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							School of Clinical Sciences and Community Health

2011 Health and Safety Internal Audits
MRC Centre for Reproductive Health (CRH), Queen's Medical Research Institute
(QMRI), University of Edinburgh.
                                                                             rd
Health and Safety Audit of ground floor laboratory and office areas, 23 June 2011
                                                th
updated and confirmed at CRB Audit meeting 25 July 2011.

The audit took the form of a walk-through inspection of all laboratory and office areas on the
ground floor of the QMRI. The principal objectives of the audit were:

1.    To assess lab areas for appropriate practices including radioactive monitoring.
2.    To check that all RA1, BA1 and COSHH Risk Assessment documentation was up-to-
      date.
3.    To check the office space for any DSE / trip hazards.
4     To confirm that items flagged for ‘Review and Re-audit July 2011’ had been completed.

Inspection Team:
Geoffrey Carlson (GC)            Frances Collins (FH)             Forbes Howie (FH)
Sarah McDonald (SM)              Rhona Stephen (RS)

Overall impression from inspection:
The last few months have seen the formation of the Centre for Reproductive Health which
incorporates the Division of Reproductive and Developmental Science and a large number of
staff formerly part of the MRC Human Reproductive Sciences Unit. There have been
considerable changes in the location of the groups working in laboratories and a large number
of office moves. In addition due to a delay in TUPE, the former HRSU staff are still employed
by the MRC and their staff safety records remain with the MRC, this has led to a delay in
integrating the management of training records. Despite all this CRH staff, students and
management are on the whole to be commended on their continuing attention to Health and
Safety within the workplace, especially as the last six month have been particularly
challenging. There are some side effects of these moves and some laboratories are clearly in
a state of flux, however these labs are safe and safety paperwork and records have clearly
been part of the move, there is an ongoing need to update signage as and when fire wardens
move, but the contacts sheet and the first aider photo sheet are both current. With a number
of office moves still ongoing updated DSE assessments will be required and assessment
forms are being sent out to people who have moved offices. Radioactivity monitoring needs to
be reviewed as groups have moved and work is now confined to three rooms although the
monitoring continues in all the main labs despite the absence of radioactive work, the
radiation sub committee will be asked to update the monitoring system once all the moves are
complete.
Risk Assessment / COSHH documentation was generally up-to-date and in good order almost
everywhere although some room number had yet to be changed and one group (Gray) were
unable to produce hard copies of risk assessments. A microtome with a blade in it was also
found in E1.35 without a warning sign (a sign has since been produced by graphics).
Compliance with mandatory lab coat requirements was generally good, although some of the
signage at the far end corridors of the main laboratories was somewhat confusing as to where
lab coats should or shouldn’t be worn; this was updated by the review team. Items highlighted
last year as being for re-audit were looked at. Lack of progress by the Building on
replacements for solvents cabinets and the procurement of maglocks during the last year was
noted.

The following items were marked on the last inspection as to be re-audited in 2011

Radioactive monitoring records / Radioactive work:
Problem:             Although CRB's controlled area and all supervised areas were
                     inspected in April 2010 by SEPA and found to be satisfactory there
                     were a few areas where it was not clear if monitoring was taking
                     place. It was also noted that in 2010 the spill kits had contained latex
                     gloves, which needed replacing, the auditors suggest at the last audit
                     that a regular check on the contents of these kits should be
                     introduced.
Responsible persons: Gary Menzies (GM), John Smith (JS)
Comment:             The auditors noted that some areas being monitored did not appear
                     to have radioactive work going on, they also noted that the monitoring
                     sheets on the wall had been replaced by an electronic system but the
                     sheets remained (although not completed), the auditors removed
                     sheets where it was clear that no work was going on and asked the
                     radiation sub committee to meet to rationalise monitoring. There was
                     still the occasional use of trefoils on racks that clearly didn’t contain
                     radioactive material; where this occurred the labels were removed. It
                     is also unclear what radioactive work is going on in room C1.33 as
                     the machines are labelled with trefoils but there is no other signage.
                     Following a meeting of the sub committee signage has now been
                     updated and a new list for monitoring has been produced reflecting
                     the changes in location.
                     Spill kit boxes have had latex gloves replaced and a regular audit of
                     contents has been introduced.
Action status:       Integrate into the general audit.

