Actions are implemented in the correct timescale.
Specific Management Responsibilities:
Procurement Services Manager is responsible for the Sustainable Procurement Strategy.
Director of Finance is responsible for the Ethical Investment Policy.
All other procedures are responsibility of Environment Team.
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4.4.2 Competence, Training and Awareness
The University of Brighton has established this procedure to ensure that any persons performing tasks
for the university that have the potential to impact on a significant Environmental Aspect are competent
on the basis of appropriate education, training or experience.
Environmental training is provided to ensure that personnel at each relevant function and level are aware
of:
The importance of conformity with the Environmental Policy and adherence with the procedures
and requirements of the EMS;
Those significant Environmental Aspects associated with their work and how improved personal
performance can benefit the environment;
Their roles and responsibilities in achieving conformity with the requirements of the EMS; and
The potential consequences of departing from specific procedures.
At induction all new personnel receive appropriate environmental awareness training. All existing
personnel are required to complete an equivalent online environmental awareness training module.
Personnel who carry out work associated with significant Environmental Aspects receive additional
Environmental Competency Training to enable them to fulfil their duties in a manner consistent with the
aims of the Environmental Policy and requirements of the EMS. Refresher training is provided for these
personnel as appropriate.
Contractors will be made aware of and be required to abide by the Environmental Policy of the university.
Any contractors bringing chemicals, oils or refrigerants onto site will be required to provide appropriate
containment units (e.g. bunding etc). All contractors dealing with these materials will be required to
provide spill training to all staff attending university premises. All waste should be removed off site by
contractors, unless previously agreed by the university. This should be included in all contracts.
Mapping of training records providing details of the type of environmental training received, date and
name of each attendee are maintained by the Environmental Team. Many of these are also duplicated by
Line Managers, Health and Safety Officers and Supervisors (to ensure that all of their direct reports have
had the requisite training).
Environmental training requirements will be assessed regularly as part of the Management Review and in
accordance with wider university policy on induction and ongoing training and development.
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4.4.3 COMMUNICATION The University of Brighton has established this procedure to manage internal and external
communications with respect to the EMS and related matters. All EMS communication materials will be
mapped across the university and the spreadsheet will be updated and maintained by the Environment
Team.
The University of Brighton receives communications around all areas of our environmental management
from a large number of different areas, communicating with a large number of personnel across the
university. Many of these communications are dealt with at source and others are escalated up to the
Environment Team.
Internal communications
The Environment Team is responsible for co-ordinating and logging all internal communications relating
to the EMS.
Environmental information is communicated internally in a variety of ways as follows:
Uncontrolled copies of certain EMS elements are displayed in appropriate locations around the
university. Only those EMS elements essential to day-to-day operations are printed and displayed
in this way to minimise paper waste and to maintain Document Control.
Where new or amended EMS elements become available these are brought to the attention of
relevant employees as soon as practicable. Personnel are also reminded to update any printed
versions of the documents under their control.
Workshops, seminars and/or other training events (including induction training) are used to
inform employees about the scope of the EMS, its purpose and the general duties which it imposes
on all employees.
Employees and contractors whose activities directly impact on Significant Environmental Aspects
are provided additional specific training as appropriate.
The university’s internal communications network is used to keep employees informed of general
EMS developments and related matters.
Specific information on the EMS and related matters is also communicated via meetings and/or
telephone conversations with relevant personnel where appropriate.
In line with 4.4.2 Contractors working at the university are made aware of the Environmental
Policy, relevant procedures and standards of environmental care required by the EMS before any
work may commence.
The Environment Team encourages the use of electronic communication wherever possible/ appropriate
in order to help minimise paper waste.
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External communications
The Environment Team are provided copies of all written communications from external interested
parties relating to the EMS and related matters and responds to these as appropriate.
All correspondence from regulatory authorities relating to suspected environmental offences will be
prioritised for urgent action. In all cases the Environmental Manager will be informed immediately and
appropriate action will be taken as soon as practicable.
Records of correspondence with regulatory authorities relating to the EMS and related matters are
retained for a minimum period of five years.
The University does not communicate our significant aspects externally. However certain environmental
information, such as performance information, is externally communicated via reports, the university’s
website (brighton.ac.uk), and/or other media as appropriate. All data derived from the EMS must be
confirmed as accurate by the Environmental Manager before publication.
Complaints
Details of any received Environmental Complaints are dealt with at source and others are escalated up to
the Environment Team, as appropriate.
The complainant will be informed that his/her complaint is being investigated and that further
information will be provided as appropriate when the investigation is complete.
Once the validity of the complaint has been verified appropriate Corrective Action and/or Preventive
Action will be implemented as soon as practicable.
