SEN09-P133 - Loughborough University by wuyunyi


                                                                                17 November 2009

Subject:      Annual Plan for Health, Safety and Environment Office –
              Review of progress in 2008/9 and new targets for 2009/10

Origin:       Health, Safety and Environment Manager

Purpose of the report
To review the progress made on the annual plan for 2008-2009 and to set out a programme
of work for the year October 2009 – October 2010.

An annual plan of work is needed to ensure that the University continues to fulfil it statutory
duty for the health, safety and well being of its staff, students and others affected by its
activities. The plan shall ensure that the work of the HS and E Office supports the strategic
planning of the university and makes best use of the resources available.

Points to note:
Section A of this report reproduces the annual plan for 2008/9 as the shaded sections of a
table. An additional column on the right hand side shows the progress made against each

Section B of the report shows the annual plan 2009/10

It should be noted that the progress report this does not show the work that has been carried
out in 2008/9 over and above those items identified in the annual plan for this period. This
includes but is not restricted to :

      Handling routine service requests from departments
      Monitoring of weekly fire tests to ensure that all buildings carry out their alarm tests at
       the designated time
      Attendance at departmental safety committees – increased involvement in 2009
      Continuing to develop formal and informal ties with the University Insurer UMAL. This
       year saw UMAL conduct their periodic audit of the University (3 year cycle)
      Review of all University radiation protection arrangements. A planned audit by the
       Environment Agency will take place on October 16th 2009 – a report on this visit is
       covered as agenda item SAF-09-P
      Moving offices – this provided an opportunity to review administrative tasks and
       record keeping
      The Occupational health database has been revised and updated. This will increase
       the breadth of data which is stored and will allow more detailed reports to be
      Hand Arm Vibration training conducted for all operational staff in Facilities
       Management exposed to vibration in their current or previous work.
      Re establishing the laser safety technical group
                                                                                                                           17 November 2009
A) Review of Progress Made Against the Annual Plan 2008/9

Health and Safety (Fire)
       Aim                        Target                                    Comment                                  Progress
To complete            Complete second round risk          Work has to be programmed around                Second round risk
targets from            assessments                         access to buildings. Higher risk                 assessments mostly are
2007/8                 Complete review of signage          priorities were addressed in 2007/8 –            completed (exceptions are
                       Check hydrant flow – needs to       in particular residential                        those areas where building
                        be coordinated with Facility        accommodation. Remaining premises                work is planned that will
                        Management to ensure that           will be scheduled according to risk              substantially alter the fire risk
                        there is no interruption to                                                          assessment.)
                        normal business                                                                   Fire hydrant flows have been
                                                                                                          Fire signage is up to date in all
                                                                                                             major buildings (approximately
                                                                                                             80% of the building stock.)
Improvement to         Support Facilities                  The programme to upgrade fire alarm      The second stage of the programme
the fire alarm          Management to proceed with          systems is staged according to risk      to have automatic fire detection in all
systems across          the second staff of the plan to     based priorities determined by fire      significant buildings will be completed
campus                  upgrade the fire systems            risk assessments. The first stage of     by the end of November 2009. It
                                                            work has been This work is on-going      should be noted that 3 times in the
                                                            to upgrade the next series of            last 12 months newly installed AFD
                                                            buildings                                has detected fire at early stages in
                                                                                                     areas where it would previously have
                                                                                                     resulted in a more substantial fire.
Monitor                Report to HSE committee in          To be monitored as part of the fire      Completed in 2009
compliance with         2009                                risk assessment process/ work to
LU fire strategy                                            prepare PEEPs and by liaison with
adopted in                                                  FM on new build and refurbishment
2007/8                                                      projects
Incorporate fire       Identify which groups of staff      A remaining difficulty is to determine   Fire extinguisher training continues to
training into the       require mandatory fire training     how training records can be matched      be delivered to all fire marshal,
training matrix –       – e.g. fire extinguisher training   against the training matrix.             wardens and sub wardens. Fire
see training            for all technicians and                                                      extinguisher training for technical and
                      research staff using flammable                                                research staff is still optional but is
                      material. Incorporate this                                                    strongly encouraged. Sufficient
                      information into the matrix          Article 21(2)(d) of the Regulatory       courses have been made available to
                     To purchase and make                 Reform(Fire Safety) Order 2005           train all staff.
                      available an electronic hosted       requires the responsible person to
                      training package that will           provide fire safety training to          E-Training is being developed and
                      provide suitable and sufficient      employees in a manner appropriate        will be in place before end of 2009.
                      fire safety awareness training       to risk. E-training with a management    (SCORM compliant and compatible
                      for all staff/(students?)            package will allow this training to be   with the Learnserve.)
                                                           delivered and monitored efficiently

