13 Appendices Appendix 1 – ‘Organogram’ – Management and Lines of Communication. Appendix 2 – Environmental Impact Assessment Form.
21 22
23
Title: Ventilation Systems Policy
Date Approved: 08/06/2016
Approved by:
Estates Governance Committee.
Date of next review: 01/05/2019
Policy Ref: E&F010
Issue:
1
Division/Department: Strategic Planning and Commercial Development / Estates & Facilities
Policy Category: Estates & Facilities
Author (post-holder): Ben Widdowson, Head of Estates & Facilities
Sponsor (Director): Peter Wozencroft, Director of Strategic Planning & Commercial Development
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1. INTRODUCTION
This policy is issued and maintained by the Director of Strategic Planning & Commercial Development
[the sponsor] on behalf of Sherwood Forest NHS Foundation Trust [herein known as The Trust], at the
issue date defined on the front sheet, which supersedes and replaces all previous versions.
The Health and Safety at Work Etc Act 1974 and the Control of Substances Hazardous to Health Regulation 2002 (as amended) places a duty on the Trust to ensure that all equipment, plant and machinery is adequately maintained in a safe condition so as not to present a risk to its employees or other persons. Ventilation is provided in healthcare premises for the comfort of the occupants of buildings and
to remove unwanted pollutants from the place of work. More specialised ventilation systems will also
closely control the temperature and humidity of the environment. In spaces such as theatres, large
quantities of filtered air are also provided to reduce hazards to patients and staff from airborne
contaminants and potentially harmful micro-organisms.
Sherwood Forest Hospitals NHS Trust (SFHFT) recognises its obligations to take necessary measures
in the provision of effective operation, inspection (including validation) and maintenance of engineering
plant, systems and services to maintain the safety and welfare of patients, employees, visitors and
contractors on Trust premises. This commitment is demonstrated through compliance with all statutory
requirements and codes of practice in all premises for which it is responsible.
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2. POLICY STATEMENT
This policy sets out the management approach to be adopted by the Trust and their PFI Partners
Central Nottinghamshire Hospitals Plc [CNH] and their service providers Skanska Facilities Services
[SFS]; for operating, inspecting and maintaining ventilation and air conditioning systems.
The Partners for the Trust complete all maintenance of Ventilation and air conditioning systems across the various properties the Trust occupy or own [This includes Mansfield Community Hospital]. The Trust recognises it still has a duty of care to ensure these systems are being managed appropriately.
The purpose of this policy is to define an appropriate terms of reference for the management of
ventilation systems. This will allow the Trust and their PFI partners to implement best practice in the
management of ventilation systems by complying with;
• Recognised industry best practice – Health Technical Memorandum – Health Building Notes
• Statutory requirements – COSHH
• The Health and Social Care Act 2008 and CQC
• Model Engineering Specifications and Approved Codes of Practice) and Legislation.
This policy should also be read in conjunction with local Standing Operational Procedures (SOP) and
the safe systems of management that they describe, for working and managing these systems on a
day-to-day basis.
Statement of Intent
The Trust, as a healthcare provider, is fully committed to maintaining an appropriate level care and
management of its key supply chains in relation to the management of ventilation systems. The Trust
recognise that, although they outsource the delivery of operation and maintenance to others (through
their PFI Contract primarily), it still retains a duty of care to manage and check appropriate controls are
in place. It is the policy of the Trust and its partners to minimise the risk of harm or infection from
airborne contaminants by ensuring the ventilation and air conditioning systems are rigorously
maintained, monitored, tested according to the following:
Comply with The Health and Safety at Work etc. Act 1974.
Comply with the Health and Safety Commission’s Approved Code of Practice & Guidance such
as ACOP L8, HSG 258.
Comply with the Control of Substances Hazardous to Health Regulation 2002 (as amended).
Comply with the Department of Health documents HTM 00-00 Policies and principles of
Healthcare Engineering.
