CRB Health _ Safety Audit 26

Document Sample
CRB Health _ Safety Audit 26 Powered By Docstoc
					DRAFT REPORT – Version 1: 17/09/2006
                                                                                                          Doc 3e

              Health and Safety Audit of ground floor laboratory and office areas, forming the
   Centre for Reproductive Biology, in the Queen's Medical Research Institute, University of Edinburgh,
                                                             th
                                47 Little France Crescent, 24 August 2006

The audit took the form of a walk-through inspection of all laboratory and office areas on the ground floor of The
Queen's Medical Research Institute. The principal objectives of the audit were:
1.   To assess lab areas for appropriate practice including radioactive monitoring and lone working risk
     assessments.
2.   To check that all RA1, BA1 and COSHH Risk Assessment documentation was up-to-date.

Inspection Team:
Dr Pamela Brown (PB) (Biological Safety Officer)
Dr Moira Nicol (MN) (Amicus Health & Safety Representative)
Dr Gordon McLean (GWM) (Business/Laboratory Manager)
Lindsay G Murray (LGM) (H&S Manager)
Mr Ian Swanston (IS) (Safety Officer/ Radiation Protection Supervisor – MRC HRSU)

For the purposes of the following notes, Laboratory Health & Safety Representatives are:
MM - Mike Millar (Histology, South East)             MP - Margaret Paterson (MRC, North East)
EF    - Elena Faccenda (MRC, North Central)          RS - Robin Sellar (MRC, South Central)
DP - Deborah Price (O&G, North West)                 GM - Garry Menzies (O&G, North West)
AFH - Forbes Howie (Clin Biochem, South West)        JT    - Jane Taylor (O&G, South West)
JW - Jean Wade (Neonatology, South West)


The following general points were identified as requiring attention:

Fire blankets: Inappropriate positioning
Action:               GWM will contact fire officer to discuss and request repositioning
Responsible persons: GWM & IS
Comments:              In a number of areas fire blankets have been located in inappropriate positions, requiring
                      staff to stretch over equipment etc.. to reach and in a number of positions there is
                      insufficient room to pull the fire blanket down and out.
Action status:        Ongoing.

Radioactive monitoring records: In general the keeping of radioactive monitoring records was poor and in
some cases non-existent.
Action:              Urgent action is required to put in place a scheme of radioactive monitoring that is CRB
                     wide.
Responsible persons: IS, GWM, SM
Comments:            Meeting have been arranged and a scheme involving a rota for weekly testing is being set-
                     up.
Action status:       Ongoing

Lone working Risk Assessments: General lack of risk assessments covering group members in a number
of areas.
Action:             Encourage all staff to attend upcoming lone working H&S presentation.
Comments:           There seems to be a general lack of understanding of the difference between lone working
                    and out of hours working. Many staff believing that they were the same thing. A number of
                    groups insisted that no lone working occurred. On one occasion this statement was offered
                    by a person who was lone working.
Action Status:      Ongoing
                                                            th
Fume Hoods requiring service: All fume hoods now in 13 month since last check.
Action:             Check with building manager to determine schedule for retesting under maintenance
                    contract.
Responsible Person:
Comments:
Action Status:      Ongoing

Mixture of Chemicals in flammable cabinets
Action: thought to be given to more appropriate labelling of cabinets

                                                        1
DRAFT REPORT – Version 1: 17/09/2006
Responsible Person: Users
Comments:             Storage cabinets with flammable signs attached are being used for a mixture of chemicals
                     (though none of these were mixing flammables & corrosives). Thought might be given to
                     removing or changing the signs (e.g. to corrosive) on some of these cupboards so that only
                     those with a flammable sign are used for flammables and the remaining for other chemicals
                     such as corrosives.
Action Status: Ongoing

Tissue culture and microbiology culture rooms: spills procedures
Action:               Notice detailing action to be taken in the advent of a spill to be prominently displayed in all
                      appropriate rooms.
Comments:             Lack of easily accessible information regarding action to be taken following spills.
Action status: Ongoing

General accumulation of polystyrene storage boxes
Action:               Staff to be reminded of the dangers of letting these boxes accumulate with regard to fire
                     risks.
Comments:
Action Status: Ongoing

First Aids Kits: Who has responsibility for ensuring these are kept up to date and restocked?
Action:                Responsibility for this should be given to lab H&S reps if they are not already doing this.
Comments:
Action status: Ongoing



Points for Action relating to specific locations or Groups

E1.35: Loose socket under work bench
Action: Confirm that this has been included in BB defects list.
Responsible persons: IS
Comments:
Action Status:          Ongoing.