Business             Fire service information packs       The University is reviewing business     The final version of the pack was
Continuity            to be provided in all higher risk    risk as part of the emergency plan       agreed in October 2009. The
                      buildings – chemistry, S             overhaul. This work to provide fire      information packs will be compiled for
                      building, Wolfson etc                service information packs should         selected high risk buildings in
                     Some departments (Chemistry          ensure that wherever possible the        2009/10 to enable the fire service
                      and Wolfson ) have been              maximum effort can be expended by        identify risks and assets. – Keeping
                      proactive in reviewing               the fire service to fight fire in        this information up to date will be a
                      business continuity risk from        buildings. If this information is not    challenge but as a minimum annual
                      fire in buildings. Departments       provided there maybe a reluctance        reminders will be sent out to HoD to
                      will be contacted to discuss         on the part of the fire service to       remind them that changes made to
                      protection of key assets             commit fire crews into buildings with    risks or assets should be reflected in
                                                           unknown fire risk.                       the fire service plan for their buildings

Health and Safety (General)
        Aim                    Target                                    Comment                                Progress
Audit                To continue with the HASMAP                                                   Wolfson School audit completed
                      audit where this applies to the                                               using HASMAP.
                      remaining large departments –
                      Wolfson School, LUSAD and                                                     All targeted audits carried out as
                      SDC and those departments                                                     planned. Further mini audits are
                      with higher risk activities. Audit                                            planned for 2009/10
                      reports will be presented to
                      HSE committee and progress

                      For smaller departments and
                       those engaged in less
                       hazardous work it has been
                       recognised that targeted audits
                       are appropriate and a separate
                       scheme shall be adopted to
Improving             To continue the work started in                                           All targets met for 2009/10. This work
communications         2007/8 and build on the DSO                                               is on-going and positive feedback has
with departments       forum, training and regular                                               been received from Departmental
                       formal and informal contact -                                             Safety Officers.
                       weekly contact by e-mail,
                       safety committee attendance
                       and newsletter.
Policy and            To replace remaining policies                                             More than 80% complete. There are
website                back onto the website                                                     still some guidance documents to be
                                                                                                 reviewed and put back onto the
                      To undertake the 2 yearly                                                 website. These will be reviewed in
                       review of the Health and          This target is scheduled for February   2009/10.
                       Safety Policy                     2009 HSE meeting
                                                                                                 Review of the Health and Safety
                      To investigate the successful                                             Policy is an agenda item for October
                       transition of University Policy                                           2009
                       into local arrangements .

                      Manual Handling                   Update current arrangements             The draft policy concerning working
                      PPE                               Update current arrangements             overseas has not yet been finalised.
                      Biological safety                 New policy                              This will be rolled forward to 2009/10/
                      Work away from the University     Request from PVC Teaching and
                       – incorporate new guidance on     Learning                                All other targets have been met
                       placement students, fieldwork
                       and other existing

                       arrangements on lone working
                       and work overseas
DSEAR /Gas            Develop training                                                       Compliance with the DSEAR policy is
safety                Audit compliance with the new                                          scheduled to be reviewed in
                       DSEAR policy – latter part of                                          November

Environmental         Adopt the epiGenesys training    Hazardous waste costs rose by 33%     An assessment was carried out to
activity               and management system for        2006/7 to 2007/8. Budget is now       provide assurance that the
                       clinical waste- £9000            £30,000                               University’s Duty of Care as a
                      Review arrangements for                                                generator of hazardous waste is met.
                       managing other hazardous                                               Hazardous waste was tracked to
                       waste                                                                  verify that once it has been collected
                      Other targets to be developed                                          from the University by a registered
                       in conjunction with                                                    waste carrier it is transferred to an
                       Sustainability Coordinator.                                            appropriate facility for treatment and
                                                                                              disposal. This assessment provided
                                                                                              the required assurance.