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Comply with the Department of Health documents HTM03-01 Parts A & B: Specialised
Ventilation for Healthcare premises.
Comply with the Department of Health documents HTM04-01: The control of Legionella,
hygiene, ‘safe’ hot water, cold water and drinking water systems.
Work with their partners in an open and co-ordinated relationship to ensure the safety of
patients, staff, visitors and others.
Through implementation of this policy, SFHFT aims too:
• Provide guidance to those responsible for the management of ventilation systems including
Local Exhaust Ventilation (LEV) systems.
• To set out responsibilities for the implementation of statutory requirements
• Ensure effective liaison between the Infection Control and the persons with overall responsibility
for maintenance management.
• Ensure that ventilation systems operate at optimum levels of performance and within the
intended design criteria and in an energy efficient manner.
• Maintain a clean and appropriate environment which facilitates the prevention and control of
HCAI (Health Care Associated Infection) in a manner conducive to quality clinical care.
Equality Impact Assessment The Trust is committed to ensuring that none of its policies, procedures and guidelines discriminate against individuals directly or indirectly on the basis of gender, colour, race, nationality, ethnic or national origin, age, sexual orientation, marital status, disability, religion, beliefs, political affiliation, trade union membership, and social and employment status. An equality impact assessment (EIA) of this policy has been conducted by the author using the EIA tool developed by the diversity and inclusivity committee. The score of this policy when assessed by the tool on the 28th April 2016 was rated as ‘low’.
Complimentary or relevant trust policies to be read in conjunction with this policy:
Control of Contractors Policy.
Water Safety Policy
CoSHH Policy
Infection control policy
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3. DEFINITIONS
Definitions of specific terms used in the policy are as follows;
The Trust means the Sherwood Forest NHS Hospitals Foundation Trust.
Staff means all employees of the Trust including those managed by a third party
organisation on behalf of the Trust.
PFI Private Finance Initiative. The initiative under which, the Trust has entered into an
agreement with its partners to build and provide certain services (such as Planned
Preventative Maintenance) at its hospitals.
PA Project Agreement. The agreement or contract between SFHFT and it’s PFI partners
(Project Co) for the building of the new hospital buildings and the provision of a
facilities management services (see also schedule 14).
Project Co. This is the term used to refer to Central Nottinghamshire Hospitals Plc. It is the
organisation appointed by the Trust to build the new hospital buildings and provide
facilities services and then manage these facilities for the life of the contract, at which
time they are then handed back to the Trust.
SFS Skanska Facilities Services. The organisation appointed by Project Co to provide
certain facilities management services including estates and maintenance functions.
Schedule 14 Service Level Specification. The part of the PFI Project Agreement mainly concerned
with the facilities management services provided by Project Co through their
subcontract with Skanska Facilities Services (SFS).
Environment means the totality of a patient’s surroundings when in healthcare premises. This
includes the fabric of the building and related fixtures, fittings and services such as air
and water supplies.
Ventilation this is the means of removing and replacing the air in a space. In its simplest form
this may be achieved by natural means by opening windows and doors etc.
Mechanical ventilation systems provide a more controllable method of delivering a
known quantity and quality of air. Basic mechanical systems consist of a fan and
collection of distribution ductwork; more complex systems may include the ability to
condition the air passing through them (Air Conditioning). Ventilation equipment may
be required in order to remove smells, dilute contaminants and ensure that a supply
of fresh air enters a space.
Air Conditioning means the ability to heat, cool, humidify, dehumidify, and filter air. This means
that the climate within a space being supplied by an air conditioning plant can be
maintained at a specific level regardless of changes in the outside air conditions or
the activities within the space. Air conditioning may be required in order to provide
comfort conditions within a space.
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A simpler form of this that does not closely control humidity is known as comfort
cooling.
LEV These are bespoke ventilation systems that are used to prevent operatives from
exposure to potentially harmful pollutants. Local Exhaust Ventilation (LEV) systems
require testing every 14 months under the current Control of Substances Hazardous
to Health Regulations (COSHH).
