Confined Spaces (Working in) Procedure

Confined Space (Working in) Procedures

Reference Number : NCAE047(20) Version: 1 Issue Date: 26/08/2020 of 42

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Confined Spaces (Working in) Procedure

Lead Author: Alasdair Cockbain, General Manager Governance & Compliance

(Estates & Facilities)

Division/ Department: Estates Division

Applies to: Bury & Rochdale Care Organisation

North Manchester Care Organisation

Oldham Care Organisation

Salford Royal Care Organisation

Approving Committee Estates and Facilities 3P General Managers Meeting

Date approved: 19/08/2020

Expiry date: 18/08/2025

Contents

Contents

Section Page

Document summary sheet 3

1 Overview 4

2 Scope & Associated Documents 4

3 Background 4

4 What is new in this version? 5

5 Procedure 5

5.1 What the Law Says 5

5.2 Definition of a Confined Space 6

5.3 Hazards 6

5.4 Risk Management 7

5.5 Risk Assessments 8

5.6 Training 10

5.7 Medical Fitness for Training and Work in Confined Spaces 10

5.8 Conditions for Entry and Work 11

5.9 Emergency Procedures 12

5.10 Monitoring by the Authorised Person (Confined Spaces) 13

Group arrangements:

Salford Royal NHS Foundation Trust (SRFT)

Pennine Acute Hospitals NHS Trust (PAT)




5.11 Management of untrained personnel 13

6 Roles and responsibilities 13

7 Monitoring document effectiveness 20

8 Abbreviations and definitions 20

9 References 21

10 Appendices

Appendix 1 Monitoring Arrangements 22

Appendix 2 Is the Area a Confined Space? 23

Appendix 3 Confined Space Medical Questionnaire 24

Appendix 4 Safe System of Work Checklist 25

Appendix 5 Salford Royal Hospital Positive Confined Space Locations 27

Appendix 6 Royal Oldham Hospital Positive Confined Space Locations 29

Appendix 7 North Manchester General Positive Confined Space Locations 31

Appendix 8 Fairfield General Hospital Positive Confined Space Locations 34

Appendix 9 Rochdale Infirmary Positive Confined Space Locations 37

Appendix 10 Floyd Unit, Birch Hill Site Positive Confined Space Locations 38

11 Document Control Information 39

12 Equality Impact Assessment (EqIA) screening tool 41




Document Summary Sheet

Confined Space (Working in) Procedures NCAE047 (20) v1 The Northern Care Alliance is committed to safely managing confined spaces, in compliance with applicable legislation and guidance. In order to do this, the following statement will be implemented

A Designated Person (Confined Spaces) will be appointed, having overall responsibility for

the management of confined spaces; to give advice on the management of confined

spaces, and to carry out audits of the confined spaces management regime.

Suitable training will be given to all Care Organisation Authorised Persons and any NCA

staff member who may need to enter confined spaces.

Contractors’ staff needing to enter confined spaces shall provide evidence of competence

in confined spaces for all those staff that will carry out the work.

Where possible, entries into confined spaces will be avoided or minimised.

Where appropriate, entries into confined spaces are contracted to a specialist contractor,

having the necessary skills, training and management systems.

A Confined Spaces Register within the NCA’s estate will be developed, maintained and

updated; containing risk assessments on each confined space with all the associated

known hazards and controls.

Suitable safety equipment for entry into confined spaces will be provided for directly

employed staff, and is repaired, maintained and periodically inspected (contractors are

required to provide their own equipment).

All entries into confined spaces are permitted only with a suitable risk assessment, a safe

system of work, and under the control of a Confined Spaces Permit to Work from an

Authorised Person.

All confined space entry teams will comprise a minimum of three suitably trained members,

including a Safety Person who continuously supervises the entry.

The confined spaces management regime will be periodically audited and reviewed.

The Confined Space Register can be found in Appendix 5 – Appendix 10

Group arrangements:

Salford Royal NHS Foundation Trust (SRFT)

Pennine Acute Hospitals NHS Trust (PAT)




1. Overview This document provides statements for compliance and guidance in relation to working in confined spaces, to ensure the Northern Care Alliance (NCA) meets all statutory requirements relating to the management and control of designated confined spaces within and between all buildings for which it is responsible. The Confined Spaces Regulations 1997 were made under the Health and Safety at Work etc. Act (HASAWA 1974), came into force January 1998 and was updated in 2008. The Regulations apply in all premises and work situations in Great Britain subject to the HASAW Act, with the exception of diving operations and below ground in a mine. To operate safely in confined spaces it is necessary to understand the risks and the legal requirements.

If you have any concerns about the content of this document please contact the author or advise the Document Control Administrator.

2. Scope

NCA staff and contractors working in confined spaces need to be aware of and understand this procedure; these documents apply to all premises owned and occupied by NCA staff Associated Documents

NCA NCAE002(19) Asbestos Policy

NCAE005(19) Asbestos Procedures

NCAE041(19) Contractors (Safe Management of) NCAE003(19) Fire Safety Policy

NCAE010(19) Reactive Planned Maintenance Policy

NCAPS003(20) Incident Management

NCAG021(19) Health and Safety PAT

EDG002 Smokefree Environment Policy

EDQ014 Records Management SRFT

Info02(18) Retention Schedules for Estates Records as per the Records Code of Practice 2016

3. Background

Every year in the UK, fatalities or serious injuries occur in confined spaces. Deaths are not limited to those people actually working in the confined space, as they can include people who try to rescue them without proper training and equipment. The Confined Spaces Regulations 1997 came into force on 28th January 1998 and the hazards that these Regulations address arise through the combination of the confined nature of the place of work and the possible presence of substances or conditions which, taken together, can increase the risk to safety or health.




Associated legislation and regulations

The Health and Safety at Work Act 1974

Confined Spaces Regulations 1997

Provision and Use of Work Equipment Regulations 1998 (PUWER)

Control of Noise at Work Regulations 2005

Control of Asbestos Regulations 2012

Control of Substances Hazardous to Health Regulations 2002

The Workplace (Health, Safety and Welfare) Regulations 1992

Electricity at Work Regulations 1989

Construction (Design and Management) Regulations 2007 (CDM)

Personal Protective Equipment Regulations 2002

Personal Protective Equipment at Work Regulations 1992 (as amended)

Records management: code of practice for health and social care 2016

Management of Health and Safety at Work regulations (MHSW) 1999

4. What is new in this version?

This is a new document for implementation throughout the whole of the NCA

5. Procedure

The potential hazards associated with entry into confined spaces cannot be underestimated and to ensure strict compliance with this document a controlled and systematic approach must be adopted which will include:-

The designation of Authorised Persons,

Staff supervision and training.

Annual audit comprising survey, risk assessments, action plans and policy review.

Co-ordination with the NCA Estates and Health & Safety Departments.

Documentation and record keeping, to ensure that evidence of good practice can be

validated.

5.1 What the Law Says

5.1.1 You must carry out a suitable and sufficient assessment of the risks for all work activities to decide what measures are necessary for safety (under the Management of Health and Safety at Work Regulations 1999, regulation 3). For work in confined spaces this means identifying the hazards present, assessing the risks and determining what precautions to take. In most cases the assessment will include consideration of:

The task;

The working environment;

Working materials and tools;

The suitability of those carrying out the task;

Arrangements for emergency rescue.




5.1.2 Competent People shall be appointed to help manage the risks and make sure that employees are adequately trained and instructed (under the Management of Health and Safety at Work Regulations 1999, regulation 7).

If your risk assessment identifies risks of serious injury from work in confined spaces, where the Confined Spaces Regulations 1997 apply. The Appointed person will have the following key duties

Avoid entry to confined spaces, e.g. by doing the work from outside;

If entry to a confined space is unavoidable, follow a safe system of work; and put in

place adequate emergency arrangements before the work starts.

5.2 Definition of a Confined Space

5.2.1 A ‘confined space’ must have both of the following defining features:

a) It must be a space which is substantially (though not always entirely) enclosed; and

b) One or more of the specified risks must be present or reasonably foreseeable.

