Environmental Management System (EMS) Team/EMS... · Environmental Management System Manual Version...

ENVIRONMENTAL MANAGEMENT SYSTEM

(EMS)

University of Brighton

ISO 14001:2015

Environmental Management System Manual

Version 0.13 Author: Rebecca Melhuish Approved by: Abigail Dombey Issue Date: 16/1/2017

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Date: 16th Jan 2017

Version number: 0.13

Owner: Abigail Dombey, Environmental Manager

Approval route: Carbon Management Programme Board

Approval status: Draft



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Table of Contents

1. Introduction & Scope ....................................................................................................................................................... 4

1.1 Introduction ....................................................................................................................................................................... 4 1.2 Scope of Certification ..................................................................................................................................................... 5

2. Normative References ..................................................................................................................................................... 6

3. Terms and Definitions ..................................................................................................................................................... 7

4. Environmental Management System Requirements .......................................................................................... 9

4.1 General Requirements ................................................................................................................................................... 9 4.2 Environmental Policy ................................................................................................................................................. 10 4.3 Planning ............................................................................................................................................................................ 11

4.3.1 Environmental Aspects ................................................................................................................................................ 11

4.3.2 Legal and Other Requirements .............................................................................................................................. 14

4.3.3 Objectives, Targets & Programmes ....................................................................................................................... 15

4.4 Implementation & Operation .................................................................................................................................. 16 4.4.1 Resources, Roles, Responsibility & Authority .................................................................................................... 16

4.4.2 Competence, Training and Awareness ................................................................................................................. 22

4.4.3 Communication ............................................................................................................................................................... 23

4.4.4 Documentation ............................................................................................................................................................... 25

4.4.5 Control of Documents................................................................................................................................................... 26

4.4.6 Operational Control ...................................................................................................................................................... 27

4.4.7 Emergency Preparedness & Response .................................................................................................................. 28

4.5 Checking ........................................................................................................................................................................... 29 4.5.1 Monitoring & measurement ...................................................................................................................................... 29

4.5.2 Evaluation of Compliance .......................................................................................................................................... 33

4.5.3 Non Conformity, Corrective and Preventive Action ....................................................................................... 34

4.5.4 Control of Records ......................................................................................................................................................... 35

4.5.5 Internal Audit .................................................................................................................................................................. 36

Appendix A – Related EMS Documents ....................................................................................................................... 40



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1. INTRODUCTION & SCOPE

1.1 INTRODUCTION

The University of Brighton has adopted Sustainability as one of its four core values, set out in the

University Strategy (2016-2021). The university strives to be a centre of excellence for sustainability

research, work with local, regional and global communities and all of our teaching and learning, across all

subject areas. This work is all supported by a belief in creating learning and working environments that

embrace sustainability at their core.

The university makes a significant contribution to sustainability, not only in our role as a recognised

provider of research and teaching, but also the way we perform as a business and engage positively with

the local and wider community. If sustainability is to be achieved, economic, social and environmental

goals must be progressed simultaneously.

The aim of this Environmental Management System Manual (EMS Manual) is to explain the core elements

of the EMS and their interaction. The EMS Manual outlines how operational elements are managed, as

well as outlining the roles and responsibilities of key individuals with the EMS.



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1.2 SCOPE OF CERTIFICATION

The scope of certification for this Environmental Management System (EMS) is:

All areas of the University of Brighton Estate

The University Estate is defined as all areas under operational control by university member of staff. This

includes five main sites across the South East of England; three sites in Brighton, one in Eastbourne and

one in Hastings. The scope also stretches to the university managed Halls of Residences in Brighton, but

not those managed by third parties.

Centrally the EMS is held and continually managed by the Environment Team of the university based at

Exion 27, Crowhurst Road, Hollingdean, Brighton, BN1 8AF.



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2. NORMATIVE REFERENCES

All references are taken from the ISO14001:2015 international Standard.



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3. TERMS AND DEFINITIONS

Auditor: person with competence to conduct an audit.

Compliance Register: Register of applicable legal and other requirements relating to the activities

undertaken by the university.

Continual Improvement: recurring process of enhancing the Environmental Management System in

order to achieve improvements in overall Environmental performance consistent with the university’s

Environmental Policy.

Corrective Action: Reactive actions to eliminate the cause of Nonconformity.

Environmental Manager: Responsible for aspects of the EMS (see 4.4.1)

Document Register: Repository of information regarding the status of EMS documents and records.

Emissions: Any output from the firms’ operations that have an impact

EMS Documents: documents that are required by and form part of EMS including the Environmental

Policy, Environmental Objectives, Environmental Targets and EMS records.

Environment: surroundings in which the University of Brighton operates, including air, water, land,

natural resources, flora, fauna, humans, and their interrelation.

Environmental Aspect: element of the university’s activities that can interact with the Environment.

Environmental Auditor: person who has received appropriate auditor training and who is named in the

Internal Auditor List.

Environmental Impact: any change to the Environment, whether adverse or beneficial, wholly or

partially resulting from the university’s Environmental Aspects.

Environmental Management System (EMS): the University of Brighton’s management system used to

develop and implement its Environmental Policy and manage its Environmental Aspects.

Environmental Objective: overall environmental goal, consistent with the university’s Environmental

Policy, which the university sets itself to achieve.

Environmental Performance: results of the university’s management of its environmental aspects

measured against its Environmental Policy, Environmental Objectives, Environmental Targets and other

environmental performance requirements.

Environmental Policy: overall intentions and direction of the University of Brighton related to its’

Environmental Performance.

Environmental Target: detailed performance requirement, applicable to the University of Brighton or

parts thereof, that arise from the Environmental Objectives and that needs to be set and met in order to

achieve those objectives.