                                                                                              The University is seeking to attain an
                                                                                              Eco Campus award and the HSEM is
                                                                                              contributing to this target

Occupational Health
        Aim                     Target                                Comment                               Progress
Facilitate            To complete the current          The Occupational Health Advisor has   The Occupational Health Advisor has
departmental           programme of health              a separate and ambitious programme    made considerable progress in
compliance with        surveillance for Facilities      of work. These targets have been      developing the University’s
the Hand-Arm           Management and agree a           picked out to address some of the     Occupational Health service.
Vibration policy       basis to carry this forward on   bigger projects                       The Hand Arm Vibration
                       an on-going basis                                                      assessments have been completed.
                      To consult with department                                             An updated HAVS policy was
                       and make suitable                                                      produced that was scrutinised and

                        arrangements to implement                                                 approved by the Health and Safety
                        the policy                                                                Executive. All operational staff in FM
                                                                                                  have had training. The HAV
                                                                                                  arrangements will now be rolled out
                                                                                                  to other departments in 2009/10
Stress                 To work with HR and develop                                               On- going. A new stress
                        the University Stress Policy in                                           management course aimed at
                        line with the findings of the                                             managers is being piloted in
                        staff survey.                                                             November.

Review university      Review the existing policy in                                             Done – agenda item for October
arrangements for        the light of Biological Safety                                            2009
management of           Policy
risks to
pathogens and
Blood Borne

Occupational Hygiene
       Aim                        Target                               Comment
On-going from          For staff in HSE to undertake     Training need identified in 2007/8      M201 has been completed.
2007/8 – to             the following British
provide an in-          Occupational Hygiene Society      The HSE office shall concentrate on     Training providers for modules M102
house resource          modules:                          in house service provision for the      and M 103 yet to be identified.
for monitoring                                            foreseeable future but there is scope
workplace           1. M102 Measurement of                to become a revenue earner by
contamination          Hazardous Substances               offering external consultancy in this
and                    (including Risk Assessment)        area in the future.
conditions          2. M103 Control of Hazardous

                    3. M201 Thermal Environment
                       and Non-Ionising Radiation)

                  4. S301 Asbestos and other                                                     The University asbestos policy is
                     fibres                                                                      being reviewed by FM and HSE in
                                                                                                 November. This action point will be
                                                                                                 considered as part of the review

        Aim                     Target                                 Comment
To coordinate        To produce a training matrix      A lot of health and safety training is   Agenda Item October 2009
and develop HSE       with suitable training courses    carried out across the university that
training              identified and made available     ensures staff are competent.
                      to staff as either optional or    Discussions with DSO has identified
                      mandatory dependent on the        a need to coordinate the training that
                      job role and risk.                is offered to better use resources.
                     To develop systems for            Discussions with Loughborough
                      monitoring attendance on          College, as part of a HEFCE funded
                      training courses                  project , have suggested that more
                     To offer more in house training   joint working on training delivery and
                      on core subjects and for this     collaboration may have benefits in
                      training to be publicised         terms of economies of scale.
                      through staff development
                     To use a wider range of means
                      to deliver training – cascade
                      training and e-training – fire
                      awareness training is seen as
                      a good pilot for e-training

B)      Annual Plan 2009/10

Fire safety

                Aim                                         Target                                             Comment

To build on and embed policies and          Monitor compliance with the fire strategy for   The necessary structure to manage fire
procedures that have been developed          new build and for re furbishment work           safety across the university has been put in
to manage fire safety                       Training - fire marshal and extinguisher        place over the last 2 years. The fire safety
                                             training for all technical staff and sub        targets for 2009/10 will ensure that these
                                             wardens                                         policies and procedures are working
                                            Ensure fire panel training is carried out for   properly.
                                             all duty staff in residential accommodation
                                            Carry out checks on a newly installed
                                             refuge alert system
                                            Audit compliance with the University’s
                                             DSEAR policy
                                            Produce fire service plans for all high risk
                                             buildings so that assets are protected in a
                                             fire situation
                                            Keep fire risk assessments up to date and
                                             follow up action points
                                            Produce CAD plans for buildings in 2D and
                                            Work with DANS to carry out Personal
                                             Emergency Evacuation Plans