E1.35: Wet work being undertaken on unsealed benches.
Action:
Responsible persons:
Comments:            This item was highlighted last year, there seems little alternative due to the high proportion
                     of mobile benches. Perhaps a sign indicating what is and what is not (e.g. GM work)
                     acceptable will suffice?
Action Status:       Ongoing

E1.35: Richard Sharpe Group Area, COSHH assessments to be reviewed September 2006
Action:              Review assessments September 2006
Responsible persons: PI
Comments:
Action Status:       Re-audit to confirm

E1.35: Richard Sharpe Group Area, only one group member had signed a lone working RA.
Action:              Make sure group are aware of the limitations put on their work by not having lone working
                     RAs covering all members
Responsible persons: PI
Comments:
Action Status:       Re-audit to confirm.

E1.35: Phillipa Saunders Group Area, COSHH assessments to be reviewed September 2006
Action:               Review assessments September 2006
Responsible persons: PI
Comments:
Action Status:        Re-audit to confirm.

E1.35: Axel Thomson Group Area, COSHH assessments to be reviewed September 2006
Action:             Review assessments September 2006

                                                          2
DRAFT REPORT – Version 1: 17/09/2006
Responsible persons: PI
Comments:
Action Status:       Re-audit to confirm.

E1.35: Axel Thomson Group Area, No evidence of lone working RAs despite having members who lone
work.
Action:              Introduce Lone working RA ASAP
Responsible persons: PI
Comments:
Action Status:       Re-audit to confirm December 2006.

E1.54: Waste Bin without required waste stream label
Action:              Label bin
Responsible persons: users
Comments:
Action Status:       Ongoing.

Wash-up: Outdoor clothing hung on same hook as lab coats
Action:              Make sure staff are aware of issue
Responsible persons: IS & GWM
Comments:
Action Status:       Ongoing

Wash-up: Corridor outside door, blue lockers need to fixed to wall.
Action:              Arrange with joiner
Responsible persons: IS
Comments:
Action Status:       Ongoing

E1.55:Orange Bin within non-CATII designated room
Action:              Remove bin or redesignate room
Responsible persons: users
Comments:
Action Status:       Ongoing

E1.50:Orange Bin within non-CAT II designated room
Archive GM forms older than three years, or submit and update over the next year.
Action:                Remove bin or relabel room
Responsible persons: users
Comments:
Action Status:         Ongoing

E1.48: Orange bin without waste stream label
Action:               Label bin
Responsible persons: users
Comments:
Action Status:        Ongoing

E1.27:(Histology) visitor lab coats missing
Action:                Make these available
Responsible persons: MM
Comments:
Action Status:         Ongoing

E1.27:(Histology) COSHH assessments to be reviewed September 2006
Action:              Review by due date
Responsible persons: MM
Comments:
Action Status:       Re-audit to confirm

E1.26: Floor filthy and need of cleaning
Action:                 Liaise with Robert Wheeler to arrange cleaning/access as required.
Responsible persons: MM
Comments:

                                                        3
DRAFT REPORT – Version 1: 17/09/2006
Action Status:          Ongoing.

E1.24: Clutter on bench near radioactive work area, waste in radioactive bin
Action:               Tidy indicated area, waste should be disposed of and staff told only radioactive waste in
                      this bin. Bin clearly labelled radioactive waste only.
Responsible persons: MM
Comments:             Designated area for radioactive work was last used 01/06, however there was waste in the
                      radioactive bin, no-one new if waste was radioactive.
Action Status:        Ongoing

E1.24:Incomplete radioactive swabbing records
Action:               Instigate system to ensure regular monitoring of work area
Responsible persons: MM
Comments:
Action Status:        Ongoing

E1.24:General lab waste found in radioactive bin
Action:              Relocate bin to radioactive workspace within lab
Responsible persons: MM
Comments:
Action Status:       Ongoing