Interested Party: person or group concerned with or affected by the Environmental Performance of the

university.



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Internal Audit: systematic, independent and documented process for obtaining audit evidence and

evaluating it objectively to determine the extent to which the environmental management system audit

criteria set by the university are fulfilled.

Internal Auditors: persons nominated within EMS and with the requisite training to audit compliance

with EMS

Legal and Other Requirements: applicable legal requirements and other requirements to which the

University of Brighton subscribes related to its Environmental Aspects (including non-regulatory

guidelines and public commitments).

Management Programme: programme detailing responsibilities, activities, budget and timescale of

achievement for each Environmental Objective and related Environmental Target(s).

Major Incident: an accident or incident which is not contained within the site boundary and/or requires

the involvement of a regulatory authority.

Minor Incident: an accident or incident which is contained within the site boundary of the university and

which does not require the involvement of a regulatory authority.

Nonconformity: non-fulfilment of an EMS or ISO14001 requirement.

Preventive Action: Proactive action to eliminate the cause of an actual or potential Nonconformity.

Prevention of Pollution: use of processes, practices, techniques, materials, products, services or energy

to avoid, reduce or control (separately or in combination) the creation, emission or discharge of any type

of pollutant or waste in order to reduce adverse Environmental Impacts.

Procedure: specified way to carry out an activity or process.

Resources: any substance or material consumed or used by the firm that has an impact

Support Services Managers and Supervisors: those with specific responsibility for one or more

procedures under EMS.

University: term used when referring to the University of Brighton as a whole.

University of Brighton: All areas of the university estate, as outlined within the scope section of the

Environmental Management System.



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4. ENVIRONMENTAL MANAGEMENT SYSTEM REQUIREMENTS

4.1 GENERAL REQUIREMENTS

The University of Brighton has established, documented, implemented, maintains and strives to

continually improve our environmental management system in accordance with the requirements of BS

EN ISO14001 through adherence with the policies and procedures laid out in this manual.



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4.2 ENVIRONMENTAL POLICY

The University of Brighton has established its Environmental Policy and ensures that, within the defined

scope of our Environmental Management System, it is communicated to all staff and persons working for

or on behalf of the university and is publically available.

The University of Brighton's Senior Management Team, Sustainable Development Management Group

and the Carbon Management Programme Board, who all share responsibility for this policy, fully support

the commitment and objectives outlined. The final sign off of this policy is the responsibility of the Vice

Chancellor on behalf of the Board of Governors.

It is the responsibility of all staff, students, visitors and contractors to help embed this policy in the

everyday life of the university community.



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4.3 PLANNING

4.3.1 ENVIRONMENTAL ASPECTS

The University of Brighton has established this procedure to identify those environmental aspects of its

activities, over which it has control or influence, taking into account planned or new developments.

Environmental aspects are evaluated to determine those which are significant and therefore require

monitoring and, where possible, mitigation. This information is taken into account when maintaining the

EMS. The results of this identification and evaluation process are recorded in the register of

environmental aspects and regularly reviewed.

The process of accurately identifying environmental aspects and evaluating associated environmental

impacts is central to the success of the EMS. The process can be summarised as follows:

All significant environmental aspects must be monitored and, where possible, mitigated. The significance

of an environmental aspect is determined by reference to its likely frequency of occurrence and the

severity of the consequences of occurrence in accordance with the following table, based upon the

recorded normal, abnormal and emergency conditions outlined within the register of environmental

aspects:

*Can be positive or negative depending if the impact is positive or negative

Significance = Frequency of Occurrence x Potential Severity

A score of 9 (+ or -) or more indicates that an environmental aspect is significant. Environmental aspects

which do not score 9 (+ or -) or more but which are the subject of a legal requirement, or which have

significant potential to damage the reputation of the university, are automatically deemed significant.

When determining the potential severity of an environmental impact consideration must be given to the

scale of the university’s activities giving rise to that impact.

Frequency of occurrence Factor Potential severity Factor*

Unlikely (less than once a year) 1 Minimal 1 or -1

Common (monthly/ more than once a

year) 2 Low 2 or -2

Frequent (daily/weekly) 3 Moderate 3 or -3

High 6 or -6

Severe 10 or -10



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Our approach to identifying environmental aspects considers the following:

Emissions to air;

Releases to water;

Releases to Land;

Waste and by products;

Energy Use;

Energy Emitted (e.g. heat);

Use of raw materials and natural resources;

Physical attributes (e.g. size, shape, colour, appearance)

University’s core activities (e.g. teaching and learning)

The results of the environmental aspect identification and evaluation process are recorded in the register

of environmental aspects.

The register contains the following information:

A list of all university’s activities within the scope of the EMS that generate environmental

aspects under normal, abnormal and emergency conditions;

A list of related environmental impacts;

An evaluation of the significance of each identified environmental aspect;

Supporting information to lend evidence to the evaluation of significance; and

The university documents and committees relevant to each impact.

The process of identifying and evaluating the significance of environmental aspects arising from our

activities is on-going and the responsibility for keeping the register up to date will be with the

Environmental Team, with the overall responsibility being the role of the Environmental Manager.

In order to ensure that the EMS continues to address priority issues we will review our register of

environmental aspects annually as part of the annual review process.

The register will also be reviewed in the following circumstances:

As a consequence of any significant changes to the organisation’s activities or services;



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As a consequence of any relevant changes to the Compliance Register;

As a consequence of feedback from environmental incidents, complaints and/or non-

conformances identified during the internal or external audit process; and

In response to stakeholders’ reported and documented concerns.