5.2.2 Some confined spaces are fairly easy to identify, for example sewers and closed tanks

used to store chemicals. However, identification may not always be so easy, as a

confined space is not necessarily:

a) enclosed on all sides – some, such as vats, silos and tanks holds, may have open

tops or sides;

b) small and/or difficult to work in

c) difficult to get in or out of – may have several entrances/exits, others have quite

large openings or are apparently easy to escape from; or

d) a place where people do not regularly work but only by individuals

5.2.3 See Appendix 2 Is the Area a Confined Space?

5.3 Hazards

5.3.1 The hazards that the Confined Spaces Regulations address arise through the

combination of the confined nature of the place of work and the possible presence of

substances or conditions which, taken together, can increase the risk to safety or

health.

5.3.2 Hazards can exist in the space (e.g. fumes or a flammable atmosphere) or they can be

introduced to a substantially enclosed space that otherwise would be safe (e.g. fumes

released when using chemical cleaners). The most likely hazards are as follows.

a. Toxic atmospheres.

- In sewers, access points, chambers and contaminated land.

- From trade effluents.

b. Explosive atmospheres.

- From flammable liquids and gases.




c. Lack of or excessive oxygen.

- From combustion processes and welding.

- Chemical reaction e.g. rusting.

- By displacement by inert gases e.g. nitrogen.

- From release of compressed or generated oxygen.

d. Carbon monoxide and / or carbon dioxide.

- From exhaust gases.

- From chalk and limestone soils.

- From pipe freezing techniques.

e. Slips trips and falls

- Poor visibility.

- Poor access and restricted movement.

- Collapse of the structure.

- Sudden ingress and flooding due to sudden storm or failure to isolate the line.

- Neglect, complacency and lack of knowledge and / or training.

- Increase of body temperature due to environment.

f. Risks

- Poisoning - dangerous atmospheres

- Fire and / or explosion.

- Burns.

- Asphyxiation.

- Major injury or death.

- Drowning.

- Physical injury.

- Temperature stress.

- Bacterial infection.

5.4 Risk Management

5.4.1 Competent People

Anyone entering or assisting entry to a confined space must be competent, trained and authorised to do so by completing a ‘Medium Risk Confined Space Entry’ course

Anyone likely to enter and work in a confined space must be initially assessed for medical fitness as set out in Appendix 3 - Confined Space Medical Questionnaire

Anyone issuing permits to enter must have received training and passed a ‘Managing Confined Spaces’ course and be appointed by the Group Associate Director Estates. Permits are issued by the Authorised Person (Confined Spaces)

5.4.2 Safe Systems of Work

A permit to enter must be issued for all entries to confined spaces.

The entry team must be made aware of all other hazards which could affect their safety and health.

See Appendix 4 Safe System of Work Checklist




5.4.3 Safety Equipment

Safety equipment must be of an approved type, (i.e. conforming to CE standards), suitable for the job and maintained to the manufacturers’ standards.

Safety equipment must be checked, by the user, immediately before use and must, for equipment in regular use, be examined six monthly by a competent person, and records kept of the inspection for the expected life of the equipment life cycle, and a minimum of 5 years. Equipment which is not in regular use must be inspected thoroughly by either an authorised or competent person accordingly.

The Provision and Use of Work Equipment Regulations (PUWER) and Lifting Operations and Lifting Equipment Regulations (LOLER) may apply to equipment in use and should be inspected in accordance with the regulations.

Lighting shall be intrinsically safe where required.

The correct protective clothing must be worn as identified in the risk assessment

NCA does not allow use of NCA safety equipment to contractors or staff that have not been trained in its use

5.4.4 Safe Working Environment

Portable internal combustion engines must not be used in or close to confined spaces if there is a risk of the exhaust fumes accumulating in the work area. Similarly awareness of vehicle exhausts must be considered.

Open chambers must be adequately guarded.

Ventilation (natural or forced) of the confined space must be carried out before entry and whilst work is being carried out (6 air changes per hour recommended.

Ignition sources are not allowed inside or within 2 meters of the confined space, unless a risk assessment / hot work permit / permit has been issued and a safe system of work developed, e.g. welding or cutting operations.

5.4.5 Emergency Procedures

Before entry to any low or medium confined space, staff will be advised of the required local emergency contact procedure

In-house rescue team to be available for first response to cover staff working in any low or medium risk environments.

Contractor when working in confined spaces to be responsible for engaging and managing their own rescue teams, and provide assurances to the NCA that their rescue and escalation procedures are in place and aligned to Health & safety requirements.

5.5 Risk Assessments

5.5.1 If it has been established that the work cannot be undertaken from outside and that entry is required; risk assessments and method statements/safe systems of work shall be undertaken in consultation with Health & Safety Advisors, Fire Safety Advisor and the NCA Emergency Planning, Resilience & Response Unit




5.5.2 The confined space risk assessment should take into account:-

Type of work to be done.

The suitability of those doing the work.

Present and previous contents.

Rates of flow.

The weather - wind, rain, frost.

Amount of ventilation.

Atmosphere quality - the working environment.

The duration of the task

Safe tools and equipment

Generation of fumes or dust.

The distance to be travelled.

Lighting level.

Noise level.

- Plant and machinery present.

- Access / egress movement difficulties.

- Suspension points for a winch if required.

- Underfoot conditions.

- Structure - damage, obstructions, lose debris.

- Any other local conditions.

- Liaison with local emergency services 5.5.3 Risk classification will be made using the following guidelines: (See Appendix 5)

Low Risk (0-3) – these are areas where there is easy access/egress and adequate natural ventilation, but the space is still partially, though not necessarily entirely enclosed. There is no history of specified risk e.g. gas alarms, flooding, entrapment. These spaces will not require Escape BA as self-rescue should be able to take place in a shorter space of time than donning of an Escape Set.

Medium Risk (3-12) – these are areas with access issues, and there is a likelihood of encountering a specified risk, or there will be introduction of a specified risk through work activity such as oxygen deficiency, flammable or toxic gases. These spaces will require entrants to have Escape BA and a Personal Gas Detector at all times as a minimum. Further equipment will be determined by risk assessment

High Risk (12-25) – these are areas where a specified hazard cannot be controlled or eliminated, and will remain present throughout the task. These can include complex access situations or areas where an electrical or mechanical hazard cannot be sufficiently controlled or isolated. Specific rescue procedures may need to be put in place. Entrants to these areas will normally need to wear self-contained breathing apparatus.

Note: NCA staff shall NOT enter High Risk confined spaces under any circumstances




5.6 Training

5.6.1 Staff shall receive adequate training and experience in the particular work involved to be

competent to work safely in a confined space.

5.6.2 Training standards shall be appropriate to the task, and to the individual’s roles and

responsibilities, so that work can be carried out safely.

5.6.3 Where the risk assessment indicates that properly trained individuals can work for

periods without supervision, the Authorised Person (Confined Spaces) shall check that

they are competent to follow the established safe system of work and have been

provided with adequate information and instruction about the work to be done.

5.6.4 Those likely to be involved in any emergency rescue (Low and Medium) shall be trained

for that purpose.

5.6.5 Refresher training shall be organised and available as required

5.6.6 Training will form part of the staff CF2 and records will be maintained and form part of

the estates training matrix

5.7 Medical Fitness for Training and Work in Confined Spaces

5.7.1 The Authorised Person (Confined Spaces) shall complete the risk assessment for work

in confined spaces and shall consider the suitability of individuals in view of the

particular work to be done. Where the risk assessment highlights exceptional

constraints from the physical layout, the Authorised Person (Confined Spaces) will

check that individuals are of suitable build. This may be necessary to protect both the

individual and others who could be affected by the work to be done.

5.7.2 The Authorised Person (Confined Spaces) will also consider other factors about an

individual, for example concerning pre-existing medical conditions (claustrophobia,

respiratory conditions like asthma, pregnancy etc.) or physical strength and abilities,

and other advice on an individual’s suitability for the work.

