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CS/H&S/003 
CAMPUS SERVICES 
Safety Manual 
August 2012
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
Date 
Issue 
Author 
Reviewed 
Approved 
Issue ...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
1.0 INTRODUCTION 
1.1 The University of Exeter ...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
2.0 BSI GUIDANCE 
Design the OHSAS 18001 Manage...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
3.0 INTEGRATED MANAGEMENT 
Campus Services achi...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
Risk Profiles will be established and maintaine...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
Risk Assessments may need to be updated accordi...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
A competence matrix will be established and a p...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
Refer to Campus Services H&S policy CS/H&S/001....
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
Campus Services H&S Documents will be managed b...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
6.2 Plant and equipment 
All plant and equipmen...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
Appendix C sets out University procedures and t...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
MAJOR ACCIDENTS 
IMMEDIATE ACTION Determine con...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
The University basic emergency procedures are i...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
Campus Service H&S Adviser will monitor with th...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
Campus Services Residential Services comply wit...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
See Campus Services H&S Policy CS/H&S/001; Sect...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
—— failure to carry out communications; 
b) for...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
Audit templates will be set up and a programme ...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
Management Review is detailed in Campus Service...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
APPENDIX A - HAZARDS AND RISKS 
A.1 A risk prof...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
A.3 Each service will summarise the status of t...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
APPENDIX B – ROLES AND RESPONSIBILITIES:- 
Comp...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
Fire Risk Assessment 
Annual review 
Estate Dev...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
Roof work 
Management 
Estate Development Servi...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
APPENDIX C - PROCEDURES 
6.7 Procedures 
Existi...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
First Aid 
H&S Office 
Dogs in University Build...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
Campus Services Procedure Ref. Issue 
Managing ...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
Noise at Work - Guidance 
CSP026 
Aug.12 
Insur...
University of Exeter Safety Manual 
Campus Services CS/H&S/Doc003 Issue A 
Insurance Works Notification 
CSP027 
Aug.12 
I...
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  1. 1. CS/H&S/003 CAMPUS SERVICES Safety Manual August 2012
  2. 2. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A Date Issue Author Reviewed Approved Issue 17/05/12 Draft SWJones Aug 12 Issue SW Jones M.Williams WK Courtney A CONTENTS PAGE NUMBER 1.0 INTRODUCTION 1 2.0 BSI GUIDANCE 2 3.0 INTEGRATED MANAGEMENT 3 4.0 H&S ARRANGEMENTS 3 APPENDICES A Hazards and Risks B Roles and Responsibilities C Procedures
  3. 3. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A 1.0 INTRODUCTION 1.1 The University of Exeter (UoE) has 2 main campuses in Exeter at Streatham and St Lukes, plus various other properties within the city of Exeter. 1.2 Campus Services(CS) is a large and diverse organisation of approximately 750 staff within the University of Exeter operating under the Universities Health and Safety Policies and procedures – see website link for details: http://www.exeter.ac.uk/staff/wellbeing/safety 1.3 Campus Services scope of services is diverse and includes functions such as catering, administration, maintenance, portering, utilities specialists, estate management and construction. 1.4 The university is supported by a H&S Office providing advice to all aspects of university function, with additional specialist advice available within Campus Services on construction health and safety. 1.5 This document assesses all aspects of H&S management within Campus Services and aims to set out an effective and efficient system of management and reporting in line with OHSAS 18001:2007. This needs to be proportionate to the risk, while ensuring we have a competent and confident workforce. 1.6 A Campus Services H&S Policy document exists (incorporating the H&S Policy Statement) – CS/H&S/ 001. 1.7 A Campus Services OHSAS 18001 Management Plan (CS/H&S/ 002) exists illustrating how compliance is to be achieved. This also incorporates the programme for compliance and improvement.
  4. 4. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A 2.0 BSI GUIDANCE Design the OHSAS 18001 Management System The OHSAS 18001 Specification follows the Plan-Do-Check-Review cycle, with a concurrent emphasis on continual improvement. This model fits in neatly with the structure of other management system documents such as ISO 14001. This alignment of the management system documents helps in the facilitation of Integrated Management Systems. The following steps help form the basic structure of the management system and link into the structure of OHSAS 18001. Plan During the planning stage you should: 1. Ensure you have the commitment of top management. 2. Define, with the authorization of top management, the company's occupational health and safety policy. 3. Planning must be completed to establish a framework for identifying hazards, the assessment of risks and the implementation of necessary control measures. 4. Legal obligations must be identified and understood, objectives set and a management programme for achieving them implemented. This entire process should be documented. Implement your Health and Safety Management System At this point you should: 1. Establish roles and responsibilities. 2. Develop procedures for the consultation and communication of OHS information to employees and other interested parties. 3. Document your processes and develop a system of document and data control. 4. Apply a system of operational control. 5. Establish plans and procedures for emergencies. Check your management system and take any necessary corrective action You should aim to continually improve your management system by: 1. Introducing performance, measuring and monitoring practices. 2. Establishing and documenting responsibility and authority for accidents, incidents, non-conformities and corrective & preventative action. 3. Establishing a procedure for records and records management. 4. Auditing and assessing the performance of the management system. 5. Performing management reviews of the system at identified and defined intervals.