C1.21: Fire blanket positioned in inaccessible location
Action:                Contact university fire officer to seek repositioning
Responsible person:            IS
Comments:
Action Status:         Ongoing

C1.21: Wet work taking place on unsealed mobile benching
Action:                Reposition activity to sealed benching
Responsible person:             IS
Comments: This item was highlighted last year, there seems little alternative due to the high proportion of mobile
benches. Perhaps a sign indicating what is and what is not (e.g. GM work) acceptable will suffice?
Action Status:         Ongoing

C1.21: Absence of visitor lab coats
Action:                Provide Lab coats labelled for visitors
Responsible Person: users
Action Status:         Ongoing

C1.21: Incomplete radioactive swabbing records
Action:               Instigate rota for regular monitoring
Responsible Person: users
Action Status:        Ongoing

C1.21: Pam Brown Group Area, None of the COSHH assessments were signed by the PI.
Action:             PI must sign COSHH assessments
Responsible Person: PB
Action Status:      Ongoing

C1.21: Pam Brown Group Area, No lone working by this group
Action:                    Make sure group are aware of difference between lone working and out-of-hours
                           working.
Responsible Person:        PB
Action Status:      Ongoing

C1.21: Robert Miller Group Area, all COSHH assessments have not been reviewed for a couple of years
Action:                       COSHH assessments to be reviewed ASAP
Responsible Person:           PI
Action Status:         Ongoing, re-audit December 2006

C1.21: Robert Miller Group Area, No evidence of a lone working RA
Action:                       Lone working RA to be put in place ASAP
Responsible Person:           PI

                                                          4
DRAFT REPORT – Version 1: 17/09/2006
Action Status:          Ongoing, re-audit December 2006

C1.21: Robert Miller Group Area, a number of areas have been designated for the use of radioactive
material. Monitoring records poor.
Action:                       Regular monitoring to be instigated as soon as feasible
Responsible Person:           PI
Action Status:         Ongoing.

C1.21: Henry Jabbour Group Area, a number of areas have been designated for the use of radioactive
material. Monitoring records poor.
Action:                       Regular monitoring to be instigated as soon as feasible
Responsible Person:           PI
Action Status:         Ongoing.


C1.35: Large pile of wall cabinets awaiting fixing causing obstruction
Action:                Arrange fixing to wall with university joiner
Responsible Person:            IS
Action Status:         Ongoing

C1.24: Wet work taking place on unsealed mobile benching
Action:                Reposition activity to sealed benching
Responsible Person:             IS
Comments: This item was highlighted last year, there seems little alternative due to the high proportion of mobile
benches. Perhaps a sign indicating what is and what is not (e.g. GM work) acceptable will suffice?
Action Status:         Ongoing

C1.34: Radioactive monitoring/swabbing records blank
Action:              Instigate rota for regular monitoring
Responsible Person:           users
Action Status:                Ongoing

Radioactive Lab: All three eyewash stations have no monitoring records
Action:                       Ensure regular testing of eyewash stations
Responsible Person:           H & S Reps
Action Status:         Ongoing

C1.23: Radioactive monitoring/swabbing records blank
Action:              Instigate rota for regular monitoring
Responsible Person:           IS
Action Status:       Ongoing

C1.06: Alan McNeilly’s Group Area, old GM forms require to be archived.
Action:                GM forms referring to any work that is not current should be archived.
Responsible Person:           PI
Action Status:         Ongoing


W1.07: 30 person laboratory bay 1: inappropriate storage under fume cupboard
Action:               Chemicals should be separated to appropriate locations
Responsible Person: Users
Comments;                    Fume cupboard storage cupboard has a bottle of Bouin‟s (mixed picric and acetic
                             acids) stored beside solvents.
Action Status:        Ongoing

W1.08: non-standard receptacle utilised for storage of pipettes
Action:               Use appropriate storage for used pipettes.
Responsible Person: Users
Comments;
Action Status:        Ongoing

W1.07, W1.08, W1.34: weekly eye wash checks not up to date
Action:               remind staff of importance
Responsible persons: GWM

                                                         5
DRAFT REPORT – Version 1: 17/09/2006
Action status:          Ongoing



The Following points were highlighted for Re-audit in last years report (updated comments in RED)

GENERAL POINT: A large number of points were highlighted in last years audit regarding building issues which
are still outstanding. E.g. heavy/sticky doors, especially between atria, extract ventilation in rooms fed with CO2
supplies, holes in bench and floor in W1.07, missing door number signage, unlocked service doors, leaking drain
pipe in dark room. IS and GWM will continue to raise these points in the appropriate meetings and review to make
sure the final making good defects period addresses all these issues.