5.7.3 NCA Staff Competencies The following describes the requirements and process of

ensuring the fitness for NCA employees to undergo training and to be assessed as fit to

enter and work in confined spaces:-

Assessment as being medically fit by completion of a questionnaire and a referral to the Occupational Health Department (OH) for assessment who will determine if staff are suitable for working in confined spaces. See Appendix 3 Confined Space Medical Questionnaire

Staff must not omit to mention anything about their health which may ultimately put their own or their colleagues, safety at risk.

Any person found to have withheld such information, which they knew to be relevant for such work, will be dealt with under Trust disciplinary procedures. Failure to disclose information may be deemed to be an act of misconduct.




Where the Authorised Person (Confined Spaces) is not satisfied that the Confined Spaces Operatives are suitably competent, they are not to proceed further with the issue of a Permit-to-Work (Confined Spaces).

5.8 Conditions for Entry and Work

5.8.1 General Requirements

To be considered competent, anyone (including contractors) required to work in a designated confined space must fulfil the following conditions:-

Attendance and assessment at a training course on safe entry and work in confined spaces, including a practical exercise, appropriate to the highest level of risk that they could be exposed to whilst at work,

Contractors must have evidence of having been assessed in safe working practices.

5.8.2 Entry Procedure

Leave openings uncovered for the minimum amount of time to ventilate the workspace and carry out the job. During this period openings must not be left unattended at any time.

Release any trapped gasses from residues by agitation from outside the confined space before atmosphere testing.

Prior to entry the atmosphere in the confined space must be tested by multi gas detection equipment at various levels, e.g. every 2 metres, allowing 2 minutes for the monitor to respond at each test. Different gases have differing density, thus forming layers in the confined space. Record the initial reading on the permit.

The atmosphere must be continuously monitored and it may be necessary to produce a log sheet to record readings.

A life-line should be attached to the harness, provided it cannot get entangled in rotating plant or pipe-work.

Follow the manufacturer’s instructions on the proper use of man-riding winches.

If appropriate, check escape breathing apparatus for contents and operation.

Escape breathing apparatus, when necessary, must be carried or within arm’s reach and ready for use.

5.8.3 Authorisation

Competence to work in confined spaces shall be reviewed every three years (unless advised otherwise)

General Managers Estates & Facilities will not authorise people to work in confined spaces based on them having attended a training course alone, on the job training / real experience whilst under supervision is required and their health. Reasonable steps should be taken to check that contractors also comply with this requirement and work under the NCA permit to work.

A person who is authorised to issue permits must be appointed by the Group Associate Director Estates.




People who cannot enter confined spaces for personal reasons may act as Safety Attendant, provided they have been trained and assessed as being competent to carry out the role.

5.9 Emergency Procedures

5.9.1 Effective arrangements for raising the alarm and carrying out rescue operations in an emergency are essential. Contingency plans will depend on the nature of the confined space, the risks identified and consequently the likely nature of an emergency rescue.

Emergency arrangements will depend on the risks. Communications, rescue and resuscitation should all be considered

Communications

How can an emergency be communicated from inside the confined space to people outside so that rescue procedures can start; including night and shift work, weekends and times when the premises are closed, e.g. holidays. Consider what might happen and how the alarm can be raised.

Rescue and resuscitation equipment

Providing suitable rescue and resuscitation equipment will depend on the likely emergencies identified. Where such equipment is provided for rescuers to use, training in correct operation is essential.

Capabilities of rescuers

Rescuers need to be properly trained, sufficient fit to carry out the task, ready at hand, and capable of using any equipment provided for rescue, e.g. breathing apparatus, lifelines and fire-fighting equipment. Rescuers also need to be protected against the cause of the emergency.

Shut down

It may be necessary to shut down adjacent plant before attempting emergency rescue.

First-aid procedures

Trained first aiders need to be available to make proper use of any necessary first-aid equipment provided.

Local emergency services

Fire and Rescue Service are more than likely to be required and an approved system will shall be arranged by the Authorised Person (Confined Spaces) prior to work commencing which will include listing all the dangers of the space which must be re-laid to the emergency services if called upon.

5.9.2 Emergency Action and Rescue High Risk Classification

Access to all high risk confined spaces will not be undertaken by NCA staff; external contractors will be appointed to undertake any works required and the emergency




service or specialist rescue team must be put in place before hand to rescue people in an emergency.

5.10 Monitoring by the Authorised Person (Confined Spaces)

5.10.1 Day-to-day monitoring will be undertaken by the Authorised Person (Confined Spaces)

to assess safety aspects of operatives on site under the Authorised Person’s control.

5.10.2 The Authorised Person (Confined Spaces) will monitor all Confined Spaces Operatives for assessment of their competence and quality of work. This will be undertaken in accordance with the Procedures and inclusion of the following would be expected:

inspections of locations, equipment and systems having significant risk, safety equipment and quality checks of workmanship and materials employed;

ensure all operatives wear the necessary PPE as per the risk assessment and take action when this is not adhered to. Failure to wear the necessary PPE may be deemed to be an act of misconduct

notifying the Authorising Engineer or Designated Person in the event of failure to reach a resolution and areas of Procedures non-compliance.

5.11 Management of untrained personnel

5.11.1 This would include personnel who do not normally undertake confined space work but who may need to enter a Confined Space to carry out a specific task. They may be exempt from the requirement to have attended a formal training course but such exemption will be subject to risk assessment by the Authorised Person (Confined Spaces). A record of the risk assessment should be entered into the Combined Spaces Operations Record along with the name and contact details of the personnel.

5.11.2 These visitors shall be under the direct control of the Person in Charge (Confined Spaces) and have been given sufficient on-site instruction and information relating to safe working and emergency procedures. The giving and receiving of such instruction shall be logged.

5.11.3 The Authorised Person (Confined Spaces) must be satisfied that the inclusion of the visitor does not create an increase in risk to the team entering the space.

6. Roles & responsibilities

6.1 All Staff will refrain from entering any confined spaces, unless they have a valid permit

to work permit, and will report to the estates helpdesk any concerns relating to

accessibility by others.

No one will enter any High Risk confined spaces unless specifically appointed to do so

by the NCA

6.2 Contractors will

Adhere to all NCA policies and procedures including NCAE041(19) Contractors

(Safe Management of);




Ensure that, prior to entry the formal permit to work is approved under the control of

the NCA Authorised Person (Confined Spaces) and that they understand the risk

assessments and method statements;

Raise with the NCA Authorised Person (Confined Spaces) any concerns regarding

confined spaces;

Attend confined spaces training and first aid training, in order to act as a “Safety

Person” if required. Provide evidence of competence as required;

Report any incidents, accidents or near misses, failed tasks and faulty equipment to

the NCA Authorised Person (Confined Spaces);

Will not be allowed access to confined space without contact / discussions with the NCA Authorised Person (Confined Spaces) and be in receipt of a valid permit to work

Will be informed by the NCA Authorised Person (Confined Spaces) of any known hazards to which they could be exposed.

6.3 Competent Person (Confined Spaces)

The Competent Person (Confined Spaces) is appointed by the by the Authorised Person (Confined Spaces).

Competent Persons (Confined Spaces) are deemed suitable for specific appointments for any of the following roles on a task-by-task basis as identified on the appropriate Safety Documentation issued by the Authorised Person (Confined Spaces):

- Person in Charge (Confined Spaces);

- Safety Attendant (Confined Spaces);

- Work Team (Confined Spaces).

6.4 Work Team (Confined Spaces) will carry out the work in the Confined Space as per

the agreed safe system.

Where more than one member of a Work Team (Confined Spaces) enters a confined space, one person is to be nominated to lead the entry team and be in direct control of their activities in the confined space. This function is separate from the Person in Charge (Confined Spaces) and the Safety Attendant (Confined Spaces) and is to be known as the Team Leader (Confined Spaces).