Door Hinges on metal Solvent Cabinets.
Problem               The hinges on some cabinet doors are corroded and new hinges
need to be ordered.
                      This was a problem with two cabinets last year these still need
                      replacing and shouldn’t be used.
Responsible Persons: GC
Comment:             No progress had been made at Building level on this since last year;
                     It looks increasingly likely that there is a general problem with the
                     hinges used on these cupboards. LM has contacted Andy Kordiak in
                     procurement who raised the matter with Fisher Scientific but with no
                     resolution. Thought should be given to specification when
                     replacements are eventually required. The damaged cabinets have
                     now been taken out of use.
Action Status:       Monitor for deterioration of other cabinets at next audit.


Updates on Points for Action relating to specific locations or Groups from last audit

Main Labs
Problems            Sashes open on fume hoods - although not an unsafe practice it was
                    suggested that a notice was displayed to request that hoods are kept
                    with the sash down or switched off when not in use.
Responsible person: GC
Comment:            Notices have been placed on hoods, and most hoods had the sash
                    down.
Action Status:      Integrate into the general audit.

W1.08 and W1.10 now C1.06
Problem:             Storage of solvents >=2.5 litres in open laboratory areas not in
                     flammables cabinets.
Responsible persons: Room managers
Comments:            This didn’t appear to be an issue, although there was one unrelated
                     instance in C1.21 of acetic acid in a flammables rather than
                     corrosives cabinet.
Action Status:       Integrate into the general audit.

Building Work
Problem:            Lab and corridor areas still need to be made good after basement
                    building work.
Responsible person: GC / SH
Comment:                This has now been completed, although there are now two areas
                        where the lino turning up onto the wall had come loose – these have
                        been reported to Estates.
Action Status:          Integrate into the general audit.

Tissue Culture Lab W1.21/ Plastic Pipette Disposal Generally
Problem:              Concern was expressed at the last audit that there was no clear SOP
                      for disposal of pipettes in this room, this has now been reviewed and
                      updated. There was however a more general issue raised by the
                      auditors concerning the labelling of the boxes that pipettes were
                      stored in prior to disposal, they are marked ‘for incineration’ whereas
                      the correct route for disposal was via the orange bag / heat
                      inactivation route.
Responsible persons: GC / LM
Comment:             As no good source of ‘heat inactivation’ boxes could be found, these
                     boxes are now placed in orange bags when they are first brought into
                     the lab, so it is clear what there final destination for these boxes is.
                     Although this is generally working well there were a couple of boxes
                     that had not been placed in orange bags, groups probably need to be
                     made more aware of the change.
Action Status:       Integrate into the general audit.

E1.51 Fire Doors in wash-up room
Problem:              Fire doors need to be on maglocks to allow frequent access of large
                      trolleys to the wash up area.
Responsible persons: LM Building Committee
Comments:             The building committee agreed that magnetic door holders could be
                      fitted that release in the event of fire (cost about £400 for a pair of
                      doors), however this has yet to happen.
Action Status:        Monitor at next audit.



New Points for Action relating to specific locations or Groups

Updating of DSE assessments
Problem:             There is presently no record of DSE assessments for MRC staff,
                     although it looks like the assessment have been undertaken (large
                     number of work stations with laptops and correctly positioned
                     monitors / keyboards), also there have been a number of moves and
                     although some assessments have been updated to reflect this not all
                     have yet been completed.
Responsible persons: Moira Nicol (MN)
Comments:            GC discussed this with the DSE assessor MN and an e-mail reminder
                     has been sent out to staff with the self assessment form attached,
                     asking staff to contact her if there are any issues.
Action Status:       Integrate into the general audit.