  5. 5. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A 3.0 INTEGRATED MANAGEMENT Campus Services achieved accreditation to ISO 14001: 2008 in May 2012. Within Campus Services, Estate Development Service have had accreditation to ISO 9001:2008 since 2010. Campus Services as part of UoE Professional Services hold accreditation to Investors in People (IiP). Campus Services also hold accreditation to Customer First, a recognised accreditation for the customer services industry. Campus Services Residential Services comply with the Universities UK (UUK) Student Housing Code of Practice and are audited against this standard. As part of corporate governance the University employ Mazars as independent auditors who audit various aspects of Campus Services operations. Campus Services aims to set out an effective and efficient system of management and reporting in line with OHSAS 18001:2007. 4.0 H&S ARRANGEMENTS The numbering system from the OHSAS 18001 standard has been used in this section for ease of reference. Risk Profiles will be developed for each of the services within Campus Services from the outlines included within the Campus Services H&S Policy CS/H&S/001. 4.3.1 Hazard and risk identification Requirement: Identification of hazards Determination of the risks associated with the identified hazards Indication of the level of the risks related to each hazard, and whether they are, or are not, tolerable Description of, or reference to, the measures to monitor and control the risks, particularly risks that are not tolerable Where appropriate, the OH&S objectives and actions to reduce identified risks and any follow-up activities to monitor progress in their reduction Identification of the competency and training requirements to implement the control measures Necessary control measures should be detailed as part of the operational control element of the system Records generated by each of the above mentioned procedures
  6. 6. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A Risk Profiles will be established and maintained at least annually for each of the CS divisions. A risk assessment will be established and maintained at least annually for each building where CS staff act as the Director of Building. Where there is sufficient commonality a generic assessment may be used. Within buildings it may be necessary to establish a particular risk assessment for a functional area e.g. a kitchen or workshop. Assessments of plant and equipment use and material/substance handling will generate Task risk assessments used to brief operation staff. Task assessments will be developed for specific tasks as required. See Appendix A and the following documents for more detail. Campus Services – Risk Profile Register CS/H&S/004 Campus Services – Building / Functional Area RA Register CS/H&S/005 Campus Services – Task RA Register CS/H&S/006 Campus Services – Fire RA Register CS/H&S/007 Campus Services – COSHH RA Register CS/H&S/008 Each of the above will be reviewed at least annually or when any change occurs. Staff will be briefed and a record kept – see 4.5.3 below. Competency and training is defined in 4.4.2 within this document. Ongoing review of legislation changes planned and implemented will be considered, and information disseminated to staff by use of bulletins or briefings. 4.3.2 Legal compliance Requirement: Procedures for identifying and accessing information Identification of which requirements apply and where [this can take the form of register(s)] Requirements (actual text, summary or analysis, where appropriate), available in locations which are to be decided by the organization Procedures for monitoring the implementation of controls consequent to new OH&S legislation.
  7. 7. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A Risk Assessments may need to be updated accordingly – see 4.3.1 above. HSE will be used as the main source but University safety professionals share information via the Hasnet e-mail group so are able to assess and assist with legislation and other changes. Refer to CS 18001 Management Plan CS/H&S/002 which demonstrates how compliance is achieved. Refer to Campus Services H&S Policy CS/H&S/001 which includes list of all nominated parties and current duty holders. Appendix B also includes responsible Services / parties for various statutory compliance and hazard management categories. 4.3.4 OH&S Programme Requirement - The organisation shall establish and maintain (an) OH&S programme(s) for achieving its objectives. It shall include documentation of : designation of responsibility and authority for achievement of the objectives at relevant functions and levels of the organisations; and the means and time-frame by which they are to be achieved 4.4.1 Resources, roles, responsibilities, accountability and authority Requirement: Definitions of OH&S responsibilities and authorities for all relevant personnel Documentation of roles/responsibilities in manuals/procedures/training packages Process for communicating roles and responsibilities to all employees and other relevant parties Active management participation and support for OH&S, at all levels. 4.3.3 Objectives and Programme(s) Requirement - Documented, measurable, OH&S objectives for each function in the organization. Examples of types of OH&S objectives include: Reduction of risk levels The introduction of additional features into the OH&S management system The steps taken to improve existing features, or the consistency of their application The elimination or the reduction in frequency of particular undesired incident(s).