The Team Leader (Confined Spaces) is to ensure that effective communications are established and maintained with the Safety Attendant (Confined Spaces) and take the relevant actions in the event of any emergency in accordance with the agreed safe system of work.

6.4.1 The duties of the Work Team (Confined Spaces) are to:

a. work in accordance with these Procedures or any local variations;

b. take reasonable care of the health and safety of themselves and of any other

person who may be affected by their actions or omissions;




c. only use equipment on which they have been trained and in the manner in

which they have been trained;

d. report to the Person in Charge (Confined Spaces) any defects found in the

tools, plant and equipment to be used in the works.

6.5 Safety Attendant (Confined Spaces)

The appointment of the Safety Attendant (Confined Spaces) is made on a task-by-task basis with the issue of appropriate safety documentation.

The Safety Attendant (Confined Spaces) is to assist the Person in Charge (Confined Spaces) in executing the Confined Space task safely. The Safety Attendant is to remain on watch outside the confined space in a safe position close to the entry point while there is anyone inside the confined space. The person should continuously monitor the progress of those within and act as a communications link.

The Safety Attendant (Confined Spaces) must know who is authorised for entry into the confined space and the maximum permitted time allowed inside. A record should be kept of persons inside at any one time.

The Safety Attendant (Confined Spaces) must not be permitted to undertake tasks that may distract from the primary role and must remain alert to any change in conditions inside or external to the confined space that may affect the safety of the entrants and must notify the Person in Charge (Confined Spaces) immediately.

6.5.1 The duties of the Safety Attendant (Confined Spaces) are:

a. understanding the site procedure and location of persons to summon help

(First Aiders, site nurse, fire, ambulance staff, trained rescuers and security);

b. establishing an effective communications system to enable the alarm to be

raised in an emergency;

c. preventing unauthorised access in the Confined Space;

d. maintaining sufficient fresh air ventilation into the Confined Space; where this

is deemed necessary and this fails, appropriate measures to withdraw the

entrants must be taken;

e. in the event of an emergency, initiating the pre-arranged emergency

procedures as laid down in the Safety Programme.

6.6 Persons in Charge (Confined Spaces)

The role of the Person in Charge (PIC) is to control directly the entry into a confined

space.

The appointment of the Person in Charge (Confined Spaces) is made on a task-by-

task basis with the issue of appropriate safety documentation. On signing the

document the PIC takes responsibility for ensuring that all work is carried out within

the limits of the Safe System of Work.




At the same entry an Authorised Person (Confined Spaces) may not act in the

capacity of a Person in Charge (Confined Spaces).The Person in Charge could be

either an NHS employee or an external contractor.

6.6.1 The duties of the Persons in Charge (Confined Spaces) include the

following:

a. undertaking suitable and sufficient risk assessment to the satisfaction of the

Authorised Person (Confined Spaces) to ensure that all safety measures

necessary to avoid danger are taken to avoid danger and prevent injury;

b. ensuring that adequate first aid and emergency arrangements including rescue

(not relying on emergency services) are in place before commencing the

works;

c. ensuring that all necessary safety equipment is available, safe and suitable for

use prior to entry into the confined space. Evidence of testing and calibration

must be provided if requested by the Authorised Person (Confined Spaces).

d. being fully conversant and able to ensure compliance with the conditions set

out in the Permit-to-Work (Confined Spaces) and agreed safety system of

work;

e. ensuring that the Work Team are aware of the method of work set out in the

agreed safe system of work, the means of communication, the emergency

arrangements and the requirements of these Procedures, and that this is

recorded on the Permit-to-Work (Confined Spaces);

f. carrying out reading ‘pre-entry’ gas test, completing the appropriate section on

the Permit-to-Work (Confined Spaces) where appropriate;

g. ensuring that the only work carried out is that for which the Permit-to-Work

(Confined Spaces) is valid;

h. stopping work and withdrawing all personnel, tools, plant and equipment from

the confined space if, for any reason, the conditions of the safe system of work

or Permit-to-Work (Confined Spaces) cannot be met;

i. reporting to the Authorised Person (Confined Spaces) any accident, dangerous

occurrence, defects found or other exceptional incidents occurring during

occupation of the Confined Space;

j. always being present at the confined space work site when any work within the

space is being carried out.

6.7 Authorised Person (Confined Space) will oversee and authorise all Confined Space

work activity that takes place, in accordance with these Procedures.

They will also:

a. Ensure, as far as is reasonably practical, that all persons on site comply with these Procedures;




b. Review all prospective Confined Space working and determine the appropriate level of control;

c. Ensure that all Confined Spaces are maintained in a safe condition at all times, reporting any potentially dangerous situations or occurrences to their responsible line manager and Health & Safety Advisor

d. Identify any difficulties in applying these procedures, any local procedures or any other actions necessary to ensure a Safe System of Work, including discussing with the Designated Person (Confined Spaces);

e. Ensure that all records, schedules and schematic drawings relating to Confined Spaces within their area of responsibility (including alterations and modifications) are maintained and up to date;

f. Ensure that all Confined Spaces operatives under the control of the Person in Charge (Confined Spaces) are adequately trained and medically fit to carry out the work required. Evidence of fitness and training of all Confined Spaces operatives must be provided if requested by the Authorised Person (Confined Spaces);

g. Ensure staff complete a Confined Space Medical Questionnaire annually and take action where required e.g. OH referral

h. Ensure that all Confined Spaces safety controls, isolation points and vessels are clearly identified on the drawings and physically labelled/tagged;

i. Ensure that safety equipment has been registered and inspected and maintained in good condition to ensure that it is fit for purpose;

j. Ensure that Confined Spaces are adequately and clearly signed and that all entry points are secured according to the assessed risk;

k. Ensure that a risk assessment and safe system of work are prepared for each Confined Space operation;

l. Review the risk assessment and safety programme for each Confined Spaces operation, prepared by others;

m. Satisfy themselves that prospective Confined Space entrants are competent to carry out the work as described to them;

n. Issue Permits-to-Work for Confined Spaces;

o. Withdraw Permits-to-Work if an unexpected hazard becomes apparent;

p. Cancel Permit-to-Work on completion of work;

q. Inform the Designated Person (Confined Spaces) and General Manager Estates & Facilities of any accident or Dangerous Occurrence that occurs relating to Confined Space working;

r. Inform the Designated Person (Confined Spaces) and General Manager Estates & Facilities of any difficulties or unusual circumstances encountered or discovered during the execution of a Confined Spaces task;

s. Ensure that any external contractors appointed to work in Confined Spaces are competent to do so;

t. Inform contractors of any known hazards to which they could be exposed;

u. Ensure that local procedures are in place for emergency evacuation;




v. Oversee entries into confined spaces, ensuring that a suitable and sufficient risk assessment and safe system of work is in place prior to entry;

w. Ensure all estates records are stored, retained and destroyed in line with https://www.gov.uk/government/publications/records-management-code-of-practice-for-health-and-social-care

6.8 Authorising Engineer or Designated Person (Confined Spaces)

The appointment of an Authorising Engineer or Designated Person will be made in writing by the Chief Executive Officer or delegated person (Group Director Capital, Estates & Facilities);

The Authorising Engineer or Designated Person (Confined Spaces) shall be a suitably trained, qualified person with relevant experience in Confined Spaces and Safe Systems of Work;

Prior to formal appointment, the proposed Authorising Engineer or Designated Person (Confined Spaces) is required to have achieved the necessary standard of competence as determined at the initial appointment interview;

The role of the Authorising Engineer or Designated Person (Confined Spaces) is to implement, administer, monitor and audit the adoption of these Procedures and all associated legislation, regulations and best practice.