Mansfield Community Hospital: NHS Property Services are the owners of Mansfield Community
Hospital and therefore have a responsibility as a duty holder. Sherwood Forest
Hospitals NHS Foundation Trust occupy certain areas of the building for services to
the local community. The Trust’s Partners through Skanska Facilities Services [SFS]
provide the maintenance via the PFI agreement
IPCC This is the Trust Infection Prevention Control Committee.
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4. ROLE AND RESPONSIBILITIES
This section details the general responsibilities of all relevant persons and groups. An ‘organogram’ showing responsibility structure is appended to this policy [Refer to Appendix 1].
The Trust and its partners all have responsibilities as duty holders to ensure they maintain the ventilation and air conditioning systems in all its premises.
Below the responsibilities are defined for each role within the Trust and its partners.
4.1 Trust Board
The Trust Board, through The Chief Executive (who is the Accountable Officer), has overall
responsibility for Health and Safety within The Trust, carries ultimate responsibility for providing a well
The Trust as and it’s PFI partners all have responsibilities as duty holders to ensure they maintain the
provision of safe Ventilation Systems. Each key party of the PFI scheme (Trust, Project Co and
Skanska Facilities services) has relevant responsibilities to develop, implement, manage and monitor
Ventilation Systems. This is undertaken through Policies and Procedures (reflecting each party’s
respective responsibilities as duty holders) as responsible partners.
The ‘principal’ duties and responsibilities of the individual parties are highlighted below.
4.3 TRUST Duty Holder
The Chief Executive is the statutory Duty Holder. The Duty Holder and the Board have overall responsibility for Health and Safety within The Trust, including for Ventilation systems. They shall appoint in writing the Trust Designated Person [Ventilation].
4.4 TRUST Designated Person [Ventilation]
Is the Trusts Director of Strategic Planning & Commercial Development, who is the Appointed Board Level Executive responsible for ventilation. Under the direction of the Chief Executive they are therefore responsible for the organisational arrangements, which will ensure that compliance with standards is achieved and that where problems occur, they are identified and resolved with minimum risk to employees, patients or members of the public. They shall appoint in writing the Trust Senior Operational Manager.
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4.5 TRUST Senior Operational Manager Is the Senior Estates Manager who is appointed in writing by the Trust Designated Person. They fulfil the appointed Senior Operational Management role, under the direction of the Trust Designated Person [Ventilation] and as such, have responsibility for co-ordinating resources, ensuring the policy is reviewed, ratified and implemented. They will be responsible for notifying SFS, via Project Co, in advance of any works on ventilation systems initiated by the Trust if undertaken outside of the formal PFI schedule 22 change process. For changes on the site covered by the PFI Variation process i.e. works undertaken by Project Co the PFI variation process will cover off notification to Project Co and SFS of new systems to be added to the scheme of control. The Trust will ensure that its directly employed contractors comply with SFS’ permit procedures.
4.6 TRUST Infection Control Officer – Director Infection Prevention and
Control
The Infection Control Officer is the person nominated by the Trust to advise on monitoring the infection
control policy and microbiological performance of the ventilation systems. Major policy decisions
should be made through an Infection Prevention and Control Committee.
It is the responsibility of the Infection Control Officer to provide input for all matters relating to the
hospital environment, maintenance of hospital buildings and engineering systems and to work with
Project Co and SFS including:
• Provide education for maintenance staff and management on infection control and reduction in
HCAI’s
• Provide guidance and support when advice on controlling the environment is required
• Provide advice and help with risk assessments for controlling access to particular
environments – e.g. review of SFS/Project Co risk assessments for the control of spaces near
LEV discharges such as the Trust Category 3 laboratory
4.7 TRUST Other Professionals [i.e. Capital planning / Strategy / Projects].
Capital Project Officer/Managers will consult with the appointed external specialist with respect to ventilation and air conditioning systems and compliance as follows: All new and altered ventilation systems shall comply with the requirements of documents series HTM 03. All new and altered ventilation systems shall comply with the requirements of this policy and current regulations. The specification and the consulting engineer’s competence and interpretation of the requirements.