  8. 8. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A A competence matrix will be established and a programme of training undertaken to meet the level required where there are shortfalls. The staff Personal Development Review (PDR) process will be used to set training requirements. This is an annual review with a 6 monthly update. New staff are provided by UoE with basic H&S courses. Campus Services staff have their own general induction. CS staff will then receive a building induction and specific training appropriate to task. Records will be maintained by UoE Training and Development – see also staff online resource. Records of building / work area and task induction will be held by line management, based on risk assessment findings. Line management should advise the CS H&S Adviser where any changes have occurred to allow risk assessments to be updated. Refresher training should be provided annually where deemed necessary ie non-regular activity, or more frequently in response to the introduction of a new hazard or non-conformance issue. Refer to Campus Services H&S Policy CS/H&S/001 for consultation. 4.4.3.1 Communication With regard to its OH&S hazards and OH&S management system, the organization shall establish, implement and maintain a procedure(s) for: a) internal communication among the various levels and functions of the organization; b) communication with contractors and other visitors to the workplace; c) receiving, documenting and responding to relevant communications from external interested parties. 4.4.2 Competence, training and awareness Requirement: Competency requirements for individual roles Analysis of training needs Training programmes/plans for individual employees Range of training courses/products available for use within the organization Training records and records of evaluation of the effectiveness of training.
  9. 9. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A Refer to Campus Services H&S policy CS/H&S/001. Campus Services H&S Management system main documents are :- Campus Services H&S Policy CS/H&S/001 CS 18001 Management plan CS/H&S/002 CS Safety Manual CS/H&S/003 (this document) The Safety Manual includes or references all procedures and work instructions. Individual services within Campus Services have safety procedures / manuals specific to their activities. The Safety Manual provides the link to theses various other documents. 4.4.3.2 Participation and consultation The organization shall establish, implement and maintain a procedure(s) for: a) the participation of workers by their : —— appropriate involvement in hazard identification, risk assessments and determination of controls; —— appropriate involvement in incident investigation; —— involvement in the development and review of OH&S policies and objectives; —— consultation where there are any changes that affect their OH&S; —— representation on OH&S matters. Workers shall be informed about their participation arrangements, including who is their representative(s) on OH&S matters. b) consultation with contractors where there are changes that affect their OH&S. The organization shall ensure that, when appropriate, relevant external interested parties are consulted about pertinent OH&S matters. 4.4.4 Documentation Requirement: OH&S management system documentation overview document or manual Document registers, master lists or indexes Procedures Work instructions. 4.4.5 Control of Documents Requirement: Document control procedure, including assigned responsibilities and authorities Document registers, master lists or indexes List of controlled documentation and its location Archive records (some of which can need to be held in accordance with legal or other time requirements).
  10. 10. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A Campus Services H&S Documents will be managed by the H&S adviser under the Estate Development Service ISO 9001:2008 Quality Management System. The main documents are listed below: Campus Services H&S Policy CS/H&S/001 Campus Services OHSAS 18001 Management Plan CS/H&S/002 Campus Services Health & Safety Manual CS/H&S/003 Campus Services – Risk Profile Register CS/H&S/004 Campus Services – Building/ Functional Area RA Register CS/H&S/005 Campus Services – Task RA Register CS/H&S/006 Campus Services – Fire RA Register CS/H&S/007 Campus Services – COSHH RA Register CS/H&S/008 University Documents Campus Services will comply with the following University documented management arrangements. The Management of Asbestos – Policy, Responsibilities and Procedures Managed by EDS Asbestos Management Plan Managed by EDS Legionella & Water Quality Management Plan Managed by EDS University of Exeter Safety case – Gas Engineering Managed by EDS Contractors’ General Code of Safe Practice Managed by EDS Confined Spaces Management Plan Managed by EDS
  11. 11. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A 6.2 Plant and equipment All plant and equipment that requires maintenance will be identified, that the maintenance done and that new or secondhand plant and equipment meets health and safety standards before we buy it. Service Managers will be responsible for identifying all equipment/plant needing maintenance, and will be responsible for ensuring effective maintenance procedures are drawn up and implemented. Staff will report any problems found with plant/equipment to Service Managers initially. Service Managers will check that new plant and equipment meets health and safety standards before it is purchased. Procedures will be put in place to ensure compliance, and suitable records maintained. Refer to Appendix C for specific procedures. 6.3 Safe handling and use of substances The University has in place the following:- COSHH Policy including Code of Practice and Guidance Notes & RA Forms Radiation and Radionuclide’s Code of Practice and Guidance Notes The Management of Asbestos; Policy, Responsibilities and Procedures Legionella & Water Quality Management Plan University of Exeter Safety Case Gas Engineering We will monitor compliance to these guides. There are a number of specialists within Campus Services and contributions to safety reports will be provided by them. Refer to Appendix B for Roles and Responsibilities relating to statutory compliance. H&S Coordinators will be responsible for identifying all substances which need a COSHH assessment, and carry out the assessment with assistance by the H&S Adviser or H&S Office as appropriate. H&S Coordinators be responsible for ensuring that all relevant employees are informed about the COSHH assessments and monitor their use and the introduction of any new substances/ products. Assessments will be reviewed every year or when the work activity changes, whichever is soonest.