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4.3.2 LEGAL AND OTHER REQUIREMENTS

The University of Brighton has established this procedure to identify and enable access to all applicable

legal and other requirements to which the university subscribes and which relate to its environmental

aspects. A list of identified legal and other requirements is recorded in our compliance register and this

information is taken into account in maintaining the Environmental Management System (EMS).

All legal and other requirements relevant to the university’s environmental aspects at the launch of the

EMS were identified. The results of the legal review are recorded in the compliance register. New legal

and other requirements are screened for their relevance to the university and the compliance register

amended as appropriate.

The introduction of new or amended legal and other requirements is principally monitored by the regular

review of resources such as Cedrec Environmental, the Environment Agency and the Health and Safety

Index.

The introduction of new or amended legal and other requirements that are considered by the

Environmental Manager, or nominated representative, to be of particular relevance and importance to

the university are cascaded to relevant employees as quickly as practicable. Communication may be via

email, intranet, oral communication or internal mail.

The Environmental Manager or nominated representative will review the subscription and other

resources to which s/he has access on a monthly basis to determine any changes to legal and other

requirements.

The Environmental Manager will appoint a competent person to review the compliance register on a

twice annual basis and update the compliance register after identification of any relevant changes to legal

and other requirements and following management review (if necessary).

The Environmental Manager will also identify and amend any elements of the EMS affected by changes to

legal and other requirements as necessary and communicate those changes to relevant employees as

quickly as practicable.

Awareness of and compliance with legal and other requirements will be assessed during the programme

of internal environmental audits, by those competent to do so.



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4.3.3 OBJECTIVES, TARGETS & PROGRAMMES

The University of Brighton has developed this procedure in order to establish, implement and maintain

environmental objectives and environmental targets consistent with our Environmental Policy, legal and

other requirements, significant environmental aspects and other considerations as appropriate.

In establishing our environmental objectives targets we have given consideration to many areas. These

include; the university’s Strategic Plan; past Environmental Policies; legal and other requirements; the

significant environmental aspects and environmental impacts of all our operations; technological and

financial options; operational and business requirements; and the views of various interested parties as

appropriate.

Specific and measurable environmental targets are set in order to help us to achieve our environmental

objectives within a specified time frame. Responsibility for specific environmental objectives and related

environmental target(s) is assigned by the Environmental Manager. The final sign off of each strategy will

lie with the relevant Board or Committee of the university. These groups include; the Carbon

Management Programme Board, Estates Committee, Learning and Teaching Committee, Sustainable

Development Policy Co-ordination Group, Finance and Audit Committee, with the final decision on all

strategies lying with the Board of Governors of the university.

For each objective a strategy is outlined, or under development, which also details the activities required

to meet objectives and targets, the time frame (including any significant milestones) for achievement, and

related budget information. The strategies do not need to be exactly followed, as they constitute a guide,

so long as the objectives and targets are met.

Where the achievement of an environmental objective or environmental target is, or is likely to be,

delayed or cancelled for any reason the responsible manager should report this to the Environmental

Manager.

The responsible manager and the Environmental Manager will then collaborate to revise the

environmental target and/or related environmental objective as appropriate.

Our environmental objectives and environmental targets will be reviewed as follows:

On an annual basis as part of the management review process;

As and when changes are made to the compliance register;

In response to other changed circumstances;

When failure to meet an environmental objective or environmental target is highlighted through

audit; and

As a consequence of documented and reported stakeholder concerns.



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4.4 IMPLEMENTATION & OPERATION

4.4.1 RESOURCES, ROLES, RESPONSIBILITY & AUTHORITY

The University of Brighton has established this procedure to ensure the availability of resources essential

to establish, implement, maintain and improve the EMS.

Resources include human resources and specialised skills, organisational infrastructure, technology and

financial resources.

Organisation

The overall organisational structure of the EMS is set out in the appended EMS Organisation Chart. The

chart illustrates the relationship between the Carbon Management Programme Board, Environment

Team and all university staff with respect to the EMS.

The Environmental Manager has been nominated as the management representative and reports on the

performance of the EMS to management at Management Review as a basis for improvement of the EMS.

EMS Organisation Chart

Board of Governors

Management Group

Carbon Management Programme Board

Environment Team

Environmental Manager

Support Service Managers and

Supervisors

All University Staff

Management Review Group



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Responsibilities

Board of Governors and Management Group are responsible for:

Sign off of all relevant EMS documents.

The Carbon Management Programme Board is responsible for:

Approving and endorsing Environmental Objectives and Targets for the university.

Ensuring that the resources essential to the implementation and control of the EMS are made

available.

Co-ordinating any review of the Environment Policy.

Conducting a Management Review Meeting to discuss the implementation of the EMS.

The Management Review Group is responsible for:

Ensuring appropriate mechanisms are in place to ensure legal compliance in all business activities

at the university.

Secure the resources required to maintain the EMS.

Ensure the EMS is established, implemented and maintained.

Monitor the performance of the EMS.

Establish, review and revise the institution’s environmental policy, objectives and other elements

of the EMS.

Report on the EMS to the Carbon Management Programme Board.

The Environment Team comprises the Environmental Manager, the Energy Management Engineer, the

Environment Officer, Assistant Environment Officer, Assistant Environmental Communications Officer

and the Sustainable Behaviour Assistant. The Environment Team can also call upon any other competent

persons deemed necessary to assist in implementing and maintaining the EMS. The Environment Team is

responsible for:

Ensuring that sufficient and appropriate measures are adopted and employed throughout the

university to prevent the occurrence and/or mitigate the effects of emergency environmental

situations or accidents.

Ensuring that the decisions and actions adopted at Management Review and Internal Audits are

implemented as appropriate.

Ensuring all documents in the Document Control Register are up to date with the correct version

number.

Devise and promote initiatives to inform interested parties about the EMS.