Autoclaves in Wash up – E1.51 Emergency Instructions
Problem:             There is not presently a notice that states what to do in the event of a
                     problem with the autoclaves or washers; this is particularly relevant
                     now as wash up is not occupied by trained staff all day.
Responsible persons: GC
Comments:            GC will liaise with wash up / Mark Marsden to get instructions on the
                     wall for what to do in an emergency.
Action Status:       Monitor at next audit.

Eye wash stations – East and Central Blocks
Problem:             Following a reduction in staffing of wash up, eye wash stations in the
                     East and Central area appear no longer to be checked on a weekly
                     basis.
Responsible persons: FH
Comments:            FH discuss this at the next Lab management meeting and wash-up
                     have agreed to do the monitoring with lab managers checking that
                     this has been done in each lab.
Action Status:       Integrate into the general audit.

Tissue Culture Room - W1.24
Problem:             This room is presently unoccupied but the room has not been
                     decommissioned.
Responsible persons: FH / Lab Group
Comments:            Since the audit new users for this room have been agreed and FH will
                     organise a management regime for the room.
Action Status:       Integrate into the general audit.


                                                                            GC CRH_11.02
Health and Safety Audit of Child Life & Health laboratory and office areas at 20 Sylvan
                                  th
Place, University of Edinburgh, 24 June 2011. Confirmed at the CRB Audit meeting
  th
25 July 2011

The audit took the form of a walk-through inspection of all Child Life & Health (CLH)
laboratory and office areas at 20 Sylvan Place. The principal objectives of the audit were:

1.    To assess lab areas for appropriate practice including induction training for new staff,
      and late and lone working arrangements.
2.    To check that all RA1, BA1 and COSHH Risk Assessment documentation was up-to-
      date.
3.    To confirm that items flagged for ‘Review and Re-audit in July 2011’ had been
      completed.

Inspection Team:
Geoff Carlson (GC)                Moira Nicol (MN)                  Rhona Stephen (RS)

Overall impression from inspection:
General standards of Health and Safety organisation within the Child Life & Health
laboratories remain good as noted in the 2010 audit. It was also noted that CLH is audited
annually by SEPA, and that there had been no adverse comments at the time of the last
inspection.

Updates on Points for Action relating to specific locations or Groups from last audit

Fire doors and exits
Problem identified: There seemed to be a general problem with a number of the fire doors
not closing properly or being stiff to open, RS agreed to keep an eye on this and call a joiner
to adjust the closing mechanism if necessary. There was also a general problem with the
signage.
Responsible Person: RS
Comments: Michael Moore (MM) the University Fire Officer had conducted a fire risk
assessment of the premises, signage has subsequently been improved by the NHS, issues
raised last year relating evacuation of people with mobility impairment, and the time limit for
use of the refuge have been addressed. Fire doors were generally closing better than had
been observed in previous years, although those into labs had a habit of sticking slightly ajar.
Action status: Integrate into general audit.

Management of training for health and safety
Problem identified: Training records are being maintained, both by individual workers and
centrally, but it was recommended that a simple matrix be prepared showing all personnel
working within or otherwise attached to CL&H and all those training courses that have been
recommended for them. It was noted that work had commenced on preparation of a training
management matrix. This will be revisited at the next audit.
Responsible person: RS
Comment: A matrix has been produced, covering staff on site.
Action status: Integrate into general audit.

Office DSE audit:
It would be helpful if staff kept their offices tidy, with boxes and books stored safely but it is
appreciated that a lack of alternative storage space is the problem. There were a number of
areas where a DSE assessment would find the present arrangements sub optimal.
Responsible person: RS
Comment: Staff should be reminded that if they have any aches or pains or want their
workstations assessed then they can contact Moira Nicol (moira.nicol@ed.ac.uk).
Assessments forms are to be given to individuals and a record of assessments needs to be
kept centrally.
Action status: Ongoing.