  12. 12. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A Appendix C sets out University procedures and those established for Campus Services. Individual Services will develop their own safety procedures for other aspects of their operations specific to that service eg Swimming Pool Safety. 4.4.6 Operational Control Requirement: Procedures Work instructions. Examples of areas in which OH&S risks typically arise, and examples of their associated control measures, include: a) general control measures including —— regular maintenance and repair of facilities, machinery and equipment to prevent unsafe conditions from developing, —— housekeeping and maintenance of clear walkways, —— training and awareness programmes relating to the use of particular controls (e.g. permit-to-work systems), —— access controls; b) performance of hazardous tasks c) use of hazardous materials including —— knowledge in the use of and availability of emergency equipment (4.4.7); d) facilities and equipment e) purchase of goods, equipment and services f) contractors g) other external personnel or visitors in the workplace. 4.4.7 Emergency Preparedness and Response Requirement: Documented emergency plans and procedures Emergency equipment list Test records for emergency equipment Records of the following: Practice drills Reviews of practice drills Recommended actions arising from the reviews Progress against the achievement of recommended actions.
  13. 13. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A MAJOR ACCIDENTS IMMEDIATE ACTION Determine continuing danger and extent of injury If necessary, evacuate area, Summon help & ensure that the following are contacted: the EMERGENCY SERVICES (999 or 112 from any phone) a FIRST AIDER (where available) the SECURITY STAFF (01392 263999 or Ext 3999) If safe to do so, ensure that the injured are accompanied until help arrives AS SOON AS POSSIBLE University staff must ensure that the following are informed: the HEALTH & SAFETY OFFICE (Ext 5340) the HEAD OF SCHOOL / DIRECTOR OF BUILDING the SCHOOL or SERVICE SAFETY OFFICER a TRADE UNION HEALTH AND SAFETY REPRESENTATIVE PERSONNEL & STAFF DEVELOPMENT (3120) Also ensure that the accident details are recorded on a UNIVERSITY ACCIDENT / NEAR MISS REPORT FORM & sent to the Health & Safety Office. MINOR ACCIDENTS IMMEDIATE ACTION Determine continuing danger and extent of injury Summon help & ensure that: a FIRST AIDER (where available) is contacted the injured are accompanied until help arrives AS SOON AS POSSIBLE University staff must ensure that: the accident details are recorded on a University Accident / Near Miss Report Form & sent to the Health & Safety Office.
  14. 14. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A The University basic emergency procedures are included above. See Campus Services H&S Policy CS/H&S/001 for more details. For records of fire drills, call outs etc reference will be made to the UoE Fire Officer in the H&S Office. A workplace compliance checklist has been developed and each Campus Service building will be assessed annually or when there is any significant change of use or function. Property Services will maintain records of all plant and equipment inspections, maintenance and calibration – see Appendix B. Other services will maintain such records where they are directly responsible for specialist equipment. Accident, incident and near miss records will be maintained by the H&S Office and be available for review and analysis by Campus Services. Safety inspection records will be maintained by Service Managers. Wherever possible benchmarking of performance shall take place. All monitoring records shall be available for review and analysis at Management Reviews. 4.5.1 Performance Measurement and Monitoring Requirement: Procedure(s) for monitoring and measuring Inspection schedules and checklists "critical" equipment lists Equipment inspection checklists Workplace conditions standards and inspection checklists Measuring equipment lists Measurement procedures Calibration scheme, and calibration records Maintenance activities and results Completed checklists, inspection reports (OH&S management system audit) Non-conformance reports Evidence of the results of implementing such procedure(s).
  15. 15. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A Campus Service H&S Adviser will monitor with the assistance of specialists within Campus Services that Legal compliance is maintained – see Appendix B for Roles and Responsibilities – Statutory Compliance. UoE H&S Office carry out audits of specific services and will monitor an independent overview of compliance. Campus Services achieved accreditation to ISO 14001: 2008 in May 2012. Within Campus Services, Estate Development Service have had accreditation to ISO 9001:2008 since 2010. Campus Services as part of UoE Professional Services hold accreditation to Investors in People (IiP). Campus Services also hold accreditation to Customer First, a recognised accreditation for the customer services industry. 4.5.2 Evaluation of compliance 4.5.2.1 Consistent with its commitment to compliance [see 4.2c)], the organization shall establish, implement and maintain a procedure(s) for periodically evaluating compliance with applicable legal requirements (see 4.3.2). The organization shall keep records of the results of the periodic evaluations. NOTE The frequency of periodic evaluation may vary for differing legal requirements. 4.5.2.2 The organization shall evaluate compliance with other requirements to which it subscribes (see 4.3.2). The organization may wish to combine this evaluation with the evaluation of legal compliance referred to in 4.5.2.1 or to establish a separate procedure(s). The organization shall keep records of the results of the periodic evaluations. Evaluation of the organization’s compliance should be performed by competent persons, either from within the organization and/or using external resources. A variety of inputs can be used to assess compliance, including: —— audits, —— the results of regulatory inspections, —— analysis of legal and other requirements, —— reviews of documents and/or records of incidents and risk assessments, —— interviews, —— facility, equipment and area inspections, —— project or work reviews, —— analysis of test results from monitoring and testing, —— facility tours and/or direct observations. A compliance evaluation programme can be integrated with other assessment activities. These can include management system audits, environmental audits or quality assurance checks.