All environmental complaints are mapped across the university. The relevant staff are responsible for
recording all complaints in relevant logs.
Records of communications with complainants are retained for a minimum period of five years.
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4.4.4 DOCUMENTATION The University of Brighton has established the following EMS Documents to ensure the effective
management of the university’s environmental performance:
An Environmental Policy, Environmental Objectives and Environmental Targets (the later
outlined within the Environmental Policy Action Plan and other associated plans);
A description of the scope of the EMS;
The Compliance Register and Environmental Impact and Aspect Register;
A description of the main elements of the EMS and their interaction, and reference to related
documents;
Documents, including records, required by ISO14001;
Documents, including records, determined by the university to be necessary to ensure the
effective planning, operation and control of processes that relate to significant Environmental
Aspects.
Controlled copies of the EMS Manual are held by the Environment Team as part of the university file
storage system.
In addition, the university holds copies of the following:
BS ISO 14001:2015
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4.4.5 CONTROL OF DOCUMENTS The University of Brighton has developed this procedure in order to ensure that all EMS Documents are
controlled.
All hard copy controlled EMS Documents are maintained by the Environment Team and approved by the
relevant Committee or Board.
All other printed versions of EMS Documents are uncontrolled copies. All EMS documents are stored in
electronic form in the university’s internal document control system (sharepoint).
Each document is given an updated version number when changed. Any printed document without a
version number will not be considered a controlled document.
EMS Documents are reviewed under the following circumstances:
On an annual basis as part of the Management Review process;
In order to help achieve an Environmental Objective or Environmental Target;
In response to changed circumstances such as new or amended Legal and Other Requirements;
As and when changes are requested by relevant personnel;
In response to audit; and
As a consequence of documented and reported stakeholder concerns.
Following review EMS Documents are amended as necessary.
Any obsolete documents that are retained for legal and/ or knowledge preservation purposes are suitably
identified and filed by the Environment Team.
Compliance with the requirements of this procedure is reviewed periodically via Internal Environmental
Management System Audits.
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4.4.6 OPERATIONAL CONTROL The University of Brighton has established this procedure in order to identify and plan those operations
that are associated with the identified significant environmental aspects consistent with the
Environmental Policy, Objectives and Targets, in order to ensure that they are carried out under specified
conditions.
The Environment Team have mapped the need for operational procedures associated with significant
Environmental Aspects. This mapping is updated taking into consideration Environmental Aspects and
any changes to operations of the university and stored in the document control system.
The following operational procedures have been established:
Waste Disposal Procedure
Chemicals Procedure
Procurement Procedure
Refrigerant Gas Procedure
Water Management Procedure
Fuel and Oil Procedure
Contractor Procedure
Noise Procedure
Energy Management Procedure
Asbestos Procedure
Legionella Procedure
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4.4.7 EMERGENCY PREPAREDNESS & RESPONSE The University of Brighton has established this procedure in order to identify potential emergency
situations and potential accidents that can have an impact(s) on the environment and document how the
university will respond to them.
In the event of an accident or emergency environmental situation arising, action will be taken as soon as
possible to prevent and/or mitigate associated adverse Environmental Impacts.
The following incidents must be immediately reported to the Environmental Manager who must record
them using the incident form:
Any unplanned and/or sudden release from pressure systems or of any solvent, or the venting,
planed or otherwise of any gas,
Failure of drainage, breach of closed water systems, or breach of open water systems other than
at a tap or drain cock.
The release of any substances other than rain water to surface water drains.
The loss of any waste load from its point of origin on the premises until it arrives at its final point
of disposal, either by accident or due to fly tipping.
The Environmental Manager will, as soon as practicable, determine the scale and severity of the
emergency environmental situation or accident and, depending on the circumstances, classify it as either
a Major Incident or a Minor Incident.
All Major Incidents must be reported to the relevant regulatory authorities as soon as reasonably
practicable.
The Environmental Manager will take all reasonable steps to ensure that any release as a result of an
emergency environmental situation or accident is contained and that any resultant harm to the
environment is minimised.
Following an emergency environmental situation or accident all reasonable measures will be taken to
ensure that any environmental damage is properly remedied and additional preventative action agreed.
Wherever spill kits or other materials have been deployed in the course of an environmental situation or
accident they will be disposed of in accordance with relevant waste management legislation.
Following an environmental situation or accident an Emergency Report Form must be completed by the
Environmental Manager as soon as practicable.