New Points for Action relating to specific locations or Groups
Lab / Office 5.79

Problem identified: Although marked as a laboratory with ‘lab coats must be worn’ notices
on the door, there was an empty mug on this central isle and the room appears to be being
used as an office rather than a laboratory. In addition to this boxes are piled in the middle of a
walkway, a gas cylinder has been lefts unsecured by the wall, and there is also a trip hazard
with a network cable starched across the floor (this is due to the central isle where people are
using laptops not having Ethernet sockets).
Responsible person: RS
Comment: The cable was removed but if it really is the intention to use this as an office re-
labelling of doors is required and some way of keeping the cable off the floor (wireless router
or running the cable through the suspended ceiling) needs to be put into action.
Action status: The majority of these problems need to be rectified asap and thought
needs to be given as to the actual use of this room. Review at next audit.

Fire Steward Checklists
Problem identified: There doesn’t appear to be any fire steward checklist records kept.
Although the NHS control the fire alarm, each floor has a UoE fire steward – checks are
carried out on a weekly basis but records aren’t kept.
Responsible person: RS
Comment: Forms can be downloaded from the Fire Office
http://www.docs.csg.ed.ac.uk/Safety/fire/ra/checklist.pdf and should be retained in a central
folder
Action status: Review at next audit.

Guillotine next to photocopier in Corridor
Problem identified: This is an old fashioned guillotine, with a blade that comes down rather
than across, it is unclear if there has been any risk assessment / SOP for this and it might be
worth replacing with a newer model
Responsible person: RS
Comment:
Action status: Review at next audit.




                                                                               GC CLH_11 V 1.1
Lab Inspection Dermatology                            2011

Laboratory Housekeeping

    It was noted in the AON Audit Recommendations that

    a) First aid eye wash bottles were out of date.

     These have been disposed of and replaced with new eye wash bottles.

     b) There were redundant samples of oil and old computer equipment in
    Room 4-118.

    The old computer equipment has been placed in a storeroom along with other
    old computer equipment waiting to be assessed and disposed of.

    The redundant samples of oil and other substances brought in by NHS patients
    as examples of irritants to be used in patch testing are the property and so
    responsibility of the NHS. Mr Craig walker, a Biomedical Scientist, employed
    by the NHS but working in University rooms is investigating the NHS
    procedure for disposing of said chemicals.

    All Clinical waste from the lab is disposed of through the NHS.


    Equipment

    PAT testing was carried out on all equipment between the 17th and the 21st
    Feb. One lead failed the test and has been disposed of.


    Engineering Controls

    The fume Hood in room 4-116 is no longer serviced and a notice has been
    placed on it to that effect.


    The Safety Cabinet in room 4-128, which is no longer serviced, has now been
    removed.

    The NHS has purchased a new Cryostat and it is situated in University room
    4-128. This has necessitated the re-commissioning of a Bench Capture Hood
    situated in the same room, which is the property of the University. The Hood
    has performance indicators and the filters will be replaced when required.
Health and safety audit of the Centre for Inflammation Research and
basement level core facilities of the building, Queen’s Medical Research
Institute, University of Edinburgh carried out on Wednesday 10th August.
Executive Summary:
There continues to be a high standard of compliance with health and safety policies and
regulations throughout areas of the QMRI occupied by the Centre for Inflammation Research
(CIR). Most laboratories were found to be in a satisfactory state of tidiness; most members of
staff and post-graduate students continue to give the impression of having a thorough
understanding of the importance of H&S-related issues and to take a sensible, well-balanced
and informed approach to the processes; and, with a few exceptions, there was a high degree
of compliance with mandatory lab coat policies. No serious deficits were observed in the
basement level core facilities either. Few items highlighted in this report require relatively
urgent attention.

Scope:
The audit took the form of a walk-through inspection of laboratory, support and office areas on
the second floor of the QMRI, and also those basement areas of the building in which several
core facilities are located. The principal objectives were:

1.    To carry out a survey of safety management and compliance within laboratories and
      offices associated with CIR and certain core facilities located within the basement of
      the QMRI.
2.    To encourage and promote suitable and sufficient record-keeping relating to risk
      assessments and health and safety training.