  16. 16. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A Campus Services Residential Services comply with the Universities UK (UUK) Student Housing Code of Practice and are audited against this standard. As part of corporate governance the University employ Mazars as independent auditors who audit various aspects of Campus Services operations. Campus Services will aim to comply with the requirements of OHSAS 18001:2007 and this will be subject to independent audit. H&S Objectives and targets are incorporated in the CS 18001 Management plan CS/H&S/002. 4.5.3 Incident investigation, nonconformity, corrective action and preventive action The Campus Services H&S Action Plan will compile actions and opportunities for improvement derived from various sources such as inspections, audits, reviews and suggestions – this will be kept up to date and be reviewed at quarterly Management Reviews. Outcomes of investigations will be reported to management at monthly meetings or sooner if urgent action is required. 4.5.3.1 Incident investigation The organization shall establish, implement and maintain a procedure(s) to record, investigate and analyse incidents in order to: a) determine underlying OH&S deficiencies and other factors that might be causing or contributing to the occurrence of incidents; b) identify the need for corrective action; c) identify opportunities for preventive action; d) identify opportunities for continual improvement; e) communicate the results of such investigations. The investigations shall be performed in a timely manner. Any identified need for corrective action or opportunities for preventive action shall be dealt with in accordance with the relevant parts of 4.5.3.2. The results of incident investigations shall be documented and maintained. Incident investigation is an important tool for preventing reoccurrence
  17. 17. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A See Campus Services H&S Policy CS/H&S/001; Section 8 - Monitoring. The Campus Services H&S Action Plan will compile actions and opportunities for improvement – this will be kept up to date and be reviewed at Management Reviews. H&S Group meetings – a report will be submitted with a summary for review. OHSAS 18001 Text Examples of issues that can give rise to nonconformities include: a) for OH&S management system performance —— failure of top management to demonstrate commitment, —— failure to establish OH&S objectives, —— failure to define responsibilities required by an OH&S management system, such as responsibilities for achieving objectives, —— failure to periodically evaluate compliance with legal requirements, —— failure to meet training needs, —— documentation being out of date or being inappropriate, 4.5.3.2 Nonconformity, corrective action and preventive action The organization shall establish, implement and maintain a procedure(s) for dealing with actual and potential nonconformity(ies) and for taking corrective action and preventive action. The procedure(s) shall define requirements for: a) identifying and correcting nonconformity(ies) and taking action(s) to mitigate their OH&S consequences; b) investigating nonconformity(ies), determining their cause(s) and taking actions in order to avoid their recurrence; c) evaluating the need for action(s) to prevent nonconformity(ies) and implementing appropriate actions designed to avoid their occurrence; d) recording and communicating the results of corrective action(s) and preventive action(s) taken; and e) reviewing the effectiveness of corrective action(s) and preventive action(s) taken. Where the corrective action and preventive action identifies new or changed hazards or the need for new or changed controls, the procedure shall require that the proposed actions shall be taken through a risk assessment prior to implementation. Any corrective action or preventive action taken to eliminate the causes of actual and potential nonconformity(ies) shall be appropriate to the magnitude of problems and commensurate with the OH&S risk(s) encountered. The organization shall ensure that any necessary changes arising from corrective action and preventive action are made to the OH&S management system documentation.
  18. 18. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A —— failure to carry out communications; b) for OH&S performance —— failure to implement the planned programme to achieve improvement objectives, —— consistent failure to achieve performance improvement objectives, —— failure to meet legal or other requirements, —— failure to record incidents, —— failure to implement corrective action in a timely manner, —— consistent high rates of illness or injury that are not being addressed, —— deviations from OH&S procedures, —— introduction of new materials or processes without appropriate risk assessments being conducted. Inputs into corrective action and preventive action can be determined from the results of: —— periodic tests of emergency procedures, —— incident investigations, —— internal or external audits, —— the periodic evaluations of compliance, —— performance monitoring, —— maintenance activities, —— employee suggestion schemes and feedback from employee opinion/satisfaction surveys, —— exposure assessments. Records will be managed under the EDS quality management system. 4.5.4 Control of Records Requirement: Procedure (for the identification, maintenance and disposition of OH&S records) Adequately stored and readily retrievable OH&S records. The organization shall establish and maintain records as necessary to demonstrate conformity to the requirements of its OH&S management system and of this OHSAS Standard, and the results achieved. The organization shall establish, implement and maintain a procedure(s) for the identification, storage, protection, retrieval, retention and disposal of records. Records shall be and remain legible, identifiable and traceable. Archive durations will be defined – and archiving will follow UoE procedures?