Duties of the Authorising Engineer or Designated Person (Confined Spaces) include:

a. Identifying the numbers of Authorised Person (Confined Spaces) necessary for the site to allow the effective adoption and implementation of these safety rules and procedures;

b. Ensuring that candidates as Authorised Person (Confined Spaces) are suitably trained prior to appointment/ reappointment;

c. Interviewing candidates for Authorised Person (Confined Spaces) and, where successful, making recommendations for appointment;

d. Reviewing the operational experience of appointed Authorised Person (Confined Spaces) to ensure that competency is maintained and where necessary withdrawing the Certificate of Competence;

e. Conducting audits of the Safe System of Work;

f. Reporting any deficiencies in the Safe System of Work to the General Manager Estates & Facilities ensuring that any accident or Dangerous Occurrence connected with confined space working are immediately notified to the Health & Safety Advisor and Fire Safety Advisor;

g. Investigating any reported Incidents and Dangerous Occurrences in respect of working in confined spaces;

h. Ensuring that any NCA Instructions and Notices, Policy Instruction, Health and Safety Notices or similar is brought to the attention of all Authorised Person (Confined Spaces) for which the Authorised Engineer or Designated Person has responsibility;

i. Providing general advice to Authorised Person (Confined Spaces) in the execution of their work;

https://www.gov.uk/government/publications/records-management-code-of-practice-for-health-and-social-care





j. Advising the Governance & Compliance Manager that all personnel responsible for issuing or managing work tasks have suitable confined spaces awareness training.

6.9 General Manager Estates & Facilities will

Take overall accountability and responsibility for ensuring that Authorised Persons

(Confined Spaces) undertake their duties in line with this document and that their

training, assessments and appointments are continually valid and not lapsed;

Ensure the confined space register is reviewed annually and the corresponding risk

assessments amended and actions actioned as necessary;

Ensure that any deficiencies relating to confined spaces are logged for remedial

action (including relevant risk registers), and where necessary, resources are

sourced;

Provide assurance that systems are in place for confined space and restricted

access work and that they meet the legal and organisational requirements, including

the adequate provision of training, resources, equipment etc.;

Ensure that the management of the Permit to Work system for the safe entry into

confined spaces is developed, implemented, complied with, monitored, and

periodically reviewed and updated at each CO;

Ensure that the Confined Spaces Register for their CO is maintained and updated by

the Authorised Person(s);

Supporting Authorised Persons in their role.

Ensure all estates records are stored, retained and destroyed in line with

https://www.gov.uk/government/publications/records-management-code-of-practice-

for-health-and-social-care

6.10 Governance & Compliance Team (Estates & Facilities) will

Assist the General Manager Governance & Compliance to monitor training records,

action plans, risks and documentation

Arrange the training of Authorised Persons and issue of assessments and

appointment letters

6.11 Group Director of Capital, Estates & Facilities has delegated responsibilities for

confined spaces from the Group Chief Executive Officer

They will be responsible for ensuring that systems are in place for confined space and

restricted access work and that they meet the legal and organisational requirements,

including the adequate provision of training, resources, equipment, risk assessments

and method statement etc. and appoint an Authorising Engineer or Designated Person

(Confined Spaces) in writing i.e. Group Associate Director Estates






7. Monitoring document effectiveness

See Appendix 1

8. Abbreviations and definitions

AE Authorising Engineer

AP Authorised Person

CO Care Organisation

CS Confined Space

DR Designated Person

E&F Estates & Facilities

GRAC Group Executive Risk Assurance Committee

H&S Health & Safety

NCA Northern Care Alliance

OH Occupational Health

PIC Person in Charge

PPE Personal Protective Equipment

Definitions

Authorised Person A suitably trained person appointed in writing by the Senior Authorised Person who takes day to day operational responsibility for compliance with this policy and procedures.

Confined Space any place such as ducts, vessels, culverts, tunnels, boreholes, manholes, excavations, sumps, inspection pits, experimental hutches, tanks, building voids, roof spaces or other similar space in which, by virtue of its enclosed nature there is a reasonably foreseeable risk of:

serious injury from fire or explosion

loss of consciousness arising from increased body temperature

loss of consciousness/asphyxiation arising from: gas, fume, vapour or lack of oxygen

drowning arising from increased levels of liquid

asphyxiation from a free flowing solid

Contractor Any person employed by or working for a third party organisation working for or acting on behalf of the NCA.

Permit to Work Ensures a formal check is undertaken to ensure all the elements of a safe system of work are in place before people are allowed to enter or work in the confined space. It is also a means of communication between site management, supervisors, and those carrying out the hazardous work.

PPE Equipment issued free of charge to the employee by the employer in order to protect them, personally, from the risk of harm from certain activities. May include but not restricted to safety footwear, coveralls, gloves, goggles, hard hat.




Risk assessment A careful examination of what could cause harm to people at work, in order to decide on precautions to prevent that harm occurring

Safe System of The systematic examination of a task in order to identify all hazards; it will

Work include a detailed analysis of the materials and the equipment to be used, the environment and the people involved and affected. This information can be gleaned from risk assessments undertaken. It is important to involve employees that carry out the work or with detailed knowledge of the activity, so that the system of work produced is effective and practical as well as safe. Involving employees with the process helps them to understand why this level of control has to be established and maintained.

9. References

Confined spaces A brief guide to working safely; INDG258(rev1), published 01/13; HSE

Safe work in confined spaces, Approved Code of Practice and guidance L101 (Third edition, published 2014) HSE

EF/PO/00003 Policy and Procedure for the Management and Safe Working in Confined Spaces; Bassildon and Thurrock University Hospitals Foundation NHS Trust (December 2017)

Health & Safety Policy & Procedures for the Management of Confined Spaces v 1.2; Royal Cornwall Hospitals NHS Trust (January 2016)

http://www.legislation.gov.uk/uksi/1997/1713/contents/made

http://www.hse.gov.uk/confinedspace/


http://www.hse.gov.uk/mothers/docs/pregnant-workers-flow-chart.pdf

https://www.ecex.co.uk/wp-content/themes/ecex/certificates/risk2.pdf

10. Appendices

http://www.legislation.gov.uk/uksi/1997/1713/contents/made

http://www.hse.gov.uk/confinedspace/



http://www.hse.gov.uk/mothers/docs/pregnant-workers-flow-chart.pdf

https://www.ecex.co.uk/wp-content/themes/ecex/certificates/risk2.pdf




Appendix 1 Monitoring Arrangements What aspects of compliance with the document will be monitored

What will be reviewed to evidence this

How and how often will this be done

Detail sample size (if applicable)

Who will co-ordinate and report findings

Which group or report will receive findings

Designated Confined Spaces at each Care Organisation

Register of Designated Confined Spaces – in place and regularly reviewed

Review of Risk Assessments Initially Annually and then 3 yearly

All Designated Confined Space RA’s

Independent Confined Spaces Consultant. General Manager Estates & Facilities

Group Associate Director of Estates E&F Compliance Team

Training Records, assessments and appointments of Estates and Contractors

Training Records, assessments and appointment letters – up to date compliant.

Review quarterly. All Training Records, assessment and appointment letters

Governance & Compliance Manager (Estates & Facilities)

General Manager Estates & Facilities E&F Governance & Compliance

Issue of Confined Space Permits.

Confined Space Permits procedures are being followed in accordance with this Policy.

Review of Permits issued at each Care Organisation Annually

Review all Permits issued in that year.

General Manager Estates & Facilities


Confined Spaces Identification

Confined Spaces Identification Forms.

3 Yearly Independent Confined Spaces Consultant. General Manager Estates & Facilities





Appendix 2 Confined Spaces Regulations 1997 Is the area a confined space?




Appendix 3 Confined Space Medical Questionnaire

This questionnaire is to be completed annually by all personnel who carry out Confined Space training, and who enter Confined Spaces as a requirement of their Job Description/Person Specification (JD/PS).

Please note the questions below; if the answer to any of the question/s is Yes, please indicate this with a tick in the box below. In this situation, an appointment will be made for you with Occupational Health where you will have the opportunity to discuss your health problem/s confidentially and guidance on any limitations and any support required would be given.

Questions

Do you have a medical condition/s that could impair your ability to work safely in confined spaces (e.g. medical conditions like asthma or other lung problems, muscular or joint problems, mental illnesses, Epilepsy, Diabetes, difficulty hearing or seeing, high blood pressure, skin problems) ?