Offices: Need for Display Screen equipment and Workstation Risk Assessments to be carried out
There were a few examples of sub-optimal workstation designs. It is recommended that the attention of office-
based workers be drawn to http://www.safety.ed.ac.uk/training/wsphtml/main.htm as a vehicle for self-training and
self-audit of workstation design. There was evidence of some personal items (including a CD player in W1.16,
though this was not the only example) that had not been PAT‟d.
Action:                  All office-based workers (includes PIs and senior technicians) to complete self audit of
                         most frequently used workstation, using the H&S Department template.
Responsible persons: All office-based workers, including PIs and senior technicians.
Comments:                GWM, IS to verify that formal and self audits carried out.
Action status:           Ongoing. A University Section workstation assessor (MN) has been formally trained
and is currently undertaking a programme of individual workstation assessment within the University
Section. A similar programme of assessment (Steve Clarke) will commence in the MRC in Jan 2006.
Review and Re-audit in July 2006: All university employees who work primarily at workstations have been
assessed, including those based in the Simpson Centre, laboratory based staff have also been offered
assessment. MRC employees still awaiting assessment (is this correct Ian?)

PAT testing: PAT testing of electrical equipment needs to be carried out
There were very few examples of appliances which had currently valid PAT status. It is recommended that PAT
testers be asked to label appliance plugs so that the status of all portable electrical equipment can be easily
checked simply by reading off the labels on all plugs connected to socket strips on compartmented trunking and
stand-alone sockets.
Action:                Gordon McLean to establish timetable for PAT testing with UoE Estates on-site controller.
Responsible persons: GWM, IS
Comments:              UoE Estates currently on site.
Action status:         Ongoing.
Review and Re-audit in July 2006:As of 16/9/06 PAT testing is underway in QMRI/CRB, re-audit to confirm
completion November 2006.

Engineered Controls: Fume cupboards require to be serviced
Many fume cupboards throughout the floor were displaying a warning light indicating that service was required.
Action:                  GWM to seek clarification on serving contracts and timing.
Responsible persons: GWM
Comments:                Must complete required servicing by December.
Action status:           Ongoing. Completed 13.12.05. Annual servicing contract established.
Review and Re-audit in July 2006: Annual serviceing of fume cabinets due to commence in next couple of
weeks, re-audit to confirm completion December 2006.

West end of central corridor: Warning signs and Fire Safety
The overhead suspended fire escape route sign mid-corridor has the correct “running man” icon on one side only.
Action:               LGM will draw this to the attention of UoE‟s Fire Safety Unit.
Responsible persons: LGM
Comments:             Mike Moore to inspect this and other outstanding fire issues in CRB.
Action status:        Ongoing. Lindsay Murray to report on progress.
Review and Re-audit in July 2006: This item is still outstanding confirmation that correct sinage is in place
required from MM.

W1.08 Primary cell culture: Fire alarms are not very audible.
Action:               Notify rooms with poor audibility to H&S Committee who will pass information to LGM and
                      Mike Moore.
Responsible persons: Lindsay Murray, Gordon Mclean to monitor action taken by Mike Moore.
Comments:             Currently W1.07, W1.10, W1.24, W1.22, W1.21, W1.39
Action Status:        Notification completed 13.12.05.

                                                        6
DRAFT REPORT – Version 1: 17/09/2006
Review and Re-audit progress in July 2006: Not aware of any progress in this area?