  19. 19. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A Audit templates will be set up and a programme established. Records of findings and follow up actions will be established. Trends will be monitored. The EDS templates for Audit Plan and Register will be used. The H&S Office also carry out Audits and these will be logged and managed as part of the Campus Services compliance process. OHSAS 18001 text The organization shall ensure that internal audits of the OH&S management system are conducted at planned intervals to: a) determine whether the OH&S management system: 1) conforms to planned arrangements for OH&S management including the requirements of this OHSAS Standard; and 2) has been properly implemented and is maintained; and 3) is effective in meeting the organization’s policy and objectives; b) provide information on the results of audits to management. Audit programme(s) shall be planned, established, implemented and maintained by the organization, based on the results of risk assessments of the organization’s activities, and the results of previous audits. Audit procedure(s) shall be established, implemented and maintained that address: the responsibilities, competencies, and a) requirements for planning and conducting audits, reporting results and retaining associated records; and b) the determination of audit criteria, scope, frequency and methods. Selection of auditors and conduct of audits shall ensure objectivity and the impartiality of the audit process. 4.5.5 Internal Audit Requirement: OH&S management system audit plan/program OH&S management system audit procedures OH&S management system audit reports, including non-conformance reports Recommendations and corrective action requests Signed-off/closed-out non-conformance reports Evidence of the reporting of the results of OH&S management system audits to management
  20. 20. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A Management Review is detailed in Campus Services H&S Policy CS/H&S/001, Section 8 – Monitoring. 4.6 Management Review Requirement: Minutes of the review Revisions to the OH&S policy and OH&S objectives Specific corrective actions for individual managers, with target dates for completion Specific improvement actions, with assigned responsibilities and target dates for completion Date for review of corrective action Areas of emphasis to be reflected in the planning of future internal OH&S management system audits.
  21. 21. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A APPENDIX A - HAZARDS AND RISKS A.1 A risk profile for each division will be established. Hazards associated with the work activities will be identified and risks assess and reported to the head of division. Head of division shall be responsible for ensuring the action required is implemented and will check that the implemented actions have removed/reduced the risks. Assessments will be reviewed at least annually or when a work activity changes, whichever is soonest. A summary of risk assessments including revision and date will be reported to the H&S adviser for monitoring purposes. A.2 The overall risk profile is set out here:- WORK ACTIVITY: Management of University of Exeter activities and facilities to ensure the safety of all staff, students, visitors, and contractors. BRIEF DESCRIPTION: Higher Education establishment with main Streatham campus in Exeter, St Lukes campus in Exeter, various halls of residence on campus and across Exeter, plus teaching facilities at Thornlea in Exeter. Activities of the divisions within Campus Service are outlined below:- Operations – including Property Services (building and facility maintenance and works), Residential Services (UoE and partners), Retail Services (catering, shops, functions, family centre and print services), Sales and Events (including Reed Hall), Security, Facilities Management (including cleaning, portering, transport and waste management), and Customer Services (including Helpdesk and stores). Sport and Student Activities – including Sports park management at Streatham and St Lukes and within Exeter (including swimming pools), and Music. Estate Development Service – responsible for capital and minor works projects, furniture procurement, space planning, energy management and sustainability. Legal and Insurance services – office staff including Business Continuity team. Business support – includes office staff involved in training and quality. Grounds – including a workforce, machinery and tree climbing/felling. ESTIMATED No OF EMPLOYEES AT RISK: Approx. 750 ESTIMATED No OF NON EMPLOYEES AT RISK: Typically 15-20,000
  22. 22. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A A.3 Each service will summarise the status of their risk assessments as follows:- CAMPUS SERVICES Hazard and Risk Assessment Register Division: Ref Title Author Rev. Date Teaching Space Office Space Circulation spaces/areas Catering Cleaners stores Above are examples of model assessments The aim will be to rationalise assessments to ensure commonality of approach. This will assist if staff movement occurs within Campus Services, and help ensure best practice and lessons learnt are incorporated and disseminated to all. The headings included are examples of model assessments that can be used by Services. A.4 A UoE template hazard and risk assessment template has been in use in each division for some time. The following UoE forms are available from :- http://www.exeter.ac.uk/staff/wellbeing/safety/formssignsandtemplates/ Hazard and Risk Assessment Template Manual handling assessment form DSE assessment form Children, young persons (or vulnerable adults) – RA form Also available on the website is guidance on how to complete assessments. http://www.exeter.ac.uk/media/universityofexeter/humanresources/documents/healthsafety/ManageOfHealthSafetyAtWorkGuideNotes.pdf normal working hours