Do you suffer from claustrophobia to the extent it would prevent you from entering/working within Low/Medium Risk Confined Spaces?

Do you suffer from any muscular/skeletal disorder or any other medical condition that would prevent you from climbing vertical ladders?

Are you on any medication/s which causes you side-effects like impaired concentration or drowsiness?

Are you pregnant?

Have there been any significant changes in your medical condition since completing your last Confined Spaces Medical Questionnaire?

If the answer to any of the above questions is Yes, please tick the box here

Low Risk – these are areas where there is easy access/egress and adequate natural ventilation, but the space is still partially, though not necessarily entirely enclosed. There is no history of specified risk e.g. gas alarms, flooding, entrapment. These spaces will not require Escape BA as self-rescue should be able to take place in a shorter space of time than donning of an Escape Set.

Medium Risk – these are areas with access issues, and there is a likelihood of encountering a specified risk, or there will be introduction of a specified risk through work activity such as oxygen deficiency, flammable or toxic gases. These spaces will require entrants to have Escape BA and a Personal Gas Detector at all times as a minimum. Further equipment will be determined by risk assessment

I confirm that my answer is correct at the time of signing, and that I will bring to the attention of my supervisor at the earliest opportunity, any changes in my personal/medical condition which is likely to put my own or my colleagues’ safety at risk. I understand that I will be given the opportunity to discuss confidentially with Occupational Health, if I have a health problem that could impair my safety while working in confined spaces. PRINT NAME.................................................... SIGNATURE........................................................ DATE...................................................




Appendix 4 Safe System of Work Checklist

The following checklist is not exhaustive, but includes many of the essential elements to help prepare a safe system of work.

a. Appointment of Competent Persons

Supervisors should be given responsibility to make sure that the necessary precautions are taken, to check safety at each stage and may need to remain present while work is underway.

b. Are people suitable for the work?

Do they have sufficient experience of the type of work to be carried out, and what training have they received? Where risk assessment highlights exceptional constraints as a result of the physical layout, are individuals of suitable build? The competent person may need to consider other factors, e.g. concerning claustrophobia or fitness to wear breathing apparatus, and may need to seek medical advice on an individual’s suitability.

c. Isolation

Mechanical and electrical isolation of equipment is essential if it could otherwise operate, or be operated, inadvertently. If gas, fume or vapour could enter the confined space, you need to isolate the pipework. In all cases, a check should be made to ensure isolation is effective.

d. Cleaning before entry

This may be necessary to ensure fumes do not develop from residues etc. while the work is done.

e. Check the size of the entrance

Is it big enough to allow workers wearing all the necessary equipment to climb in and out easily, and provide ready access and exit in an emergency? For example, the size of the opening may mean choosing air-line breathing apparatus in place of self-contained equipment which is more bulky and therefore likely to restrict ready passage.

f. Provision of ventilation

You may be able to increase the number of openings and therefore improve ventilation. Mechanical ventilation may be needed to make sure there is an adequate supply of fresh air. This is essential where portable gas cylinders and diesel-fuelled equipment are used inside the space because of the dangers from build-up of engine exhaust. Warning: carbon monoxide in the exhaust from petrol-fuelled engines is so dangerous that use of such equipment in confined spaces should never be allowed.

g. Testing the air

Testing the air may be necessary to check that it is free from both toxic and flammable vapours and that it is fit to breathe. Testing should be carried out by a competent person using a suitable gas detector which is correctly calibrated. Where the risk assessment indicates that conditions may change, or as a further precaution, continuous monitoring of the air may be needed.

h. Provision of special tools and lighting

Non-sparking tools and specially protected lighting are essential where flammable or potentially explosive atmospheres are likely. In certain confined spaces (e.g. inside metal




tanks) suitable precautions to prevent electric shock include use of extra low voltage equipment (typically less than 25 V) and, where necessary, residual current devices.

i. Provision of breathing apparatus

Breathing apparatus is essential if the air inside the space cannot be made fit to breathe because of gas, fume or vapour present, or lack of oxygen. Never try to ‘sweeten’ the air in a confined space with oxygen as this can greatly increase the risk of a fire or explosion.

j. Preparation of emergency arrangements

Emergency arrangements will need to cover the necessary equipment, training and practice drills.

k. Provision of rescue harnesses

Lifelines attached to harnesses should run back to a point outside the confined space.

l. Communications

An adequate communications system is needed to enable communication between people inside and outside the confined space and to summon help in an emergency.

m. Check how the alarm is raised

Do you need to position someone outside to keep watch and to communicate with anyone inside, raise the alarm quickly in an emergency, and take charge of the rescue procedures?

n. Is a permit-to-work system required?

A permit-to-work ensures a formal check is undertaken to make sure all the elements of a safe system of work are in place before people are allowed to enter or work in the confined space. It is also a means of communication between site management, supervisors, and those carrying out the hazardous work. Essential features of a permit-to-work are:

- Clear identification of who may authorise particular jobs (and any limits to their authority) and who is responsible for specifying the necessary precautions (e.g. isolation, air testing, emergency arrangements etc.);

- making sure that contractors engaged to carry out work are included;

- training and instruction in the issue of permits;

- Monitoring and auditing to make sure that the system works as intended.




Appendix 5 Salford Royal Hospital Positive Confined Space Locations According To Regulations 1997

This Confined Space Register does not remove the requirement for contractors to complete their own work-based risk assessment. Please refer to master register held in the estates office for other spaces assessed.

Space I.D

Location Location Description

Space Description Confined Space?

Specified Risks Present Comments

CS01 36-41 Turnberg Building 5th Floor tank room

Cold water storage tank No. 1 (out of service)

Yes Drowning Asphyxiation O2 Deficiency A Safety Programme and Permit to Work will be required to enter this space


Cold water storage tank No. 2 (in service)

















CS08 36-41 Turnberg Building

5th Floor tank room Hot water storage tank No. 8 (in service)



5th Floor tank room Hot water storage tank No. 9 (out of service)



5th Floor tank room Hot water storage tank No. 10 (in service)


CS11 58 Brooke Tank room South Cold water storage

tank (in service) Yes Drowning Asphyxiation O2 Deficiency

A Safety Programme and Permit to Work will be required to enter this space

CS12 58 Brooke Tank room North Cold water storage

tank (in service) Yes Drowning Asphyxiation O2 Deficiency





CS13 77 Water pump house

Water pump house Cold water storage tank (in service)


CS14 8, Neuroscience generator compound

Neuroscience generator compound

Dieso Fuel storage tank

Yes Fire/ Explosion Drowning Asphyxiation O2 Deficiency


CS15 16, Boiler house yard Boiler house yard, behind building 24.

External Generator (Dieso) Fuel storage tank



CS16 77 Water pump house

Bossaris tank

Cold water storage tank, main incoming site water tank


CS17 Site Wide Site wide Sewerage System/Manholes

Yes Fire/ Explosion Asphyxiation O2 Deficiency Drowning


CS13 Ground Floor Mechanical Plant Room

Clarifier Yes Drowning Temperature Asphyxiation O2 Deficiency





Appendix 6 The Royal Oldham Hospital Positive Confined Space Locations According To Regulations 1997


Space I.D

Building/ Location

Location Description


Specified Risks Present Comments:-

CS01 Site wide Under crofts Under crofts No Possible, task dependant Drowning, Asphyxiation, O2 Deficiency, Fire/ Explosion

No Specified Risk noted during inspection, however these maybe introduced dependant on task and will required risk assessment if work task introduce items which could heighten risk A Safety Programme and Permit to Work may be required to enter this space, depending on the task.