Cold Room ground floor blue corridor west: Untidy – needs major revision.
Action:                  Lab H&S reps to organise a „clear-up‟ and to dispose of unclaimed items.
Responsible persons: AFH, JW, JT, DP, GM, users.
Comments:                Polystyrene transport boxes to be eliminated and green plastic storage trays to be
purchased as necessary to permit better use of space and kick stool for access to higher shelves
Action status:           Ongoing. GWM to monitor and remind Lab Reps.
Review and Re-audit in July 2006: This area is still a major problem, one person to be given overall responsibility
for good order of cold room, more storage boxes to be ordered.

C1.06: Instability of drawer units.
Several people commented that the drawer units (with the large file drawer) could be unstable when the bottom
drawer was open.
Action:                 Awaiting replacement of drawer units.
Responsible persons: GWM, IS to monitor
Comments:               Drawer units will not be replaced, but an insert will be produced for the file drawer. Units
can be stabilised by wedging such as an empty pipette box between the back top surface of the cabinet and the
underside of eth bench. Crude, but effective!
Action Status:          Ongoing. GWM to monitor availability of inserts.
Review & Re-audit in July 2006: After many delays work is due to be completed in next couple of weeks

W1.16 (Divisional Office): Risk of reaching to high shelves.
Action:                Kick stool for the office to prevent over reaching to high shelves.
Responsible persons: VS to consult GWM, VS and office staff
Comments:              Office staff to complete UoE online risk assessment to cover this and other risks.
Action Status:         Ongoing. GWM to monitor.
Review and Re-audit in July 2006: Kick stool now provided, also only light items to be stored on high shelves
from now on.

C1.07: Wet lab work is being carried out on unsealed benches.
Action:
Responsible persons: Lab C1.07 users and EF, IS.
Comments                 Lab members commented: Is this really C1.07? This lab only has mobile benching units.
Where else are staff to carry out their work?
Action Status:           Ongoing. In dispute; guidance sought from Lindsay Murray.
Review & Re-audit in July 2006: This issue has not been resolved due to the large number of mobile benches in
MRC area, perhaps provision of a warning sign indicating unsealed bench will suffice ?

C1.10, C1.21, E1.27, E1.35: Eye wash checklists need to be provided.
Action:                Put up printed stickers and check eye washes weekly
Responsible persons: EF, RS, MM, IS
Comments:              Provided with printed stickers. Checklist installed, weekly procedure instigated
Action Status:         Completed 06.12.05.
Review & Re-audit in July 2006: In the majority of areas except a couple of specific examples noted in this years
report eye wash records are excellent and up to date.

C1.21: An example of a fairly common phenomenon where room numbers have not been affixed to doors
(or have fallen off and not been replaced), or where a long lab is signed only at one end.
Action:                 Notify IS. Lab numbers to be instated or replaced as necessary.
Responsible persons: RS, IS
Comments:               Contractors have been informed.
Action Status:          Ongoing.
Review & Re-audit in July 2006. :


E1.35 – Philippa Saunders group GMRAs in good order, but should archive or update forms reaching three
years old over the next year.
Action:               Update GMRAs on new template.
Responsible persons: Philippa Saunders
Comments:             PB to review in August 2006.
Action Status:        Ongoing.
PB to Review and Re-audit progress in July 2006.


                                                         7
DRAFT REPORT – Version 1: 17/09/2006
E1.44 - Axel Thomson’s group: Archive old forms and submit updates for others, within the next year.
Action:              Update GMRAs on new template.
Responsible persons: Axel Thomson
Comments:            PB to review in August 2006.
Action Status:       Ongoing.
Review and Re-audit progress in July 2006: Completed


Wash-up Room: Does autoclave training need to be carried out – availability of an SOP?
Action:              Write or obtain an SOP to use for training purposes.
Responsible persons: Wendy Skedd, IS
Comments:            Designated Autoclave operators to be trained (Wendy Skedd, Pam Kane).
Action Status:       Ongoing.
IS to Review and Re-audit progress in July 2006.

Wash-up Room: A door to an area behind autoclave and glass washer was labelled “Danger Live Steam”.
Action:              Ensure that door is locked and key placed with keyholder.
Responsible persons: Wendy Skedd, IS
Comments:            It is recommended that this be locked to prevent unauthorised access into the area.
Action Status:       Ongoing. Requested that a new key be supplied.
IS to Review and Re-audit in July 2006.