  23. 23. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A APPENDIX B – ROLES AND RESPONSIBILITIES:- Compliance Management including Statutory compliance Item Aspect Responsibility Dutyholder Air conditioning plant Testing Property Services Compliance Manager Air handling plant Inspection Property Services Compliance Manager Performance Property Services Compliance Manager Fan cleaning Property Services Compliance Manager Filter change Property Services Compliance Manager Asbestos Management Estate Development Service Asbestos Manager Bio-hazards All H&S Office Building Management Systems Management Estate Development Service Head of Engineering BSL 3 lab ventilation equipment Testing Property Services Compliance Manager Maintenance Property Services Compliance Manager Cleaning Property Services Compliance Manager Catering equipment Testing Property Services Compliance Manager Maintenance Property Services Compliance Manager Cleaning Property Services Compliance Manager Confined Spaces Management Estate Development Service H&S adviser Commercial fridges and freezers Testing Property Services Compliance Manager Maintenance Property Services Compliance Manager Compressed gases Testing Property Services Compliance Manager COSHH Management All H&S Coordinators Emergency lights Testing Property Services Compliance Manager Emergency procedures – Fire Drills H&S Office Emergency procedures - other Management and Testing Insurance and Business Continuity Business Continuity Manager Fire alarms Testing Property Services Compliance Manager Fire extinguishers Supply and testing Property Services Compliance Manager Fire extinguishing systems Management Property Services Compliance Manager Fire Doors Inspection Property Services Compliance Manager Maintenance Property Services Compliance Manager Fire door frame fire stopping Management Estate Development Head of Building
  24. 24. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A Fire Risk Assessment Annual review Estate Development Service H&S adviser Fixed wiring Testing Property Services Compliance Manager Fume cupboards Testing Property Services Compliance Manager Gas Network Management Estate Development Service Gas Safety Engineer via Head of Engineering Gas installations Inspections Property Services Compliance Manager Generators Testing Property Services Compliance Manager Maintenance Property Services Compliance Manager Fuelling Property Services Compliance Manager Grounds maintenance equipment Maintenance HV Network Management Estate Development Service Authorised Electrical Engineer via Head of Engineering Insurance inspections Inspections Property Services on behalf of insurance office Compliance manager Lasers H&S Office Legionella Testing Property Services Compliance Manager Lightening protection Testing Property Services Compliance Manager Lifts Testing Property Services Compliance Manager Maintenance Property Services Compliance Manager Alarms Property Services Compliance Manager Mansafe systems - fixed Testing Property Services Compliance Manager Mansafe systems – harnesses (incl Grounds equipment) Management PAT testing Organising Property Services Compliance Manager Pest control Management Property Services Compliance Manager Plant and Equipment (other) Purchasing Maintenance Pressure vessels Property Services Compliance Manager Radiation H&S Office Roof work Management Property Services Assistant Managers
  25. 25. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A Roof work Management Estate Development Service Construction H&S Officer Security - CCTV Management Estate Patrol Head Security – Door access Management Property Services Manager Temporary Works Management Estate Development Service Construction H&S Officer Water features Management Property Services Assistant Managers Workplace assessments Management incl annual review All Director of Building
  26. 26. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A APPENDIX C - PROCEDURES 6.7 Procedures Existing procedures such as those of Property Services and UoE Guides etc need to be incorporated into a Campus Services management arrangements (Safety Manual), again sharing best practice where appropriate. University Policy Statements, Guidance Notes and Codes of Practice Campus Services will comply with the University Policy Statements, Codes of Practice and Guidance Notes on individual health and safety issues. Some of these are listed below. Campus Services procedures are also listed. For a full guide refer to all procedures relevant to Campus Services see CS H&S Procedures A-Z below. University Procedure General Risk Assessment H&S Office Smoking H&S Office Portable Electrical Appliance Inspection and Testing H&S Office Driving vehicles on University Business H&S Office - Minibus Passenger Transport Vehicles - The staff use of private vehicles on University of Exeter Business H&S Policy and Management H&S Office Fire Safety H&S Office COSHH Policy including Code of Practice and Guidance Notes & RA Forms H&S Office Working with Display Screen Equipment H&S Office Manual Handling H&S Office Radiation Safety - Radiation and Radionuclide’s Code of Practice and Guidance Notes H&S Office Meningitis H&S Office Children, Young People and Vulnerable Adults on Campus H&S Office Safety in Fieldwork H&S Office