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Help the EMS Manager to regularly audit the EMS.

The Environmental Manager is responsible for:

Represents all environmentally related work carried out at the university, at the EMS

Management Review Group meetings.

The establishment and maintenance of the Register of Environmental Aspects.

Evaluating the significance of the identified Environmental Aspects.

To ensure day to day compliance with the Compliance Register and, in consultation with Support

Services Managers and Supervisors, and any other relevant parties, to modify procedures, and

document changes to procedures, to ensure compliance.

Monitoring progress against the Environmental Objectives and Environmental Targets and

reporting periodically to the Carbon Management Programme Board.

Compiling information with respect to progress towards Environmental Objectives and

Environmental Targets and communicating this internally.

Assigns Roles, Responsibilities and authority and informs individuals about their obligations

including suppliers and contractors.

Maintaining a record of official correspondence relating to the EMS and related issues and for

maintaining a Register of Environmental Complaints.

Ensuring that actual and potential Nonconformities are resolved quickly and efficiently.

Authorising, issuing and maintaining EMS Documents (in consultation with related personnel

where appropriate).

Ensuring that the EMS is established implemented and maintained in accordance with the

requirements of EcoCampus and ISO14001.

Reporting to the Carbon Management Programme Board on the performance of the EMS for

review, including recommendations for improvement.

Ensuring that all relevant personnel are informed about EMS Documents which impact on their

duties.

Ensuring that controlled EMS Documents are current and available at the point of use, and is also

responsible the maintenance of the Document Control Register.

Organises the programme of Internal Audits and EMS Management Reviews.

Auditing the EMS in accordance with the requirements of EcoCampus and ISO14001 and to report

the results to the EMS Management Review Group.

Appointing an accredited external auditor to ensure that external audits are conducted at a

frequency appropriate to the maintenance of both EcoCampus and ISO14001 certification.



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Preparing the EMS Management Review agenda and co-ordinating the provision of information

necessary to complete the Management Review to attendees.

Arranging for minutes of the EMS Management Review Meeting to be taken and for retaining

these records.

Communications on the EMS or related issues with regulatory bodies, local authorities or the

emergency services.

Compiling an annual report on the implementation of the EMS across the university.

The Environmental Officer is responsible for:

Establishing and maintaining the Compliance Register.

Appraising the Carbon Management Programme Board Members, Auditors, Site, Departmental

and Line Managers, of the Compliance Register and specifically any changes that are made.

Identification of training needs across the University.

Development and implementation of an environmental training plan (which includes a schedule

of training).

The Assistant Environmental Communications Officer is responsible for:

Maintaining one full controlled copy of the EMS in hard copy.

External communication of certain environmental information via media as appropriate.

Communicating to partners and staff important aspects of the EMS and maintaining a log of

internal communications.

The Assistant Director of Estate and Facilities Management (Facilities) is responsible for:

Working with Safety Committee to investigate all emergency incidents and, where there is an

environmental impact, to report to the Environmental Manager, the Carbon Management

Programme Board and to the Board of Governors where appropriate on:

o Causes of accidents, including any non-conformities,

o Arrangements taken to prevent or mitigate any further environmental impact,

o Arrangements, if necessary, to make good any damage to property,

o Action plan to prevent recurrence of the incident (including modification of those parts of

the EMS as required)

Coordinating the response to an emergency environmental situation or accident.

Ensuring that spill kits are available and maintained at appropriate locations across the

university.



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Ensuring that individuals who may be called upon to respond to an emergency environmental

situation or accident have had appropriate training and instruction, and where possible follow

documented procedures to minimise the environmental impact of an incident.

Individual managers are responsible for:

Allocating responsibility for managing the achievement of Environmental Objectives and

Environmental Targets relating to their activities, and reporting on progress to the Environment

Team.

Ensuring that personnel (including external contractors) under their control are appropriately

trained to complete their tasks.

Ensuring that the Environmental Policy and relevant elements of the EMS are communicated to

employees and/or contractors within their line management function prior to commencement of

work.

Reporting environmental performance information to the Environmental Manager.

Ensuring that any contractors operating under their authority in or around the university are

made aware of, and comply with, these requirements.

Ensuring that corrective and/or preventive actions are properly implemented within the specified

time frame.

All managers and staff are responsible for:

Notifying the Environmental Manager of any incidents or accidents.

Notifying the Environmental Manager of any known changes to their activities that are likely to

affect the Register of Environmental Aspects.

Advising the Environmental Manager if they become aware of changes to current or proposed

Legal and Other Requirements which may impact on their duties or related activities.

Proposing Environmental Objectives and Environmental Targets for the University, through

contacting the Environmental Manager.

Contributing to the achievement of the University of Brighton’s Environmental Objectives and

Environmental Targets.

Ensuring that they comply with the provisions of this procedure to the extent that it relates to

matters within their control.

Communicating any issues which may affect the Environmental Policy or EMS to the

Environmental Manager.

Cooperating with internal and/or external auditors.

Ensuring that they are familiar with the current versions of documents as required.



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Providing feedback on the continuing suitability of EMS Documents which impact on their duties

to the Environmental Manager.

Bringing suspected, potential or actual Nonconformities to the attention of the Environmental

Manager as soon as practicable.

Any other duties specified in the EMS in which specific responsibility has been allocated to them.

Internal Auditors are responsible for:

Ensuring that Internal Audits are carried out in accordance with the requirements of ISO14001.

Familiarising themselves with the activity or element of the EMS to be audited and prepare an

Internal Audit Checklist prior to Internal Audit.

Follow-up on any Nonconformity identified in the course of an Internal Audit and ensure that

agreed Corrective Actions are implemented in the correct timescale.