The contractor’s competence and their interpretation of the requirements.
The engineer’s competence and interpretation with respect to site conditions, the existing and new installation and commissioning requirements.
The Clerk of Works competence and interpretation of the requirements.
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4.8 Trust Theatre Manager/Co-Ordinator
Any maintenance activity with regards to the critical ventilation systems within the Trust will require to
be agreed with the Trust Theatre Manager/Co-Ordinator to ensure that there is minimal disruption to
Trust activities.
4.9 User
The User is the person responsible for the management of the unit in which the ventilation system is
installed (for example head of department, operating theatre manager, head of laboratory, production
pharmacist, head of research or other responsible person).
4.10 PROJECT CO [CNH] Duty Holder Project Co is not an employer and therefore does not have duties under Section 2 and 3 of the Health and Safety at Work etc. Act, the Management of Health and Safety at Work Regulations 1999 or the Control of Substances Hazardous to Health Regulations 2002. Project Co has entered into a sub-contract with SFS in respect of certain of its obligations under the PFI agreement with the Trust. SFS is an employer and has duties under the above requirements. Project Co does however have duties under Section 4 of the Health and Safety at Work etc. Act to take such steps as are reasonable to ensure so far as is reasonably practicable the premises over which it has control are safe and, as such is a "Dutyholder" for the purposes of both this policy and Section 4 of the Health and Safety at Work etc. Act in relation to those matters for which it is responsible under the PFI agreement with the Trust. They shall appoint in writing the PROJECT CO Designated Person [Ventilation].
4.11 PROJECT CO Designated Person [Ventilation] The General Manager for Project Co is the PROJECT CO Designated Person [Ventilation] they shall be appointed in writing by the PROJECT CO Duty Holder for Project Co. They shall have responsibility for compliance with this policy document.
4.12 SKANSKA FACILITIES SERVICES [SFS] Duty Holder The SFS Chief Executive is the statutory Duty Holder. The Duty Holder has overall responsibility for Health and Safety within SFS, including ventilation systems. They shall appoint in writing the SFS Designated Person [Ventilation].
4.13 SFS Designated Person [Ventilation] The General Manager for SFS is the SFS Designated Person [Ventilation] they shall be appointed in writing by the SFS Duty Holder.
Has responsibility for ensuring that suitable information, instruction and training is provided to the SFS Authorised Person/s [Ventilation] & SFS Competent Persons and formally appoint each. Ensure any risk assessments remain current and are reviewed and updated as required.
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They shall inform the TRUST, Project CO & SFS Designated Person [Ventilation] when system non compliances / deficiencies are found. They shall appoint in writing the Independent Authorising Engineer [Ventilation].
4.14 SFS Independent Authorising Engineer [Ventilation] This independent engineer (contracted by SFS to provide expert support and to control the
appointment of their AP’s) will be suitably qualified in accordance with the requirements of HTM 03
series and have specialist knowledge of the systems on each site.
The specialist acting in this role will be responsible for:
Having specialist knowledge of Ventilation and air conditioning systems in SFHFT, in particular the
systems for which an Authorised Person(s) (Ventilation) will assume responsibility on appointment.
The Authorising Engineer (Ventilation) will, subsequent to performing an assessment of a potential
Authorised Person (Ventilation), recommend to the Designated Person of the submitting
organisation either that the person is able to proceed to written appointment or requires further
training.
To ensure that all Authorised Persons (Ventilation) have satisfactorily completed an appropriate
training course and that all training is documented.
To ensure that all Authorised Persons (Ventilation) are re-assessed every three years and have
attended a refresher or other training course prior to such re-assessment.