Specific types of emergency are dealt with in detailed emergency procedures:
Fire Procedure
Emergency Spill and Leak Procedure
Legionella Procedure
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4.5 CHECKING
4.5.1 MONITORING & MEASUREMENT
The University of Brighton has established documented procedures to ensure that the key characteristics
of its operations and activities that may have a significant impact on the environment are regularly
monitored and measured.
Those measurements that are not performed by university personnel are carried out by suitably qualified
sub-contractors.
There are several environmental aspects of operations carried out at the university which are routinely
monitored and measured as follows:
This Table needs to be completed, aspects added if needed, or removed.
Resources Units Report
Frequency
Responsible person Data systems
Electricity
KWh Quarterly Environmental
Manager
Gas
KWh Quarterly Environmental
Manager
Water
Litres Quarterly Environmental
Manager
Fuel oil and diesel Litres
Paper purchase Reams
Other chemicals and
substances
Kg
Emissions/waste Streams Units Report
Frequency
Responsible person Data system
Carbon Tonnes (CO2e) Environmental
Manager
Refrigerants Kg Annually Environmental
Manager
F gas Register
Hazardous Waste
Kg Monthly? Cox Group?
Controlled Waste Kg Monthly? Cox Group?
Mixed general office waste for
recycling
Kg Monthly? Cox Group?
WEEE Kg Monthly? Cox Group?
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Cooking oil Kg Monthly? Cox Group?
Scrap metal Kg Monthly? Cox Group?
Wood Kg Monthly? Cox Group?
Cardboard Kg Monthly? Cox Group?
Other Parameters Units Report
Frequency
Responsible person Data system
Drinking water (Microbial
TVC)
Cooling water (legionella) Detected/Not
detected
Cooling water (Microbial TVC) Cfu/l
Cooling water (pH) value
Cooling water (Temp) °C
Cooling water (Conductivity) Micro-siemens /cm
Cooling water (Dipslides) cfu
Cooling water (Bromine) ppm
Cooling water (TDS) ppm
Cooling water (TSS) ppm
Redox?
Tap temps (infreq)
Cold water tanks (Temp) °C
Cold water tank (Microbial
TVC)
Cfu/l
Air (CO) ppm
Air (CO2) ppm
Air (particle count) No. of particles @
size 0.5/1.0/5.0
microns
Air (dust1) mg/m3
Air (microorganism) cfu’s per 180l
1 Indoor air quality, hence not counted as an emission
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Air (temp) °C
Air (humidity) %RH
Air (head height flow) m/s
Washrooms, drinking water,
vending machines and kitchen
outlets (microbial TVC)
Cfu/l (@22°C and
37°C)
Washrooms, drinking water,
vending machines and kitchen
outlets – pseudomonas
aeruginosa
Detected/Not
detected
Washrooms, drinking water,
vending machines and kitchen
outlets – TT E. coli
Detected/Not
detected
Washrooms, drinking water,
vending machines and kitchen
outlets – Coliform species
Detected/Not
detected
Tap temps °C
If there is an unexpected increase in resource consumption or waste disposal that cannot be accounted
for (other than as a result of increased business activity or planned programmes) an investigation is
mounted and, if appropriate, corrective and preventive measures are instigated.
Water
We monitor all closed water systems for total dissolved solids and look for evidence of copper for
corrosion on a quarterly basis. The procedures for and records kept in respect of these tests are retained
by the Building Services Manager.
Internal tests for biocides and microbiological contamination (such as Legionella) are carried out once
per week. An independent check for microbes and general water quality is also carried out by external
contractor quarterly. The procedures for and records kept in respect of these checks are retained by the
Building Services Manager.
Air quality
External contractors measure air quality across the University estate for particulates, microbes,
temperature and relative humidity twice each year. The procedures for and records kept in respect of
these tests are retained by the Environmental Manager.
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Objectives and Targets
Information regarding progress against stated Objectives and Targets is recorded as described in section
4.3.3.
Legal Compliance
The effectiveness of this procedure is reviewed periodically via Internal Audit. Information on
monitoring and measurement activities is reviewed at Management Review.
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4.5.2 EVALUATION OF COMPLIANCE
The University of Brighton has established procedures for periodically evaluating compliance with
applicable legal requirements.
Evaluation of compliance against legal and other requirements is scheduled and carried out on a 6
monthly basis via the internal audit process.
Evidence of compliance against legal and other requirements is recorded in the compliance register along
with the date compliance was last checked. Any non conformities arising from audits will be dealt with
through use of the procedure detailed in 4.5.3.
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4.5.3 NON CONFORMITY, CORRECTIVE AND PREVENTIVE ACTION
The University of Brighton has established this procedure to ensure a managed response to actual or
potential Nonconformities through effective corrective and preventive action.