Specific Management Responsibilities:

Procurement Services Manager is responsible for the Sustainable Procurement Strategy.

Director of Finance is responsible for the Ethical Investment Policy.

All other procedures are responsibility of Environment Team.



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4.4.2 Competence, Training and Awareness

The University of Brighton has established this procedure to ensure that any persons performing tasks

for the university that have the potential to impact on a significant Environmental Aspect are competent

on the basis of appropriate education, training or experience.

Environmental training is provided to ensure that personnel at each relevant function and level are aware

of:

The importance of conformity with the Environmental Policy and adherence with the procedures

and requirements of the EMS;

Those significant Environmental Aspects associated with their work and how improved personal

performance can benefit the environment;

Their roles and responsibilities in achieving conformity with the requirements of the EMS; and

The potential consequences of departing from specific procedures.

At induction all new personnel receive appropriate environmental awareness training. All existing

personnel are required to complete an equivalent online environmental awareness training module.

Personnel who carry out work associated with significant Environmental Aspects receive additional

Environmental Competency Training to enable them to fulfil their duties in a manner consistent with the

aims of the Environmental Policy and requirements of the EMS. Refresher training is provided for these

personnel as appropriate.

Contractors will be made aware of and be required to abide by the Environmental Policy of the university.

Any contractors bringing chemicals, oils or refrigerants onto site will be required to provide appropriate

containment units (e.g. bunding etc). All contractors dealing with these materials will be required to

provide spill training to all staff attending university premises. All waste should be removed off site by

contractors, unless previously agreed by the university. This should be included in all contracts.

Mapping of training records providing details of the type of environmental training received, date and

name of each attendee are maintained by the Environmental Team. Many of these are also duplicated by

Line Managers, Health and Safety Officers and Supervisors (to ensure that all of their direct reports have

had the requisite training).

Environmental training requirements will be assessed regularly as part of the Management Review and in

accordance with wider university policy on induction and ongoing training and development.



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4.4.3 COMMUNICATION The University of Brighton has established this procedure to manage internal and external

communications with respect to the EMS and related matters. All EMS communication materials will be

mapped across the university and the spreadsheet will be updated and maintained by the Environment

Team.

The University of Brighton receives communications around all areas of our environmental management

from a large number of different areas, communicating with a large number of personnel across the

university. Many of these communications are dealt with at source and others are escalated up to the

Environment Team.

Internal communications

The Environment Team is responsible for co-ordinating and logging all internal communications relating

to the EMS.

Environmental information is communicated internally in a variety of ways as follows:

Uncontrolled copies of certain EMS elements are displayed in appropriate locations around the

university. Only those EMS elements essential to day-to-day operations are printed and displayed

in this way to minimise paper waste and to maintain Document Control.

Where new or amended EMS elements become available these are brought to the attention of

relevant employees as soon as practicable. Personnel are also reminded to update any printed

versions of the documents under their control.

Workshops, seminars and/or other training events (including induction training) are used to

inform employees about the scope of the EMS, its purpose and the general duties which it imposes

on all employees.

Employees and contractors whose activities directly impact on Significant Environmental Aspects

are provided additional specific training as appropriate.

The university’s internal communications network is used to keep employees informed of general

EMS developments and related matters.

Specific information on the EMS and related matters is also communicated via meetings and/or

telephone conversations with relevant personnel where appropriate.

In line with 4.4.2 Contractors working at the university are made aware of the Environmental

Policy, relevant procedures and standards of environmental care required by the EMS before any

work may commence.

The Environment Team encourages the use of electronic communication wherever possible/ appropriate

in order to help minimise paper waste.



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External communications

The Environment Team are provided copies of all written communications from external interested

parties relating to the EMS and related matters and responds to these as appropriate.

All correspondence from regulatory authorities relating to suspected environmental offences will be

prioritised for urgent action. In all cases the Environmental Manager will be informed immediately and

appropriate action will be taken as soon as practicable.

Records of correspondence with regulatory authorities relating to the EMS and related matters are

retained for a minimum period of five years.

The University does not communicate our significant aspects externally. However certain environmental

information, such as performance information, is externally communicated via reports, the university’s

website (brighton.ac.uk), and/or other media as appropriate. All data derived from the EMS must be

confirmed as accurate by the Environmental Manager before publication.

Complaints

Details of any received Environmental Complaints are dealt with at source and others are escalated up to

the Environment Team, as appropriate.

The complainant will be informed that his/her complaint is being investigated and that further

information will be provided as appropriate when the investigation is complete.

Once the validity of the complaint has been verified appropriate Corrective Action and/or Preventive

Action will be implemented as soon as practicable.

All environmental complaints are mapped across the university. The relevant staff are responsible for

recording all complaints in relevant logs.

Records of communications with complainants are retained for a minimum period of five years.



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4.4.4 DOCUMENTATION The University of Brighton has established the following EMS Documents to ensure the effective

management of the university’s environmental performance:

An Environmental Policy, Environmental Objectives and Environmental Targets (the later

outlined within the Environmental Policy Action Plan and other associated plans);

A description of the scope of the EMS;

The Compliance Register and Environmental Impact and Aspect Register;

A description of the main elements of the EMS and their interaction, and reference to related

documents;

Documents, including records, required by ISO14001;

Documents, including records, determined by the university to be necessary to ensure the

effective planning, operation and control of processes that relate to significant Environmental

Aspects.

Controlled copies of the EMS Manual are held by the Environment Team as part of the university file

storage system.

In addition, the university holds copies of the following:

BS ISO 14001:2015



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4.4.5 CONTROL OF DOCUMENTS The University of Brighton has developed this procedure in order to ensure that all EMS Documents are

controlled.