To conduct an annual audit and review of the management systems of the Ventilation and air
conditioning systems including Permit to Work and SOP, to be submitted for review by the Trust
and its Partners in a timely manner.
Review of written procedures and operational policies as well advising on changes in technology.
To assist the Authorised Person (Ventilation), when required, with monitoring the implementation of
the Ventilation Policy and SOP’s.
The role shall be kept independent of organisations submitting potential Authorised Persons
(Ventilation) for assessment.
4.15 SFS Authorised Person [Ventilation] [AP[V]]
The AP[V] will be individuals appointed by SFS who possess adequate technical knowledge and has received appropriate training, and is appointed in writing by the Designated Person (in this case the SFS General Manager) in conjunction with the advice provided by the AE[V]]. The AP[V] is responsible
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for the practical implementation and operation of this policy and associated procedures relating to the engineering aspects of ventilation systems. The AP[V] ensures that all mechanical services are safe and available for their intended use and that the Trust complies with its statutory obligations. The Estates Officer for SFS is the SFS Authorised Person [Ventilation]. The Authorised Person[s] [Ventilation] are responsible for the practical implementation and operation of this policy and the systems and installations for which management is in control of, this includes known dangers for which the AP has been appointed to manage. More than one Authorised Person may be appointed for a system or installation but, at any one time, only one Authorised Person is required to be on duty. Each transfer of responsibility between Authorised Persons is to be recorded in the Ventilation logbook as appropriate. The Authorised Person[s] [Ventilation] must ensure that any person working on the Ventilation systems are competent to do so and that test equipment is maintained in good condition and in calibration. Where any defects, dangerous practices, dangerous and/or unusual occurrences are experienced, the Authorised Person[s] must report these to the Designated Person and Authorising Engineer in writing. They will also ensure their respective SFS Competent Persons remain current and up to date with training. The Authorised Person [Ventilation] shall issue/cancel Permits to Work and Permission for Disconnection forms as prescribed in the HTM 03 series of documents. The Authorised Person shall carry out duties as prescribed in the HTM 03 series of documents. Adequate numbers of Authorised Persons shall be available to cover for sickness or annual leave etc.
4.16 SFS Competent Person [Ventilation] [CP[V]]
Competent Persons are SFS own trades staff. They will be appointed in writing by the SFS Designated Person [Ventilation] and work under the direction of the Authorised Person [Ventilation]. They must carry out all works in accordance with this policy, HTM’s, current legislation and the PPM programme. These persons are skilled and have sufficient technical knowledge in the installation, inspection and testing and / or maintenance of ventilation and air conditioning systems. Any non-compliances they discover they shall try to rectify immediately, alerting the SFS Authorised Person [Ventilation] of the issue and actions taken. The Competent Person should use safe systems of work, safe means of access and the personal protective equipment and clothing provided for their safety.
4.17 SFS Competent Persons [External Consultants & Contractors] All external individuals who will have an impact on the ventilation and air conditioning systems will need to demonstrate and provide evidence of training appropriate to their activities. These persons are skilled and have sufficient technical knowledge in the installation, inspection and testing and / or maintenance of Ventilation and air conditioning systems. They shall be required to follow this policy and supporting reference documents. They shall immediately report any non-compliant issues to the SFS Authorised Person [Ventilation]. They shall be appointed in writing by the SFS Designated Person [Ventilation]. The Competent Person should use safe systems of work, safe means of access and the personal protective equipment and clothing provided for their safety. For further guidance please reference the Control of Contractors Policy.
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4.18 Plant Operator
The Plant Operator is any person who operates a ventilation installation.
4.19 NHS Property Services Duty Holder
The Chief Executive of NHS Property Services is the statutory Duty Holder. The Duty Holder and the Board have overall responsibility for Health and Safety within NHS Property Services, including Ventilation and air conditioning systems. They shall appoint in writing the NHS Property Services Designated Person [Ventilation].