Auditors:
Sharon Hannah (SH), Convenor of CIR’s H&S Committee and Senior Laboratory Manager;
Mark Marsden (MM), Laboratory Manager, CIR; and
Lindsay Murray (LGM), Health & Safety Manager, College of Medicine & Veterinary Medicine.

The following general points were identified as requiring attention throughout
the CIR:

Observation 1:      Risk assessments and training records were sampled during a recent
                    aid by Aon Risk Solutions (July 2011), and those which the auditors
                    examined were found to be perfectly satisfactory.
Action:             No remedial action warranted or required at this time.
Responsible Person: Laboratory managers from each group
Action Status:      On-going, and re-audit in 2012

Observation 2:       There were a few examples of poisons being stored on the open
                     bench, rather than in locked poisons cupboards (e.g. E2.39, C2.08,
                     and C2.25).
Action:              Poisons, when not in use, must be secured in appropriately labelled
                     (and locked) poisons cupboards.
Responsible persons: Laboratory managers from each group
Action status:       On-going, and re-audit in 2012

Observation 3:       There was a small accumulation of mercury vapour light bulbs, which
                     require to be consigned for disposal.
Action:              There is a prescribed pathway for disposal of Hg waste, and this
                     should be employed to avoid accumulation of hazardous chemical
                     waste (not limited to Hg).
Responsible persons: Laboratory managers from each group
Action status:       On-going, and re-audit in 2012
Observation 4:       A degree of untidiness was noted in a very few laboratory and office
                     areas, and some equipment and materials were observed that do not
                     seem to be in regular use (some of which, in fact, did not seem to
                     have been used in many years).
Action:              Assess to what extent better use might be made of QMRI Stores to
                     avoid the need for consumables to be stock-piled in laboratories,
                     decide what items are no longer in regular use and which might
                     simply be discarded, and generally tidy-up the working environment.
Responsible persons: Laboratory managers from each group
Action status:       On-going, and re-audit in 2012

Observation 5:       There were several laboratories (particularly in the Centre block)
                     where there was no evidence that eye wash stations had been
                     routinely checked (to be done on a weekly basis).
Action:              Individuals may need to be identified and allocated specific
                     responsibility for checking eye wash stations, and for updating the
                     record to confirm that has been done.
Responsible persons: Laboratory managers from each group
Action status:       On-going, and re-audit in 2012

Observation 6:      Although CIR management have made efforts to encourage the use
                    of docking stations, there remain a few examples of workers using
                    lap-top computers without the benefit of docking stations, and doing
                    so in a fashion that has the potential to create at least discomfort,
                    and at worst actual long-term physical damage to users.
Action:             All groups to continue to encourage use of docking stations, and
                    draw attention to the availability within Little France of regular display
                    screen equipment safety training courses, perhaps making
                    attendance on a relevant training course mandatory for those who
                    persist in preference for the use of a lap-top computer. CIR-internal
                    safety inspections should periodically include examination of risk
                    assessments related to use of display screen equipment, which
                    should      be    undertaken       by      all     DSE      users     (see
                    http://www.docs.csg.ed.ac.uk/Safety/ra/DSE.pdf).
Responsible Person: CIR H&S Committee
Action Status:      On-going, and re-audit in 2012

Observation 7:      In several cases it was noted that fume hood sashes are still being
                    left wide open, and the fans left running at speed, with no evidence of
                    work being done in these at the time of the audit, which represents a
                    potentially considerable waste of electricity.
Action:             Local induction training should emphasise aspects of energy
                    conservation, also including switching off lights etc. An exception to
                    this general recommendation is highlighted at Observation 16.
Responsible Person: CIR H&S Committee
Action Status:      On-going, and re-audit in 2012


Points for Action relating to specific locations or groups within CIR:

E2.52 (Wash-Up Room)
Observation 8:      Fire doors remain wedged open, largely because of the need to move
                    equipment through these on a very regular basis.
Action:             UofE Estates & Buildings have commissioned works necessary to
                    retrofit magnetic door catches set to release when fire alarms begin
                    to sound.
Responsible Person: QMRI Management Committee
Action Status:      Re-audit in 2012