  27. 27. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A First Aid H&S Office Dogs in University Buildings H&S Office Staff Counselling Occ. Health Workplace assessment Occ. Health Staff assessment – pre-employment and during Occ. Health Health Surveillance Occ. Health Alcohol abuse: Policy and Guidelines HR Bullying and Harassment HR Disability Policy statement HR Drug Abuse: Policy and Guidelines HR Fit Notes: Guidance for managers HR Homeworking HR Induction Code of Practice HR Learning and Development Policy HR Mental Health: Guidance HR Stress: staff guidelines HR Substance abuse: Policy and Guidelines HR Whistleblowing – see Public Interest disclosure policy HR
  28. 28. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A Campus Services Procedure Ref. Issue Managing the Workplace CSP001 Aug.12 General Hazards and Controls CSP002 Aug.12 Health and Safety Training CSP003 Aug.12 Contractor Performance Monitoring CSP004 Aug.12 Out of Hours Emergency Callout (plus Appendices A to E) CSP005 Aug.12 CDM Clients Representatives Guidance CSP006 Aug.12 CDM Management Arrangements CSP007 Aug.12 Reporting of Incidents (RIDDOR) CSP008 Aug.12 Investigating Accidents & Incidents CSP009 Aug.12 HV Systems – refer to HTM 2021 available via the Principal Electrical Engineer, Lafrowda House CSP010 Aug.12 LV Electrical Safety Rules CSP011 Aug.12 Hot work CSP012 Aug.12 Confined Space Working CSP013 Aug.12 Noise and Vibration in the Workplace CSP014 Aug.12 Personal Protective Equipment Use and Storage CSP015 Aug.12 Provision and Use of Work Equipment CSP016 Aug.12 Lifting Equipment and Lifting Operations CSP017 Aug.12 Safe Use of Machinery CSP018 Aug.12 Transport Safety CSP019 Aug.12 Lone Working CSP020 Aug.12 Working at Height CSP021 Aug.12 Working on the Grounds CSP022 Aug.12 Working in University Laboratories CSP023 Aug.12 Estate Statutory Compliance CSP024 Aug.12 Fire Risk Assessment CSP025 Aug.12
  29. 29. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A Noise at Work - Guidance CSP026 Aug.12 Insurance Works Notification CSP027 Aug.12 Health & Safety Procedures (combined list) Alcohol abuse: Policy and Guidelines HR Asbestos Management Plan EDS doc Asbestos - The Management of Asbestos – Policy, Responsibilities and Procedures CS website A-Z Bullying and Harassment HR Business Continuity Plan Confidential CDM Clients Representatives Guidance CSP006 Aug.12 CDM Management Arrangements CSP007 Aug.12 Children, Young People and Vulnerable Adults on Campus H&S Office Confined Spaces Management Plan EDS doc Confined Space Working CSP013 Aug.12 COSHH Policy including Code of Practice and Guidance Notes & RA Forms H&S Office Contractors’ General Code of Safe Practice EDS doc Contractor Performance Monitoring CSP004 Aug.12 Counselling service for staff Occ.Health Disability Policy Statement HR Display Screen Equipment – Working with… H&S Office Dogs in University Buildings H&S Office Driving vehicles on University Business H&S Office - Minibus Passenger Transport Vehicles - The staff use of private vehicles on University of Exeter Business Drug abuse: Policy and Guidelines HR Estate Statutory Compliance CSP024 Aug.12 Fieldwork – Safety in… H&S Office Fire Safety H&S Office Fire Risk Assessment CSP025 Aug.12 First Aid H&S Office Fit notes: Guidance for managers HR Gas - University of Exeter Safety Case – Gas Engineering EDS doc General Hazards and Controls CSP002 Aug.12 General Risk Assessment H&S Office H&S Policy and Management H&S Office Health and Safety Training CSP003 Aug.12 Health Surveillance Occ. Health Homeworking HR Hot Work CSP012 Aug.12 HV Systems – refer to HTM 2021 available via the Principal Electrical Engineer, EDS, Lafrowda House CSP010 Aug.12 Induction code of practice HR
  30. 30. University of Exeter Safety Manual Campus Services CS/H&S/Doc003 Issue A Insurance Works Notification CSP027 Aug.12 Investigating Accidents & Incidents CSP009 Aug.12 Learning and Development Policy HR Legionella & Water Quality Management Plan EDS doc Lifting Equipment and Lifting Operations CSP017 Aug.12 Lone Working CSP020 Aug.12 LV Electrical Safety Rules CSP011 Aug.12 Machinery… Safe Use of CSP018 Aug.12 Major Incident Plan Confidential Managing the Workplace CSP001 Aug.12 Manual Handling H&S Office Meningitis H&S Office Mental Health: Guidance HR Noise and Vibration in the Workplace CSP014 Aug.12 Noise at Work - Guidance CSP026 Aug.12 Out of Hours Emergency Callout (plus Appendices A to E) CSP005 Aug.12 Personal Protective Equipment Use and Storage CSP015 Aug.12 Portable Electrical Appliance Inspection and Testing H&S Office Provision and Use of Work Equipment CSP016 Aug.12 Radiation Safety - Radiation and Radionuclide’s Code of Practice and Guidance Notes H&S Office Reporting of Incidents (RIDDOR) CSP008 Aug.12 Smoking H&S Office Staff assessment – pre-employment and during Occ. Health Stress: Staff guidelines HR Substance abuse HR Transport Safety CSP019 Aug.12 Whistleblowing – see Public interest disclosure policy and procedure HR Working at Height CSP021 Aug.12 Working on the Grounds CSP022 Aug.12 Working in University Laboratories CSP023 Aug.12 Workplace assessment Occ. Health

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