Wash-up Room: Signage required to warn against unauthorised use of autoclave and glass washing plant.
Action:              Draft and display appropriate signage.
Responsible persons: Wendy Skedd, IS
Comments:
Action Status:       Ongoing.
IS to Review and Re-audit progress in July 2006.

Break Room Area: confusing fire signs.
One senior researcher commented that the coherence of signage of fire escape routes broke down in the vicinity of
the break room area at the far east end of the floor.
Action:                 LGM will draw this to the attention of UoE‟s Fire Safety Unit.
Responsible persons: LGM
Comments:
Action Status:          Ongoing.
IS to Review and Re-audit in July 2006.

W1.20 Brown, Neonatology, Clin Biochem, Wilmut: Solvent cupboards under fume hoods – not vented.
Action:                 Re-notify Balfour Beatty of need
Responsible persons: GWM
Comments:
Action Status:          Ongoing.
Review and Re-audit in July 2006: Balfour Beatty have since confirmed that fume cupboards were installed as
specified, cupboards are therefore unlikely to be vented unless we pay for it ourselves.

W1.20 Clin Biochem: GMRAs on old forms.
Either archive GM forms greater than three years old, or submit an updated form on new UoE H&S Department
template over the next year.
Action:
Responsible persons: Ian Mason/SM
Comments:               AFH to coordinate
Action Status:          Ongoing.
Review and Re-audit in July 2006.

W1.24 Cell line culture: CO2 build-up risk.
A researcher asked if the provision of piped CO 2 dictated any need for O2 depletion monitoring. LGM suspected
not, given the forced ventilation that was serving the room, and awareness of a leak that would probably arise from
noise generated by a breached pipe, but will obtain a definitive response from UoE Occupational Hygiene.
Action:                 LGM to assess and report.
Responsible persons: LGM
Comments:               Cell culture labs assessed by John and Rab Calder. Noted that ventilation went off
between 20.00-07.00 overnight and thus a need to understand the function of the ventilation overrides provided in
each Room, to enable ventilation to be restored during „Out of hours‟ working. Rab Calder to seek advice from

                                                        8
DRAFT REPORT – Version 1: 17/09/2006
Balfour Beattie and brief LM. Once reactivation procedure understood, LM to include an instruction in the LF H&S
manual that people using the cell culture rooms „between the hours of 20.00-0.700, should activate the ventilation
at the override box on eth wall. This also to be included in Cell Culture Risk Assessments.
Action Status:           Ongoing. LM awaiting Rab Calder’s feedback.
LM to Review & Re-audit in July 2006

W1.37 O&G Equipment room: Inappropriate filing cabinet.
Action:               Filing cabinet needs to be replaced to eliminate tip risk.
Responsible persons: Rose Leask
Comments:
Action Status:        Ongoing.
Review & Re-audit in July 2006.

C1.03 – Alan McNeilly: GM Risk Assessments on old forms.
Action:               Archive GM forms older that three years, or submit an update over the next year.
Responsible persons: Alan McNeilly, Linda Nicol
Comments:
Action Status:        Ongoing.
Review & Re-audit in July 2006.

C1.06: Door into C1.30 needs a glass panel.
Action:              Notify IS and UoE Estates
Responsible persons: EF
Comments:
Action Status:       Ongoing. Post hoc modification.
IS to Review & Re-audit in July 2006.

C1.06: Solvent cabinet missing under the fume hood.
Action:              Notify IS of need for replacement.
Responsible persons: EF
Comments:
Action Status:       Ongoing. Cabinet on order.
IS to Review & Re-audit in July 2006.




                                                         9
DRAFT REPORT – Version 1: 17/09/2006
Health and Safety Audit of Child Life & Health laboratory and office areas at 20 Sylvan Place, University of
                               Edinburgh, 25th August 2006 (09.00-10.30).
                      DRAFT Report passed to Rhona Stephen for action 15.09.06

The audit took the form of a walk-through inspection of all Child Life & Health 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 following
      continued reorganisation of the CL&H Section.
3.    To confirm that items flagged for ‘Review and Re-audit July 2006’ had been completed.

Inspection Team:
Dr Steve Morley (Convenor CRB H&S Committee),
Dr Gordon McLean (Clinical Biochemistry, Laboratory Manager),
Mr Lindsay Murray (Little France Buildings H&S Manager).