CS02 21, D Block 3rd Floor plantroom

Heating Feed and Expansion Tank

Yes Drowning Asphyxiation O2 Deficiency


CS03 21, D Block 3rd Floor plantroom

Cold water storage tank



CS04 21, D Block Plantroom Cold water storage tank (in service)



CS05 21, D Block Plantroom Domestic Hot Water Storage clarifier

Yes Drowning Temperature Asphyxiation O2 Deficiency

A Safety Programme and Permit to Work will be required to enter this space Isolations to be carried out by AP PS

CS06 6,Cherrywood Plantroom Domestic Hot Water Storage clarifier



CS07 Block 80 Water storage tanks




CS08 Block 80 Water storage tanks

Cold water storage tank No.2 (in service)



CS09 Block 80 External Building

Dieso fuel storage tank No.1.



CS10 Block 80 External Building




CS11 81 Boiler house

First floor Steam hot well No.1 Yes Drowning Asphyxiation O2 Deficiency



First floor Steam hot well No.2. Yes Drowning Asphyxiation O2 Deficiency


CS13 81 Boiler First floor Cold water storage Yes Drowning Asphyxiation O2 A Safety Programme and Permit to Work will be required to




house tank No.1 Deficiency enter this space


Rear of Boiler house















Boiler house Steam boiler No.1. Yes Fire/ Explosion Temperature Asphyxiation O2 Deficiency








CS20 93 Mortuary Ground Floor Mechanical Plant Room

Cold water storage tank



CS21 93 Mortuary Ground Floor Mechanical Plant Room

Hot Water Clarifier Yes Drowning Temperature Asphyxiation O2 Deficiency


CS22 Site wide Site wide Sewerage System Manhole/ Pits



CS23 Substation B Substation B Dieso fuel storage tank



CS24 Substation C Substation C Dieso fuel storage tank



CS25 Substation D Substation D Dieso fuel storage tank



CS26 Substation G Substation G Dieso fuel storage tank






Appendix 7 North Manchester General Hospital Positive Confined Space Locations According To Regulations 1997


Space I.D

Location Location Description



CS01 A to G Blocks Under crofts under each block

Under crofts No

CS02 K Block Antenatal

3rd Floor plantroom



CS03 K Block Antenatal

3rd Floor plantroom



CS04 H Block (phase 1)

Plantroom Cold water storage tank No. 1 (in service)


CS05 H Block (phase 1)

Plantroom Cold water storage tank No. 2 (out of service)


CS06 I Block Plantroom Cold water storage tank No. 1








CS10 I Block Plantroom Domestic Hot Water Clarifier No. 1



CS11 I Block Plantroom Domestic Hot Water Clarifier No. 2



CS12 J Block Plantroom Cold water storage tank (in service)





CS13 J Block Plantroom Cold water storage tank (in service)


CS14 J Block Plantroom Chilled water buffer vessel


CS15 Site wide. Under crofts Puffin Billy No

CS16 Boiler house First floor Salt break tank Yes Drowning Asphyxiation O2 Deficiency A Safety Programme and Permit to Work will be required to enter this space

CS17 Boiler house Under boiler Redundant ash way under boilers

Yes Asphyxiation O2 Deficiency A Safety Programme and Permit to Work will be required to enter this space

CS18 Boiler house Second floor Steam hot well No.1. Yes Drowning Asphyxiation O2 Deficiency A Safety Programme and Permit to Work will be required to enter this space

CS19 Boiler house Second floor Steam hot well No.2 Yes Drowning Asphyxiation O2 Deficiency A Safety Programme and Permit to Work will be required to enter this space

CS20 Boiler house Above boiler Redundant coal hopper No.1.

Yes Fire/Explosion Drowning Asphyxiation O2 Deficiency


CS21 Boiler house Above boiler Redundant coal hopper No.2.



CS22 Boiler house Above boiler Redundant coal hopper No.3



CS23 Boiler house Rear of boiler house

Redundant coal silo No.1



CS24 Boiler house Rear of boiler house

Redundant coal silo No.2



CS25 Boiler house Boiler house Steam boiler No.1. Yes Fire/Explosion Temperature Asphyxiation O2 Deficiency






CS28 Site Wide Site wide Sewerage System Manhole/ Pits

Yes Fire/Explosion Asphyxiation O2 Deficiency Drowning


CS29 Cold Water Reservoir Tank

Adjacent to Estates Office

Cold Water Reservoir valve chamber







Cold Water Reservoir Tank No. 1




Cold Water Reservoir Tank No. 2


CS32 Crumpsall Vale Basement plantroom

Cold water storage tank No.1


CS33 Crumpsall Vale Basement plantroom

Cold water storage tank No.2 (Out of service)


CS34 D Block Western tower water tank



CS35 D Block Western tower water tank



CS36 Trust HQ Tower water tank

Cold water storage tank (out of service)





Appendix 8 Fairfield General Hospital Positive Confined Space Locations According To Regulations 1997


Space I.D

Building Location Description



CS01 Site Wide Under crofts Under crofts under each block.

No Possible, task dependant Drowning, Asphyxiation, O2 Deficiency, Fire/ Explosion


CS02 Site Wide Duct work Duct under each block. No Possible, task dependant Drowning, Asphyxiation, O2 Deficiency, Fire/ Explosion


CS03 68 Below main entrance

Tank storage enclosure.

Dieso fuel storage tank (Split into two sections)



CS04 20 A&E/X-Ray/ theatres/wards

Plantroom Hot water storage tank No. 1 (in service)




Plantroom Hot water storage tank No. 2 (out of service)




Plantroom Boosted cold water storage tank (out of service)




Plantroom Heating system Feed and Expansion water storage tank



CS08 64 Broad Oak Plant room above kitchen




















Hazardous water storage tank No. 1 (out of service)




Hazardous water storage tank No. 2 (out of service)



CS14 24 Medical records

Water tower Cold water storage tank (out of service)




Boiler house under removed boilers.

Redundant ash way under boilers.

Yes Fire/ Explosion, Asphyxiation, O2 Deficiency



Boiler house Redundant ash hopper. Yes Fire/ Explosion, Asphyxiation, O2 Deficiency



Boiler house Boiler coal hopper No.1 (Redundant)
















Oil Tank above coal hopper No.3

Fuel Storage Tank No.1 Yes Fire/ Explosion Drowning Asphyxiation O2 Deficiency



Oil Tank above coal hopper No.3

Fuel Storage Tank No.2 Yes Fire/ Explosion Drowning Asphyxiation O2 Deficiency



HV substation above coal hopper No.4

HV Substation. No access, due to new substation being locked.


Boiler house Boiler No.1 (Hoval), combustion chamber














CS27 Site Wide Site wide Sewerage System/Manholes


A Safety Programme and Permit to Work will be required to enter these spaces.

CS28 Block 40 Plantroom Chilled Water Buffer Vessel



CS29 Block 40 Plantroom Domestic Hot Water Storage Vessel



CS30 Block 40 Plantroom Domestic Hot Water Storage Vessel



CS31 Block 40 Plantroom Domestic Hot Water storage Clarifier No.1



CS32 Block 40 Plantroom Domestic Hot Water storage Clarifier No.2













YES Drowning Asphyxiation O2 Deficiency




YES Drowning Asphyxiation O2 Deficiency



Plantroom Chilled water buffer vessel YES Drowning Asphyxiation O2 Deficiency





Appendix 9 Rochdale Infirmary Positive Confined Space Locations According To Regulations 1997


Space I.D




CS01 Site wide Duct work Duct work site wide. No Possible, task dependant Drowning, Asphyxiation, O2 Deficiency, Fire/ Explosion


CS02 16 Oil pump house

Underground oil tank behind building 16

Dieso underground fuel storage tank No.1



CS03 16 Oil pump house

Underground oil tank behind building 16

Dieso underground fuel storage tank No.2



CS04 Water tank room

Water tank room Cold water storage tank No. 1



CS05 Water tank room

Water tank room Cold water storage tank No. 1



CS06 Boiler house Plant room E Boiler No.1 (Hoval), combustion chamber












CS10 Site wide Site wide Sewerage System/Manholes


A Safety Programme and Permit to Work will be required to enter these spaces.