4.20 NHS Property Services Designated Person [Ventilation] Is NHS Property Services Regional Director, who is the Appointed Board Level Executive responsible for Ventilation and air conditioning systems. Under the direction of the Chief Executive they are therefore responsible for the organisational arrangements, which will ensure that compliance with standards is achieved and that where problems occur, they are identified and resolved with minimum risk to employees, patients or members of the public. They shall appoint in writing the NHS Property Services Responsible Manager.
4.21 NHS Property Services Responsible Manager [Ventilation] The FM Support Service Manager for NHS Property Services is the NHS Property Services Responsible Manager [Ventilation] they shall be appointed in writing by the NHS Property Services Designated Person. They shall have responsibility for compliance with this policy document.
4.22 All staff
All Trust staff and staff working for the Trust’s or it’s PFI partners, together with any contractors
appointed by any party, are responsible for co-operating with the operational requirements of this
Policy.
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5. SCOPE OF POLICY
This policy seeks to both set out and define Trust’s management approach and commitment to
maintaining effective ventilation and air conditioning systems as well as providing a vehicle for the
coordination for the management of this complex site between the relevant responsible PFI parties.
This policy and the procedures outlined require the cooperation of all employees, all regular building users and contractors who also have responsibilities to ensure a safe and healthy working environment is maintained at all times.
For the purposes of this policy the Trust Estate comprises all the buildings owned or occupied under a full maintenance lease or otherwise by the Trust. This policy applies to all the properties owned or managed on behalf of Sherwood Forest Hospitals NHS Foundation Trust.
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6. CONSULTATION
Contributors: Method Timings [Dates consulted]
Hard Facilities Management Group Face to face
May 2016
Trust Health and Safety Committee; Email May 2016
Trust Risk Management Group [Non Clinical].
Email May 2016
Estates Governance Committee Email May 2016
Central Nottinghamshire Hospitals PLC Email May 2016
SFS Email May 2016
NHS Property Services Email May 2016
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7. EVIDENCE BASE A list of the information or guidance that has been used to develop the policy
Health and Safety at Work etc., Act 1974 [HASAWA]
Management of Health & Safety at Work Regulations (1992)
Workplace (Health, safety and Welfare) Regulations (1992)
The PFI Project Agreement
Heating and ventilation systems Health Technical Memorandum 03-01; specialised ventilation for healthcare premises Part A & B
Health Technical Memorandum 2025 - ‘Ventilation in healthcare premises’ where
design criteria was used.
Health and Safety Commission’s Approved Code of Practice and guidance document
‘Legionnaires’ disease; the control of Legionella bacteria in water systems’ (L8)
Health Technical Memorandum 04-01 ’The control of Legionella, hygiene, ‘safe’ hot
water, cold water and drinking water systems’
Heating and Ventilating Contractors’ Association (HVCA), SFG20.
Department of Health HTM 00 Policies and Principles of healthcare engineering
CIBSE Guidance documents
The O&M records and manufactures instructions
Regulation 9 of the COSHH Regulations
HBN 13 Sterile Services
HBN 15 Pathology Facilities
HBN 20 Mortuary
European/British requirements e.g. BS EN ISO 14644
Other ISO standards e.g. associated with CSSD
Other guidance such as HSG 258 Controlling airborne contaminants at work: A guide
to local exhaust ventilation (LEV)
Health Technical Memorandum 05-02 – ‘Guidance in support of functional provisions for healthcare premises’.
Fire Safety Policy
Control of Contractors Policy
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8. MONITORING COMPLIANCE The arrangements to monitor compliance.
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9. TRAINING REQUIREMENTS
Operation, inspection and maintenance procedures can cause risks to the health of staff carrying out
the work and those receiving air from the plant. All those involved should be trained appropriately to
fulfil the task, be aware of the risks, and must work to the agreed safe systems of work (typically
provided by SFS). This may also involve the Trust’s PFI management team receiving training in
awareness and refresher courses in relation to critical ventilation systems.