Radiation Protection

                 Aim                                         Target                                             Comment
To provide assurance that radiation   Review the University’s badging policy and             In 2008/9 the Radiation Protection Officer
protection arrangements continue to   designation of controlled or supervised areas          carried out a review of all documentation
meet the needs of the University                                                             relating to radiation protection. In 2009/10

Radiation Protection Continued

                Aim                                       Target                                         Comment

                                          Audit departments with areas designated      this work will be expanded by carrying out
                                           as “controlled” or “supervised” in           audits on site to ensure that working
                                           accordance with the Ionising Radiation       arrangements continue to be satisfactory.
                                          Produce the Radon Survey
                                          Prepare for legislative changes resulting
                                           from the introduction of Environmental
                                           Procedures Permits in April 2010 – report to
                                           HSE committee

General Health and safety

                Aim                                       Target                                         Comment

To build on and embed policies and        Use HASMAP on one department                 A variety of audits were conducted in
procedures that have been developed       Conduct the following targeted audits:       2008/9 and it is the intention of the HSE
to manage general health and safety                                                     department to
                                          1. Risk Assessment                                Use HASMAP to audit the
                                          2. Dangerous Substances Explosive                    University’s management systems
                                             Atmospheres                                    ensure compliance with University
                                          3. Biological Safety – including holding 2           policies by targeting specific risk
                                             meetings of the Biological Safety                 topics
                                             Committee                                      Use structured interviews
                                          4. Control of Substances Hazardous to                /questionnaires to investigate the
                                             Health                                            successful transfer of information to
                                          5. Provision and Use of Work Equipment               staff.
                                          6. Laser Safety
                                          Review event planning and risk assessment
                                           arrangements (in conjunction with
                                           Loughborough Students’ Union.)
General Health and Safety Continued

                 Aim                                       Target                                             Comment

Training                                  To ensure that courses specified in the          See training matrix 2009
                                           2009/10 training matrix are made available
                                           to target groups of staff

Environmental Protection                  Develop hazardous waste management               These targets are the commitments agreed
                                           systems                                          by the HSEM to contribute to a wider
                                          Contribution to Eco campus where                 agenda of developing sustainability.
                                          Work with IT/FM to develop systems for
                                           managing Waste Electronic Electrical
                                           Equipment (WEEE)

Laser Safety                              To produce University guidance as                The laser safety policy was updated in 2009
                                           standards for using lasers at Loughborough       but it is recognised that without supporting
                                           University                                       guidance there may be differences of
                                                                                            opinion within the University concerning the
                                                                                            practical application of this policy. Guidance
                                                                                            based on BS 60825 will be drafted,
                                                                                            circulated for consultation and agreed upon
                                                                                            before being used for audit purposes. This
                                                                                            work shall be reported upon in detail at the
                                                                                            February meeting of the HSE committee

Accident reporting/investigation and      Changes made to the way in which
first aid provision                        accident data is collected in 2009 will
                                           enable Loughborough University to make
                                           comparisons with similar institutions from
                                           Jan 2010.
                                          Review provision of first aid training to meet
                                           the needs of the university and to

General Health and Safety Continued

                 Aim                                       Target                                           Comment

                                              accommodate changes to the first aid at     HSE Approved Code of Practice on First aid
                                              work regulations.                           Training has been amended and the
                                            Report to the HSE committee giving details   schedules for initial training, interim training
                                             of claims arising or concluding in the       and refresher training have implications for
                                             2009/10 reporting period                     the courses offered by Loughborough

Occupational Health
                 Aim                                        Target                                           Comment
To provide a service that continues to      Rolling out HAVS management procedures       A new sickness absence management
meet the needs of all service users.         to a wider University population             policy is being introduced by Human
                                            Audit Blood Borne Virus Policy               Resources. This will have resource
                                                                                          implications for the Occupational Health
                                                                                          service. Any plans to develop this service
                                                                                          will be constrained by the additional
                                                                                          workload and a further report will be made
                                                                                          to the HSE committee in due course to
                                                                                          expand on Occupational Health plans for

HSE Office October 2009

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