Child Life & Health (20 Sylvan Place):

Overall impression from inspection:
Child Life & Health Laboratories have undergone extensive reorganisation and refocussing over the last 12-18
months, following the relocation of the Neonatology sub-section to Little France, although some outstanding issues
still remain to be resolved. Currently liaising with Estates & Rab Calder over reorientation layout of laboratory
5.79, but need to continue to press for action. General standards of organisation of Health and Safety Child Life &
Health Laboratories at 20 Sylvan Place remain excellent as per 2005.
The following general points were identified as requiring attention:
All PIs are asked to action the following general and specific points as they relate to individual groups. Additional
advice can be sought from the Laboratory Heath & Safety Representatives.

Level [2]

Room 5.79 - Mothballed -Tissue Culture Suite : Flagged for Review and Re-audit July 2006
Action: Cell culture hood remains decommissioned and mothballed and will require to be recommissioned if use
is envisaged. Currently awaiting appointment of New Professorial Chair to determine whether they will require
cell culture facilities. Unused equipment largely disposed of. Fate of remaining equipment will be decided
following arrival of new Chair. Possible use as a biomechanical laboratory remains.
Responsible persons: RS & Users.
Comments: Lab currently mothballed
Action status: Ongoing. Review and Re-audit August 2007

Room 5.79 - Mothballed -Tissue Culture Suite : Absence of smoke detector in cell culture suite. Flagged for
Review and Re-audit July 2006
Action: No immediate action required, but review again when new use of room is decided to see if any of the new
activates to be conducted there carry an increased risk of fire.
Responsible persons: RS & Users.
Comments: A meeting arranged with Mike Moore on the 31.01.06 had addressed the lack of smoke detectors
within the offices and Tissue Culture suite [5.79] in Child Life and Health. Mike Moore expressed the view that
smoke detectors were not necessary in these rooms as there are several detectors located nearby.
Action status: Completed

Room 5.79 – Biomechanical Research Laboratory: Compressed gas cylinder in the lab, but no compressed
gas sign on the door.
Action: Obtain compressed gas sign and affix to the outside of the door.
Responsible persons: RS
Comments:
Action status: Ongoing. Review and Re-audit August 2007
Remedial Action:-Compressed gas sign now displayed on door. RS


                                                         10
DRAFT REPORT – Version 1: 17/09/2006
Room 5.79 –Biomechanical Research Laboratory designated for patient testing: Ongoing benching
modifications
Action: Room currently contains a wooden desk as short term solution to bench height problem – wooden surface
of this desk not suitable of laboratory use.
Responsible persons: RS & users.
Comments: Monitor bench installation to check fitness for purpose of final installation and remove desk on
completion of bench refit.
Action status: Ongoing. Review and Re-audit August 2007
Remedial Action:-Appropriate adjustable work bench ordered and wooden desk removed. The final
alterations will be completed by 30/10/06. RS

Room 5.79 – Biomechanical Research Laboratory designated for patient testing:: Evidence of 2-3 people
working in this laboratory, but only one person had signed the general risk assessments.
Action: Require users to read and sign risk assessments
Responsible persons: RS & users.
Comments: Staff to attend COSHH and Risk Assessment training courses as necessary
Action status: Ongoing. Review and Re-audit August 2007
Remedial Action:-Risk Assessment declaration now signed by all staff working in this area. RS


**NB** Due to the creation of a new Paediatric Clinical Research Facility, the following research areas 5.73,
5.75 and 5.87 will be decommissioned as research laboratories and consequently there will be a general
clearance of obsolete equipment and chemicals. The chemicals and equipment will be disposed of via the
appropriate waste disposal route as advised by the UoE Estates Department.