Actual or potential Nonconformities may be identified as a result of:
Internal or external audits;
Environmental complaints;
Observations / identified opportunities for improvement;
Incidents or near misses;
Changes to the EMS:
Changes to Legal and Other Requirements; and
Housekeeping inspections.
Once an actual or potential Nonconformity has been identified the Environmental Manager must
investigate the underlying cause(s) and determine, in consultation with relevant personnel as necessary,
appropriate corrective and/or preventive action with a specified time frame for execution.
In determining what Corrective Action and/or Preventive Action is appropriate the Environmental
Manager will take into account the scale and severity of any associated Environmental Impacts.
Details of identified Nonconformities and related corrective and preventive action (including a timescale
for completion) are recorded on a Nonconformity Report Form. Once completed all paperwork is sent to
the Environment Team for filing.
Preventive Action might include implementing new or amended procedures or controls. Where such
Preventive Action necessitates changes to the EMS those changes are documented and recorded in
accordance with our Document Control Procedure.
Nonconformities and the effectiveness of related corrective and preventive action are reviewed as part of
the Management Review process.
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4.5.4 CONTROL OF RECORDS
The University of Brighton has established procedures for the identification, storage, protection, retrieval,
retention and disposal of environmental records.
The university maintains its records so that they are legible, identifiable and traceable to the related
activity or element of the EMS.
The appended table lists those records that form part of the EMS, their specified retention period, any
related EMS elements and the personnel responsible for their maintenance. These personnel are
responsible for ensuring that records are legible, identifiable, traceable and appropriately stored and
disposed of.
The effectiveness of this procedure is reviewed periodically via Internal Audit.
The Environmental Manager will review Environmental Records periodically to identify any issues or
trends that may highlight areas for improvement.
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4.5.5 INTERNAL AUDIT
The University of Brighton has established this procedure to ensure that Internal Audits of the EMS are
conducted at planned intervals to:
Determine whether the EMS conforms to planned arrangements for environmental management
including the requirements of ISO14001; and
Has been properly implemented and is maintained.
Information on the results of Internal Audits is provided to management as appropriate.
In order to ensure that Internal Audits of the EMS are conducted at appropriate intervals the
Environmental Manager/Environmental Officer has devised an annual Audit Schedule. The Audit
Schedule may be expanded where necessary to allow for one-off Internal Audits and the re-auditing of
corrective action from previous Internal Audits.
The frequency with which a particular activity or element of the EMS is audited is determined according
to the significance of each Environmental Aspect associated with that activity or element of the EMS. The
greater the significance of an Environmental Aspect the more frequently any associated activities or
elements of the EMS are audited.
An Internal Auditor List indicating the name and position of each Environmental Auditor is maintained by
the Environment Team. All Environmental Auditors receive appropriate training before undertaking an
Internal Audit. Appropriate training records are maintained.
Environmental Auditors record details of any observations or Nonconformities identified in the course of
Internal Audits. Nonconformities are classified as either Major or Minor. This distinction is used in the
planning of Corrective Action as follows:
A Major Nonconformity is one causing a serious departure from the requirements of the EMS or
ISO14001 and a possible breakdown of the system. This would include any legislative or regulatory
infringement with the potential to cause a failure in the EMS. In the case of a Major Nonconformity
Corrective Action must be taken immediately. Examples of Major Non Conformities are:
A missing requirement of the ISO 14001: 2015 standard
A series of minor concerns relating to the same clause that cannot be resolved by a single
corrective or preventive action but require systemic activity over time.
Repeated instance of the same problem in several different areas or at several different times or
after preventive action has been recorded as having taken place.
A lack of corrective action from a previous non-conformity highlighted in subsequent audit.
A Minor Nonconformity is a single departure from the EMS or requirements of ISO14001 that will not
cause a breakdown of the system and can be corrected on a time scale appropriate to the severity of the
infringement (as determined by the Environmental Manager).
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An Observation is an opportunity to raise a concern which does not form part of the management system
at the time it is raised. This may be because it is a concern that is currently outside the scope of the
management system, or a previously unconsidered potential aspect or impact, or a new legislative
requirement, and/or where procedures have not yet been developed to manage this concern. It is an
acceptable outcome for an observation not to give rise to corrective and/or preventive action only if it
can be shown that the concern does not give rise to a breach of legislation or a significant environmental
impact.
Internal Audits are conducted as follows:
The Environmental Manager/Environmental Officer maintains the Audit Schedule (and any Audit Plan for
forthcoming years required to maintain the Schedule) on an annual basis and allocates an Environmental
Auditor to each activity or element of the EMS which is scheduled to be audited. Internal Auditors are not
permitted to audit their own areas of responsibility.