Training requirements for SFS will be regularly assessed and appropriate training undertaken and
recorded, together with the date of delivery and topics covered. Any contractors involved in the
installation, commissioning, modification or maintenance of ventilation systems shall be fully conversant
with this policy and shall be suitably qualified and trained. Tool box talks should also be provided to
technicians on a regular basis covering ventilation topics.
Suitable safety equipment should be used wherever necessary, and staff should be trained in its use.
Training in the use of safety equipment and a safe system of work will need to be repeated periodically
in order to cater for changes in staff.
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10. DISTRIBUTION
The policy will be made available by the author to the following parties:
CEO;
Trust Board Directors;
The Risk Management Group [Non clinical];
Health and Safety Committee;
Estates Governance Committee;
Executive Director of Human Resources;
Departmental Managers;
All Trust staff [via the intranet];
Project Co;
Skanska Facilities Services;
NHS Property Services
Medirest;
IPCC
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11. COMMUNICATION
This policy will be communicated via heads of Directorates and disseminated. It will also be available on the Trust intranet for all staff to review.
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12. AUTHOR AND REVIEW DETAILS
Issue/ Version: 1
Date issued: 26-10-2016
Date to be reviewed by:
May 2019
To be reviewed by: Head of Estates & Facilities / Ben Widdowson
Executive Sponsor: Director of Strategic Planning & Commercial Development
Supersedes: None.
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13. APPENDICES
Appendix 1 – Organogram’ – Management and Lines of Communication. Appendix 2 – Environmental Impact Assessment Form.
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Appendix 1 – Organogram’ – Management and Lines of Communication
Trust Project Co S.F.S.
Duty Holder
C.E.O.
Duty Holder
See Roles and Responsibilities
.
Duty Holder
C.E.O.
Designated Person.
Director of Strategic
Planning & Commercial
Development
Trust Senior Operational
Manager
Senior Estates Manager
Designated Person
General Manager
Designated Person
General Manager
Authorised Person (Vent)
Estates Officer
Independent Authorising Engineer
Competent Persons (Vent)
Internal/External
NHS Property Services
Duty Holder
C.E.O.
Designated Person
Regional Director
Responsible Manager
FM Service
Support Manager
Infection Control Officer
Infection
Control Officer
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Appendix 2 – Environmental Impact Assessment Form. Environmental Impact Assessment The purpose of an environmental impact assessment is to identify the environmental impact of policies, assess the significance of the consequences and, if required, reduce and mitigate the effect by either, a) amend the policy b) implement mitigating actions.
Area of impact
Environmental Risk/Impacts to consider
Action Taken (where necessary)
Waste and materials
Is the policy encouraging using more materials/supplies? No
Is the policy likely to increase the waste produced? No
Does the policy fail to utilise opportunities for introduction/replacement of materials that can be recycled? No
Not applicable
Soil/Land Is the policy likely to promote the use of substances dangerous to the land if released (e.g. lubricants, liquid chemicals) No
Does the policy fail to consider the need to provide adequate containment for these substances? (for example bunded containers, etc.) No
Not applicable
Water Is the policy likely to result in an increase of water usage? (estimate quantities) No
Is the policy likely to result in water being polluted? (e.g. dangerous chemicals being introduced in the water) No
Does the policy fail to include a mitigating procedure? (e.g. modify procedure to prevent water from being polluted; polluted water containment for adequate disposal) No
Not applicable
Air Is the policy likely to result in the introduction of procedures and equipment with resulting emissions to air? (For example use of a furnaces; combustion of fuels, emission or particles to the atmosphere, etc.) No
Does the policy fail to include a procedure to mitigate the effects? No
Does the policy fail to require compliance with the limits of emission
Not applicable
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imposed by the relevant regulations? No
Energy Does the policy result in an increase in energy consumption levels in the Trust? (estimate quantities) No
Not applicable
Nuisances Would the policy result in the creation of nuisances such as noise or odour (for staff, patients, visitors, neighbours and other relevant stakeholders)? No