All hard copy controlled EMS Documents are maintained by the Environment Team and approved by the

relevant Committee or Board.

All other printed versions of EMS Documents are uncontrolled copies. All EMS documents are stored in

electronic form in the university’s internal document control system (sharepoint).

Each document is given an updated version number when changed. Any printed document without a

version number will not be considered a controlled document.

EMS Documents are reviewed under the following circumstances:

On an annual basis as part of the Management Review process;

In order to help achieve an Environmental Objective or Environmental Target;

In response to changed circumstances such as new or amended Legal and Other Requirements;

As and when changes are requested by relevant personnel;

In response to audit; and

As a consequence of documented and reported stakeholder concerns.

Following review EMS Documents are amended as necessary.

Any obsolete documents that are retained for legal and/ or knowledge preservation purposes are suitably

identified and filed by the Environment Team.

Compliance with the requirements of this procedure is reviewed periodically via Internal Environmental

Management System Audits.



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4.4.6 OPERATIONAL CONTROL The University of Brighton has established this procedure in order to identify and plan those operations

that are associated with the identified significant environmental aspects consistent with the

Environmental Policy, Objectives and Targets, in order to ensure that they are carried out under specified

conditions.

The Environment Team have mapped the need for operational procedures associated with significant

Environmental Aspects. This mapping is updated taking into consideration Environmental Aspects and

any changes to operations of the university and stored in the document control system.

The following operational procedures have been established:

Waste Disposal Procedure

Chemicals Procedure

Procurement Procedure

Refrigerant Gas Procedure

Water Management Procedure

Fuel and Oil Procedure

Contractor Procedure

Noise Procedure

Energy Management Procedure

Asbestos Procedure

Legionella Procedure



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4.4.7 EMERGENCY PREPAREDNESS & RESPONSE The University of Brighton has established this procedure in order to identify potential emergency

situations and potential accidents that can have an impact(s) on the environment and document how the

university will respond to them.

In the event of an accident or emergency environmental situation arising, action will be taken as soon as

possible to prevent and/or mitigate associated adverse Environmental Impacts.

The following incidents must be immediately reported to the Environmental Manager who must record

them using the incident form:

Any unplanned and/or sudden release from pressure systems or of any solvent, or the venting,

planed or otherwise of any gas,

Failure of drainage, breach of closed water systems, or breach of open water systems other than

at a tap or drain cock.

The release of any substances other than rain water to surface water drains.

The loss of any waste load from its point of origin on the premises until it arrives at its final point

of disposal, either by accident or due to fly tipping.

The Environmental Manager will, as soon as practicable, determine the scale and severity of the

emergency environmental situation or accident and, depending on the circumstances, classify it as either

a Major Incident or a Minor Incident.

All Major Incidents must be reported to the relevant regulatory authorities as soon as reasonably

practicable.

The Environmental Manager will take all reasonable steps to ensure that any release as a result of an

emergency environmental situation or accident is contained and that any resultant harm to the

environment is minimised.

Following an emergency environmental situation or accident all reasonable measures will be taken to

ensure that any environmental damage is properly remedied and additional preventative action agreed.

Wherever spill kits or other materials have been deployed in the course of an environmental situation or

accident they will be disposed of in accordance with relevant waste management legislation.

Following an environmental situation or accident an Emergency Report Form must be completed by the

Environmental Manager as soon as practicable.

Specific types of emergency are dealt with in detailed emergency procedures:

Fire Procedure

Emergency Spill and Leak Procedure

Legionella Procedure



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4.5 CHECKING

4.5.1 MONITORING & MEASUREMENT

The University of Brighton has established documented procedures to ensure that the key characteristics

of its operations and activities that may have a significant impact on the environment are regularly

monitored and measured.

Those measurements that are not performed by university personnel are carried out by suitably qualified

sub-contractors.

There are several environmental aspects of operations carried out at the university which are routinely

monitored and measured as follows:

This Table needs to be completed, aspects added if needed, or removed.

Resources Units Report

Frequency

Responsible person Data systems

Electricity

KWh Quarterly Environmental

Manager

Gas

KWh Quarterly Environmental

Manager

Water

Litres Quarterly Environmental

Manager

Fuel oil and diesel Litres

Paper purchase Reams

Other chemicals and

substances

Kg

Emissions/waste Streams Units Report

Frequency

Responsible person Data system

Carbon Tonnes (CO2e) Environmental

Manager

Refrigerants Kg Annually Environmental

Manager

F gas Register

Hazardous Waste

Kg Monthly? Cox Group?

Controlled Waste Kg Monthly? Cox Group?

Mixed general office waste for

recycling

Kg Monthly? Cox Group?

WEEE Kg Monthly? Cox Group?



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Cooking oil Kg Monthly? Cox Group?

Scrap metal Kg Monthly? Cox Group?

Wood Kg Monthly? Cox Group?

Cardboard Kg Monthly? Cox Group?

Other Parameters Units Report

Frequency

Responsible person Data system

Drinking water (Microbial

TVC)

Cooling water (legionella) Detected/Not

detected

Cooling water (Microbial TVC) Cfu/l

Cooling water (pH) value

Cooling water (Temp) °C

Cooling water (Conductivity) Micro-siemens /cm

Cooling water (Dipslides) cfu

Cooling water (Bromine) ppm

Cooling water (TDS) ppm

Cooling water (TSS) ppm

Redox?