Room 5.75 - Supervised Radiation laboratory [Proposed New Clinical Research Facility]: Flagged for
Review and Re-audit July 2006
Action: Complete ongoing relocation of John Smith’s current activities to the downstairs supervised radiation
laboratory during the forthcoming year, and arrange decommissioning of laboratory prior to change of use, as no
longer planned that Clinical Staff will use radioisotopes in this room.
Responsible persons: RS and John Smith (CL&H Radioisotope Officer).
Comments: Now anticipated that this room will become a Clinical Research Facility, linked to the hospital.
Because patients will be brought into this environment, it is essential to complete official decommissioning
procedures in liaison with UoE Estates and SEPA. Architectural redesign of room in prospect to allow new entry
point from RHSC.
Action status: Ongoing. Review and Re-audit August 2007

Room 5.75 – Supervised Radiation Laboratory [Proposed New Clinical Research Facility]: Chemicals &
Research samples present
Action: Organise disposal of remaining chemicals. In the meantime, Highly Toxic chemicals must be stored
appropriately under lock and key. The COSSH list will require to be updated accordingly when the chemicals are
finally removed from Child Life and Health.
Responsible persons: RS.
Comments: Previous major chemical disposal completed, but have accumulated some additional chemicals
awaiting disposal via the usual route.
Action status: Ongoing. Review and Re-audit August 2007
Planned Remedial Action:- All the residual chemical and solvents in this area will be disposed of via the
appropriate route [i.e. Chemistry Department at KB] as part of the general planned decommissioning of this
area. RS

Room 5.75 - Supervised Radiation laboratory [Proposed New Clinical Research Facility]: currently being
used to store defunct computer equipment
Action: Complete disposal of monitors an printers via standard UoE routes
Responsible persons: RS
Comments: Short term storage of equipment prior to disposal acceptable, because little work is going on in this
room at present.
Action status: Ongoing. Review and Re-audit August 2007


                                                       11
DRAFT REPORT – Version 1: 17/09/2006


Rooms 5.73 & 5.75 – Controlled and Supervised Radiation Labs: Waste from previous workers should be
disposed of. Flagged for Review and Re-audit July 2006
Action: No further action required
Responsible persons: RS, Jean Wade
Comments: Radioisotope waste has been appropriately disposed of.
Action status: Completed

Level [1]

Room 2.75 – RIA Lab/Supervised radioisotope area: Office attached to Lab 2.75 does not meet general
requirements for office-based workstations
Action: Finance allowing, should in due course seek to replace outdated monitors with flat screens (not sure that
I’d refer to finance, since the current situation is basically unacceptable in terms of of display screen equipment
safety).
Responsible persons: RS
Comments:
Action status: Ongoing. Review and Re-audit August 2007
Remedial Action:-A Toshiba Notebook has been purchased to replace the obsolete PC and monitor in this
area.
The outdated monitor and PC will be disposed of appropriately along with other listed obsolete IT
equipment. This will be part of a general clearance of equipment due to a change of use and creation of the
new Clinical Research Facility within the present research areas of 5.73, 5.75, 5.76 and 5.87. RS

Room 2.75 – RIA Lab/Supervised radioisotope area: Centrifuge not PAT tested
Action: Resurvey all laboratories and offices and arrange PAT testing as required to bring all items up to test
programme specifications
Responsible persons: RS
Comments:
Action status: Ongoing. Review and Re-audit August 2007
Remedial Action:-A request has been made to the Estates department of the RHSC [NHS] Trust to come
and PAT test this centrifuge along with some newly acquired laboratory equipment. RS

Ground Floor

Room 1.79 – Seminar Room: Fire door in far left corner inappropriately locked. Flagged for Review and
Re-audit July 2006
Action: As existing lock will be retained, LM suggested that a notice explaining the ‘twist’ mechanism of the lock
should be drawn up and posted by the door, to enable rapid egress in the event of an emergency.
Responsible persons: RS.
Comments: At meeting on 31.01.06 Mike Moore expressed the view that a quick release lock was unnecessary
and that the existing ‘twist’ lock was adequate.
Action status: Ongoing. Review and Re-audit July 2007

General Fridges in Laboratories: Currently unclear if all fridges should be labelled ‘Spark free’ or ‘risk of
sparking’. Several fridges identified as risky for solvent storage.
Action: Determine which fridges are ‘spark free’ and which present a ‘risk of sparking’ and label all accordingly.
Responsible persons: RS.
Comments:
Action status: Ongoing. Review and Re-audit July 2007
Remedial Action:-All fridges are now labelled accordingly. RS




                                                         12

				
DOCUMENT INFO