CS11 Boiler house Plant room E Domestic Hot Water Storage Vessel


A Safety Programme and Permit to Work will be required to enter this space Isolations to be




carried out by AP PS

CS12 Boiler house Plant room E Domestic Hot Water Storage Vessel



CS13 Boiler house Plant room E Clarifier Yes Drowning Temperature Asphyxiation O2 Deficiency


Appendix 10 Floyd Unit, Birch Hill Site Positive Confined Space Locations According To Regulations 1997


Space I.D


Space Description

Confined Space?

Specified Risks Present Comments:-

CS01 Site wide Site wide Sewage System/ Manhole pits

Yes Drowning, Asphyxiation, O2 Deficiency, Fire/ Explosion

A Safety Programme and Permit to Work may be required to enter this space, depending on the task.




11. Document Control Information

All sections must be completed by the author prior to submission for approval

Lead Author: Alasdair Cockbain, General Manager Governance & Compliance (Estates & Facilities)

Lead author contact details:

[email protected] 0161 206 3240

Consultation List the persons or groups who have contributed to this

procedure. (please

state which Care Organisation)

Name of person or group Role / Department / Committee (Care Org) Date

Emma Hayes Senior Estates Operations Manager (OCO) 1/11/2019

Trevor Matthew Estates Operations Manager 9BARCO) 1/11/2019

David Harwood Fire Safety Advisor (OCO) 1/11/2019

Steven Johnson Estates Operations Manager (BARCO) 1/11/2019

Colin Oddie Estates Operations Manager (OCO) 1/11/2019

Kath Briody Occupational Health 1/11/2019

Michael O’Donovan Estates Officer (MCO) 1/11/2019

Paul Prendergast Estates Officer (BARCO) 1/11/2019

Paul Howarth Estates & Facilities Manager (MCO) 1/11/2019

Alexandra Larkin SRFT 1/11/2019

Maxine Pamphlett Occupational Health , SRFT 1/11/2019

Sue Oxford Occupational Health 1/11/2019

Philip James Group Director IM&T 1/11/2019

Jiten Patel Deputy Chief Information Officer IM&T 1/11/2019

David Armstrong Head Facilities & PFI Monitoring (SCO) 1/11/2019

Dave Townsend Project Manager Capital Development 1/11/2019

Ian Waghorn Estates Operations Manager (SCO) 1/11/2019

Spencer Gorton Estates Operations Manager (NCO) 1/11/2019

Jackie Schofield Staff Side Secretary – NCA Staff Side Reps 1/11/2019

Committee Members Circulated to CO Health & Safety members 1/11/2019

Alan Cordwell Head EPRR 1/11/2019

Steph Mills Assistant Director of Health & Safety 1/11/2019

Endorsement List the persons or groups who have seen given their support to this

procedure. (please

state which Care Organisation)

Name of person or group Role / Department / Committee (Care Org) Date

Estates and Facilities 3P General Managers Mtg 19/08/2020

mailto:[email protected]




Keywords / phrases: Confined, space, estates, contractor, rescue, top person, competent person, authorised person, risk assessment, method statement, oxygen, explosion, hazard, risk, asphyxia, drowning

Communication plan:

This document will be placed on the Document Control policy and procedures pages of the staff intranet and shared and discussed at Team meetings and this will be documented

Document review arrangements:

This document will be reviewed by the author, or a nominated person, at least once every three years or earlier should a change in legislation, best practice or other change in circumstance dictate.

This section will be completed following committee approval

Procedure Approval:

Name of Approving Committee: Estates and Facilities 3P General Managers Mtg

Chairperson: Andrew Montgomery

Approval date: 19/08/2020

Formal Committee decision Chairperson’s approval (tick)




12. Equality Impact Assessment (EqIA) screening tool Legislation requires that our documents consider the potential to affect groups differently, and eliminate or minimise this where possible. This process helps to reduce health inequalities by identifying where steps can be taken to ensure the same access, experience and outcomes are achieved across all groups of people. This may require you to do things differently for some groups to reduce any potential differences.

1a) Have you undertaken any consultation/ involvement with service users, staff or other groups in relation to this document?

Yes Please state: All Senior E&F Managers, IM&T, H&S, OHD, Staff side

1b) Have any amendments been made as a result?

Yes Please Comment: confined space medical questionnaire drafted

2) Does this procedure have the potential to affect any of the groups below differently or negatively? This may be linked to access, how the process/procedure is experienced, and/or intended outcomes. Prompts for consideration are provided, but are not an exhaustive list.

Protected Group Yes No Unsure Reasons for decision

Age (e.g. are specific age groups excluded? Would the same

process affect age groups in different ways?) x Individual risk

assessment

Sex (e.g. is gender neutral language used in the way the

procedure or information leaflet is written?) x

Race (e.g. any specific needs identified for certain groups such

as dress, diet, individual care needs? Are interpretation and translation services required and do staff know how to book these?)

x Individual risk assessment

Religion & Belief (e.g. Jehovah Witness stance on blood

transfusions; dietary needs that may conflict with medication offered.)

x

Sexual orientation (e.g. is inclusive language used? Are there

different access/prevalence rates?) x

Pregnancy & Maternity (e.g. are procedures suitable for

pregnant and/or breastfeeding women?) Individual risk assessment required due to build/size of individual entering confined space


Marital status/civil partnership (e.g. would there be any

difference because the individual is/is not married/in a civil partnership?)

x

Gender Reassignment (e.g. are there particular tests related

to gender? Is confidentiality of the patient or staff member maintained?)

x

Human Rights (e.g. does it uphold the principles of Fairness,

Respect, Equality, Dignity and Autonomy?) x Individual risk

assessment

Carers (e.g. is sufficient notice built in so can take time off work

to attend appointment?) x

Socio/economic (e.g. would there be any requirement or

expectation that may not be able to be met by those on low or limited income, such as costs incurred?)

x

Disability (e.g. are information/questionnaires/consent forms

available in different formats upon request? Are waiting areas suitable?) Includes hearing and/or visual impairments, physical disability, neurodevelopmental impairments e.g. autism, mental health conditions, and long term conditions e.g. cancer.





Are there any adjustments that need to be made to ensure that people with disabilities have the same access to and outcomes from the service or employment activities as those without disabilities? (e.g. allow extra time for appointments, allow advocates to be

present in the room, having access to visual aids, removing requirement to wait in unsuitable environments, etc.)

x Individual risk assessment required

3) Where you have identified that there are potential differences, what steps have you taken to mitigate these? A medical checklist has been developed for all staff to answer if they have any medical conditions which may affect them working in a confined space. If the member of staff answers Yes or is unsure, they will be referred to OH to assess if they are fit to undertake the task. Medical conditions may include asthma, claustrophobia, COPD, hearing impairment, visual impairment, pregnancy. An individual risk assessment will also be undertaken An individual risk assessment will be undertaken for all staff where the AP has concerns in relation to the member of staff working in a confined space e.g. age and race (fully understanding the hazards and risks associated with working in a confined space)

4) Where you have identified adjustments would need to be made for those with disabilities, what action has been taken? An individual risk assessment will be undertaken and advice from OH to ascertain if adjustments can be made or if it is in the interest of the member of staff to refrain from undertaking work in a confined space

5) Where the policy, procedure, guidelines, patient information leaflet or project impacts on patients how have you ensured that you have met the Accessible Information Standard – please state below: Individual risk Assessment/adjustment plan ……………………………………………………………………………………………………………… EDI Team/Champion only: does the above ensure compliance with Accessible Information Standard

o Yes

o No

If no what additional mitigation is required:

Will this procedure require a full impact assessment? Yes / No Please State your Rationale for the Decision (a full impact assessment will be required if you are unsure of the potential to affect a group differently, or if you

believe there is a potential for it to affect a group differently and do not know how to mitigate against this - Please

contact the Inclusion and Equality team for advice on [email protected]) Author: Type/sign: Michelle S Davis Date: 22/11/2019

Sign off from Equality Champion: Date: 03/12/2019

mailto:[email protected]

Confined Spaces (Working in) Procedure

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Transcript of Confined Spaces (Working in) Procedure