E2.39
Observation 9:      A microwave oven, specifically labelled to indicate hazards
                    associated with superheated steam, had not been provided with a full
                    face shield.
Action:             Provide full face shields at all microwave ovens being used to heat
                    growth media etc.
Responsible Person: Laboratory manager for E2.39 but also CIR H&S Committee more
                    generally for the whole floor
Action Status:      Re-audit in 2012

E2.41
Observation 10:        Cold room found to be rather untidy.
Action:                Cold room to be tidied up.
Responsible Person:    Laboratory manager for E2.41
Action Status:         Re-audit in 2012

E2.25
Observation 11:     Mandatory eye protection sign is ambiguous in the location where it is
                    currently displayed.
Action:             Relocate signage to correspond to specific area where risk of eye
                    injury actually exists.
Responsible Person: Laboratory manager for E2.25
Action Status:      Re-audit in 2012

C2.38
Observation 12:     There seems currently to be some confusion regarding the status of
                    the room with regard to mandatory lab coat requirements.
Action:             Clear and unequivocal signage is required to indicate the agreed
                    status of the room, and whether laboratory coats are required (which
                    is the audit team’s recommendation) or whether lab coats are to be
                    prohibited (which, in the audit team’s opinion, would be difficult to
                    enforce, even if there was confidence that unfixed biological materials
                    would never be carried into the room on occasions, which also may
                    be difficult to guarantee).
Responsible Person: CIR H&S Committee
Action Status:      Re-audit in 2012

C2.08
Observation 13:     There are very significant accumulations of materials below benches,
                    not all of which seems to be regularly in use (if, indeed, it’s actually
                    being used at all). This is making it difficult for workers to sit at
                    workstations in comfort, and also adds to fire-loading in the
                    laboratory.
Action:             Discard all inessential materials either to storage elsewhere or to
                    disposal from the building.
Responsible Person: Laboratory manager for C2.08
Action Status:      Re-audit in 2012

Observation 14:     Not uniquely, but highlighting a concern that may need to be
                    addressed throughout the whole building, is the continued use within
                    some fume hoods of glass bottles for the disposal of chemical waste.
                    Even though these seem to be being used to correctly segregate
                    different classes of chemical waste, they have the potential to shatter
                    and eject glass fragments over quite a distance, with the potential to
                    harm workers and damage the fume hood.
Action:             Replace all glass bottles being used to contain liquid chemical waste,
                    and use clearly labelled plastic bottles instead.
Responsible Person: Laboratory manager for C2.08, but also CIR H&S Committee more
                    generally for the whole floor
Action Status:      Re-audit in 2012
C2.Z5 (Emergency Shower)
Observation 15:     Although kept clean and tidy, there were inadequately seated roof
                    tiles above the shower cubicle.
Action:             Request relocation of roof tiles
Responsible Person: CIR H&S Committee
Action Status:      Re-audit in 2012

C2.25
Observation 16:     There was a distinct smell of solvents in the vicinity of a fume hood in
                    this laboratory, which dissipated almost as soon as the hood fan was
                    restarted by the audit team. A volume of formalin seems to have been
                    accumulated within the hood, possibly over a long period of time, and
                    a second container was also being used to commit formalin waste.
                    Some glass bottles were being used for chemical waste (see
                    Observation 14).
Action:             Ensure that fume hood fans are left switched on when volumes of
                    solvents are being used (or when they genuinely must be held within
                    the hood for periods of time), but do not allow significant volumes of
                    waste to accumulate, taking steps instead to dispose of these to
                    external stores on a regular basis so that they can be uplifted by
                    contractors and removed from the site. Hood sashes should also be
                    lowered when not in use (see Observation 7).
Responsible Person: Laboratory manager for C2.25
Action Status:      Re-audit in 2012