Tap temps (infreq)

Cold water tanks (Temp) °C

Cold water tank (Microbial

TVC)

Cfu/l

Air (CO) ppm

Air (CO2) ppm

Air (particle count) No. of particles @

size 0.5/1.0/5.0

microns

Air (dust1) mg/m3

Air (microorganism) cfu’s per 180l

1 Indoor air quality, hence not counted as an emission



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Air (temp) °C

Air (humidity) %RH

Air (head height flow) m/s

Washrooms, drinking water,

vending machines and kitchen

outlets (microbial TVC)

Cfu/l (@22°C and

37°C)



outlets – pseudomonas

aeruginosa

Detected/Not

detected



outlets – TT E. coli

Detected/Not

detected



outlets – Coliform species

Detected/Not

detected

Tap temps °C

If there is an unexpected increase in resource consumption or waste disposal that cannot be accounted

for (other than as a result of increased business activity or planned programmes) an investigation is

mounted and, if appropriate, corrective and preventive measures are instigated.

Water

We monitor all closed water systems for total dissolved solids and look for evidence of copper for

corrosion on a quarterly basis. The procedures for and records kept in respect of these tests are retained

by the Building Services Manager.

Internal tests for biocides and microbiological contamination (such as Legionella) are carried out once

per week. An independent check for microbes and general water quality is also carried out by external

contractor quarterly. The procedures for and records kept in respect of these checks are retained by the

Building Services Manager.

Air quality

External contractors measure air quality across the University estate for particulates, microbes,

temperature and relative humidity twice each year. The procedures for and records kept in respect of

these tests are retained by the Environmental Manager.



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Objectives and Targets

Information regarding progress against stated Objectives and Targets is recorded as described in section

4.3.3.

Legal Compliance

The effectiveness of this procedure is reviewed periodically via Internal Audit. Information on

monitoring and measurement activities is reviewed at Management Review.



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4.5.2 EVALUATION OF COMPLIANCE

The University of Brighton has established procedures for periodically evaluating compliance with

applicable legal requirements.

Evaluation of compliance against legal and other requirements is scheduled and carried out on a 6

monthly basis via the internal audit process.

Evidence of compliance against legal and other requirements is recorded in the compliance register along

with the date compliance was last checked. Any non conformities arising from audits will be dealt with

through use of the procedure detailed in 4.5.3.



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4.5.3 NON CONFORMITY, CORRECTIVE AND PREVENTIVE ACTION

The University of Brighton has established this procedure to ensure a managed response to actual or

potential Nonconformities through effective corrective and preventive action.

Actual or potential Nonconformities may be identified as a result of:

Internal or external audits;

Environmental complaints;

Observations / identified opportunities for improvement;

Incidents or near misses;

Changes to the EMS:

Changes to Legal and Other Requirements; and

Housekeeping inspections.

Once an actual or potential Nonconformity has been identified the Environmental Manager must

investigate the underlying cause(s) and determine, in consultation with relevant personnel as necessary,

appropriate corrective and/or preventive action with a specified time frame for execution.

In determining what Corrective Action and/or Preventive Action is appropriate the Environmental

Manager will take into account the scale and severity of any associated Environmental Impacts.

Details of identified Nonconformities and related corrective and preventive action (including a timescale

for completion) are recorded on a Nonconformity Report Form. Once completed all paperwork is sent to

the Environment Team for filing.

Preventive Action might include implementing new or amended procedures or controls. Where such

Preventive Action necessitates changes to the EMS those changes are documented and recorded in

accordance with our Document Control Procedure.

Nonconformities and the effectiveness of related corrective and preventive action are reviewed as part of

the Management Review process.



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4.5.4 CONTROL OF RECORDS

The University of Brighton has established procedures for the identification, storage, protection, retrieval,

retention and disposal of environmental records.

The university maintains its records so that they are legible, identifiable and traceable to the related

activity or element of the EMS.

The appended table lists those records that form part of the EMS, their specified retention period, any

related EMS elements and the personnel responsible for their maintenance. These personnel are

responsible for ensuring that records are legible, identifiable, traceable and appropriately stored and

disposed of.

The effectiveness of this procedure is reviewed periodically via Internal Audit.

The Environmental Manager will review Environmental Records periodically to identify any issues or

trends that may highlight areas for improvement.



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4.5.5 INTERNAL AUDIT

The University of Brighton has established this procedure to ensure that Internal Audits of the EMS are

conducted at planned intervals to:

Determine whether the EMS conforms to planned arrangements for environmental management

including the requirements of ISO14001; and

Has been properly implemented and is maintained.

Information on the results of Internal Audits is provided to management as appropriate.

In order to ensure that Internal Audits of the EMS are conducted at appropriate intervals the

Environmental Manager/Environmental Officer has devised an annual Audit Schedule. The Audit

Schedule may be expanded where necessary to allow for one-off Internal Audits and the re-auditing of

corrective action from previous Internal Audits.

The frequency with which a particular activity or element of the EMS is audited is determined according

to the significance of each Environmental Aspect associated with that activity or element of the EMS. The

greater the significance of an Environmental Aspect the more frequently any associated activities or

elements of the EMS are audited.

An Internal Auditor List indicating the name and position of each Environmental Auditor is maintained by

the Environment Team. All Environmental Auditors receive appropriate training before undertaking an

Internal Audit. Appropriate training records are maintained.

Environmental Auditors record details of any observations or Nonconformities identified in the course of

Internal Audits. Nonconformities are classified as either Major or Minor. This distinction is used in the

planning of Corrective Action as follows:

A Major Nonconformity is one causing a serious departure from the requirements of the EMS or

ISO14001 and a possible breakdown of the system. This would include any legislative or regulatory

infringement with the potential to cause a failure in the EMS. In the case of a Major Nonconformity

Corrective Action must be taken immediately. Examples of Major Non Conformities are:

A missing requirement of the ISO 14001: 2015 standard

A series of minor concerns relating to the same clause that cannot be resolved by a single

corrective or preventive action but require systemic activity over time.