The Environmental Manager/Environmental Officer then alerts relevant management personnel that an
Internal Audit is due to take place and agrees a date for performance.
The allocated Environmental Auditor plans and prepares for the scheduled Internal Audit by producing in
advance an Internal Audit Checklist listing the EMS and/or ISO14001 requirements against which
performance will be measured and recorded.
Preparations for Internal Audit include reviewing the results of previous audits of the activity or element
of the EMS which is to be audited (if available) to determine any aspects which may require particular
scrutiny.
Before conducting the scheduled Internal Audit the allocated Environmental Auditor explains the
purpose and scope of the audit to relevant personnel.
The Environmental Auditor then undertakes the scheduled Internal Audit in accordance with the
requirements of ISO14001 and this procedure. If Nonconformity is identified during the Internal Audit
the Environmental Auditor carries out further investigation to identify the nature and scale of the issue
(even if the identified Nonconformity is beyond the original remit of the Internal Audit).
On completing the scheduled Internal Audit the Environmental Auditor meets with relevant management
personnel (including the Environmental Manager/Environmental Officer) to relay findings, give an
opportunity for factual errors to be corrected, discuss any identified Nonconformities, agree Corrective
and Preventive Actions and sign-off the Internal Audit Checklist.
The Environmental Auditor follows up with a written Audit Report to the relevant management
personnel and the Environmental Manager/Environmental Officer within two weeks of the Internal
Audit. Audit Reports contain full details of any observations, Nonconformities and agreed Corrective and
Preventive Actions and a timescale for implementation where appropriate.
The Environmental Manager shall enter observations and nonconformities into the Corrective Action Log
which records corrective and preventive actions, the relevant clause (including any information as to root
cause where this can be discerned), when they are to be resolved and the results of any follow up to check
on the effectiveness of corrective and preventive actions.
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A copy of the Audit Report is kept by the Environment Team for internal records.
External audits are carried out by an accredited external auditor to an agreed programme to ensure that
they are conducted at a frequency appropriate to the maintenance of ISO14001 certification.
The Environmental Manager reports to the Carbon Management Programme Board at least annually on
the results of all audits undertaken since the last reporting session.
Housekeeping inspections are informal walks around the estate noting where site maintenance is
required. A housekeeping inspection report is issued to the relevant maintenance managers and helpline
tasks are raised for urgent issues. Actions are assigned with due dates.
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4.6 EMS MANAGEMENT REVIEW
The University of Brighton has established this procedure to ensure that senior management formally
review the EMS at regular intervals to ensure its continuing suitability, adequacy and effectiveness.
The review process includes an assessment of potential areas for improvement and the need for changes
to the EMS including the Environmental Policy, Environmental Objectives and Environmental Targets.
The EMS Management Review process is documented and records are retained by the Environment
Team.
The EMS Management Review Process is conducted as part of the Carbon Management Programme
Board’s business and is therefore chaired by the Director of Finance.
Do we want this or do we want to set up a small group of only 3 people to review documents etc?
The EMS Management Review process considers any changes that might be necessary to the
Environmental Policy and other elements of the EMS in the light of:
The results of Internal Audits and evaluations of compliance with Legal and Other Requirements;
Communications from external interested parties, including environmental complaints;
The environmental performance of the university;
The extent to which Environmental Objectives and Environmental Targets have been met;
The status of Corrective Actions and Preventive Actions;
Follow up actions from previous Management Reviews;
Changing circumstances (including in Legal and Other Requirements) relating to our
Environmental Aspects; and
Recommendations for improvement.
The Management Review agenda lists each of the above items and any other environmental topics for
discussion at the meeting.
Details of any decisions and/or actions adopted at Management Review are recorded in the Management
Review minutes. Management Review minutes are maintained for a minimum period of three years.
The Management Review takes place at least once annually. Management Reviews may be held more
regularly where circumstances require.
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APPENDIX A – RELATED EMS DOCUMENTS
1. Environmental Policy
2. Objectives, Targets and Programmes
3. University of Brighton Compliance Register
4. Document Control Register
5. Aspects & Impacts Register
6. Internal audit schedule
7. Process Control Flow Chart
8. Forms and system document templates
9. Procedures (Operational and Emergency)
Records Folder:
1. Training Records
2. Evidence of Communications
3. Supplier Appraisal Forms
4. Corrective Action Log (includes NC Reports P001 – P005)
5. Stage 1 Audit Report – Action Record
6. Internal Audits
7. Management Reports
8. Management Review Minutes
9. Emergency Spill and Leak Desk Drill Exercise