Observation 17:     Some waste bins in this lab were filled to overflowing.
Action:             Waste should not be allowed to accumulate in great quantities, and
                    bins should certainly not be filled to overflowing.
Responsible Person: Laboratory manager for C2.25
Action Status:      Re-audit in 2012

W2.20
Observation 18:     A microtome was located on an open bench with no safety signage in
                    evidence.
Action:             Consider the suitability of the current location from a safety
                    perspective, and (in any event) display appropriate safety signage
                    (indicating, also when the blade is or is not in place).
Responsible Person: Laboratory manager for W2.20
Action Status:      Re-audit in 2012

W2.21
Observation 19:     One waste bin in this lab was filled to overflowing.
Action:             Waste should not be allowed to accumulate in great quantities, and
                    bins should certainly not be filled to overflowing.
Responsible Person: Laboratory manager for W2.21
Action Status:      Re-audit in 2012

W2.07
Observation 20:     An observation that one person was working within the lab while not
                    wearing a lab coat inspired a discussion regarding possible special
                    requirements for tissue and cell culture work.
Action:             It is unlikely that the regulatory authorities would accept the nature of
                    the work (TC and CC) as justification for departure from their own
                    mandatory requirements for lab coats to be worn in containment level
                    laboratories (which W2.07 most certainly is). Managers for W2.07
                    and similar areas throughout the whole building should consider the
                    use of disposable lab coats or lab coats reserved for use within
                    laboratories doing TC or CC work.
Responsible Person: Laboratory manager for W2.07, but also CIR H&S Committee more
                    generally for the whole floor.
Action Status:         Re-audit in 2012

W2.32
Observation 21:     Two compressed gas cylinders were stored horizontally, and only one
                    was (partly) secured.
Action:             Compressed gas cylinders must be stored vertically and secured
                    using proper bench straps or chains. In any event, since these
                    cylinders no longer seem to be required within W2.32, they should be
                    returned to the external cylinder storage cages.
Responsible Person: Laboratory manager for W2.08
Action Status:      Re-audit in 2012

W2.11
Observation 22:     Room found to be rather untidy.
Action:             Dispose of unnecessary materials or commit to storage in a more
                    appropriate location.
Responsible Person: Laboratory manager for W2.08
Action Status:      Re-audit in 2012

W2.08
Observation 23:        Cold room found to be rather untidy.
Action:                Cold room to be tidied up.
Responsible Person:    Laboratory manager for W2.08
Action Status:         Re-audit in 2012

Points for Action relating to specific locations or groups occupying other areas
within QMRI:

Level 0 Freezer Farm
Observation 24:       The area was generally much cleaner than in recent months, with a
                      rota of floor-by-floor lead-involvement having recently been agreed.
                      Nevertheless, a blue nitrile glove was discovered beneath one
                      freezer.
Action:              Maintain vigilance, and extend awareness to visible areas beneath
                     freezers and not only around them.
Responsible Person: ‘Duty floor’ in rotation.
Comments:
Action Status:       Re-audit in 2012

Level 0 Waste Stores
Observation 25:      The two rooms were generally clean and well-organised, although
                     the door to the clinical waste had been left unsecured.
Action:              Stores Manager to ensure, by regular vigilance, that clinical waste
                     store is not left unsecured by room users and contractors.
Responsible Person: Stores Manager
Action Status:       Re-audit in 2012

Stores and Associated Areas
Observation 26:      Areas are clean and well-organised.
Action:              NFA
Responsible Person: Stores Manager
Action Status:       Re-audit in 2012

Post Room
Observation 27:        Area is clean and well-organised.
Action:                NFA
Responsible Person:    Support Services Manager
Action Status:         Re-audit in 2012

LN2 Plant Room
Observation 28:     Area has become quite untidy.
Action:             CIR have agreed to find storage for unutilised towers, leaving some
                    items (believed to be owned by CCVS) to be retrieved and stored
                    elsewhere by those who are responsible for that equipment.
Responsible Person: Mark Marsden
Comments:
Action Status:      Re-audit in 2012

						
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