Repeated instance of the same problem in several different areas or at several different times or

after preventive action has been recorded as having taken place.

A lack of corrective action from a previous non-conformity highlighted in subsequent audit.

A Minor Nonconformity is a single departure from the EMS or requirements of ISO14001 that will not

cause a breakdown of the system and can be corrected on a time scale appropriate to the severity of the

infringement (as determined by the Environmental Manager).



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An Observation is an opportunity to raise a concern which does not form part of the management system

at the time it is raised. This may be because it is a concern that is currently outside the scope of the

management system, or a previously unconsidered potential aspect or impact, or a new legislative

requirement, and/or where procedures have not yet been developed to manage this concern. It is an

acceptable outcome for an observation not to give rise to corrective and/or preventive action only if it

can be shown that the concern does not give rise to a breach of legislation or a significant environmental

impact.

Internal Audits are conducted as follows:

The Environmental Manager/Environmental Officer maintains the Audit Schedule (and any Audit Plan for

forthcoming years required to maintain the Schedule) on an annual basis and allocates an Environmental

Auditor to each activity or element of the EMS which is scheduled to be audited. Internal Auditors are not

permitted to audit their own areas of responsibility.

The Environmental Manager/Environmental Officer then alerts relevant management personnel that an

Internal Audit is due to take place and agrees a date for performance.

The allocated Environmental Auditor plans and prepares for the scheduled Internal Audit by producing in

advance an Internal Audit Checklist listing the EMS and/or ISO14001 requirements against which

performance will be measured and recorded.

Preparations for Internal Audit include reviewing the results of previous audits of the activity or element

of the EMS which is to be audited (if available) to determine any aspects which may require particular

scrutiny.

Before conducting the scheduled Internal Audit the allocated Environmental Auditor explains the

purpose and scope of the audit to relevant personnel.

The Environmental Auditor then undertakes the scheduled Internal Audit in accordance with the

requirements of ISO14001 and this procedure. If Nonconformity is identified during the Internal Audit

the Environmental Auditor carries out further investigation to identify the nature and scale of the issue

(even if the identified Nonconformity is beyond the original remit of the Internal Audit).

On completing the scheduled Internal Audit the Environmental Auditor meets with relevant management

personnel (including the Environmental Manager/Environmental Officer) to relay findings, give an

opportunity for factual errors to be corrected, discuss any identified Nonconformities, agree Corrective

and Preventive Actions and sign-off the Internal Audit Checklist.

The Environmental Auditor follows up with a written Audit Report to the relevant management

personnel and the Environmental Manager/Environmental Officer within two weeks of the Internal

Audit. Audit Reports contain full details of any observations, Nonconformities and agreed Corrective and

Preventive Actions and a timescale for implementation where appropriate.

The Environmental Manager shall enter observations and nonconformities into the Corrective Action Log

which records corrective and preventive actions, the relevant clause (including any information as to root

cause where this can be discerned), when they are to be resolved and the results of any follow up to check

on the effectiveness of corrective and preventive actions.



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A copy of the Audit Report is kept by the Environment Team for internal records.

External audits are carried out by an accredited external auditor to an agreed programme to ensure that

they are conducted at a frequency appropriate to the maintenance of ISO14001 certification.

The Environmental Manager reports to the Carbon Management Programme Board at least annually on

the results of all audits undertaken since the last reporting session.

Housekeeping inspections are informal walks around the estate noting where site maintenance is

required. A housekeeping inspection report is issued to the relevant maintenance managers and helpline

tasks are raised for urgent issues. Actions are assigned with due dates.



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4.6 EMS MANAGEMENT REVIEW

The University of Brighton has established this procedure to ensure that senior management formally

review the EMS at regular intervals to ensure its continuing suitability, adequacy and effectiveness.

The review process includes an assessment of potential areas for improvement and the need for changes

to the EMS including the Environmental Policy, Environmental Objectives and Environmental Targets.

The EMS Management Review process is documented and records are retained by the Environment

Team.

The EMS Management Review Process is conducted as part of the Carbon Management Programme

Board’s business and is therefore chaired by the Director of Finance.

Do we want this or do we want to set up a small group of only 3 people to review documents etc?

The EMS Management Review process considers any changes that might be necessary to the

Environmental Policy and other elements of the EMS in the light of:

The results of Internal Audits and evaluations of compliance with Legal and Other Requirements;

Communications from external interested parties, including environmental complaints;

The environmental performance of the university;

The extent to which Environmental Objectives and Environmental Targets have been met;

The status of Corrective Actions and Preventive Actions;

Follow up actions from previous Management Reviews;

Changing circumstances (including in Legal and Other Requirements) relating to our

Environmental Aspects; and

Recommendations for improvement.

The Management Review agenda lists each of the above items and any other environmental topics for

discussion at the meeting.

Details of any decisions and/or actions adopted at Management Review are recorded in the Management

Review minutes. Management Review minutes are maintained for a minimum period of three years.

The Management Review takes place at least once annually. Management Reviews may be held more

regularly where circumstances require.



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APPENDIX A – RELATED EMS DOCUMENTS

1. Environmental Policy

2. Objectives, Targets and Programmes

3. University of Brighton Compliance Register

4. Document Control Register

5. Aspects & Impacts Register

6. Internal audit schedule

7. Process Control Flow Chart

8. Forms and system document templates

9. Procedures (Operational and Emergency)

Records Folder:

1. Training Records

2. Evidence of Communications

3. Supplier Appraisal Forms

4. Corrective Action Log (includes NC Reports P001 – P005)

5. Stage 1 Audit Report – Action Record

6. Internal Audits

7. Management Reports

8. Management Review Minutes

9. Emergency Spill and Leak Desk Drill Exercise

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