CORP/HSFS 31 v.

Permit to Work
Policy and Procedures
This procedural document supersedes: CORP/HSFS 31 v.1 – Permit to Work Policy and
Procedures.

Did you print this document yourself?

The Trust discourages the retention of hard copies of policies and can only guarantee that
the policy on the Trust website is the most up-to-date version. If, for exceptional reasons,
you need to print a policy off, it is only valid for 24 hours.

Executive Sponsor: Kirsty Edmondson-Jones

Director of Estates & Facilities
Author/reviewer: (this Neil Donegan
version) Health and Safety Adviser
Date written/revised: September 2020
Approved by: Trust Health & Safety Committee
Date of approval: 28 October 2020
Date issued: 25 November 2020
Next review date: October 2023
Target audience: All Staff Trust Wide, All Contractors

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Amendment Form

Please record brief details of the changes made alongside the next version number. If the
procedural document has been reviewed without change, this information will still need to
be recorded although the version number will remain the same.

Version Date Issued Brief Summary of Changes Author

Version 2 25 November  Changes have been made from Care Neil Donegan
2020 Groups to Divisions.

Version 1 11 Oct 2017 This is a new procedural document for the Sean Tyler
Permit to Work Policy and Procedures, Neil Donegan
please read in full.

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Contents
Page No.
1. INTRODUCTION............................................................................................................................... 4
2. PURPOSE ......................................................................................................................................... 4
3. DUTIES AND RESPONSIBILITIES ....................................................................................................... 5
3.1 The Trust Board .................................................................................................................... 5
3.2 Chief Executive ..................................................................................................................... 5
3.3 Director of Estates and Facilities .......................................................................................... 5
3.4 All Directors and Deputy Directors ....................................................................................... 5
3.5 Deputy Director of Estates and Facilities ............................................................................. 5
3.6 Departmental/Estates and Facilities Managers and Authorised Persons ............................ 6
3.7 Issuing Officer ....................................................................................................................... 7
3.8 Authorised Persons .............................................................................................................. 7
3.9 Competent Persons .............................................................................................................. 7
3.10 Other Staff............................................................................................................................. 7
3.11 Health and Safety Adviser ..................................................................................................... 8
3.12 Fire Safety Adviser ................................................................................................................ 8
3.13 Local Security Management Specialist.................................................................................. 8
3.14 Infection, Prevention and Control Team............................................................................... 8
3.15 Contractors ........................................................................................................................... 8
4. PERMIT TO WORK (PTW) PROCEDURE ........................................................................................... 9
4.1 Types of Permits ................................................................................................................... 10
4.2 Objections or Work outside the Scope of the Permit .......................................................... 12
4.2 Safety Documentation .......................................................................................................... 12
5. TRAINING/ SUPPORT .................................................................................................................... 13
6. MONITORING COMPLIANCE WITH THE PROCEDURAL DOCUMENT ............................................ 13
7. DEFINITIONS ................................................................................................................................. 13
8. EQUALITY IMPACT ASSESSMENT .................................................................................................. 14
9. ASSOCIATED TRUST PROCEDURAL DOCUMENTS ......................................................................... 14
10. DATA PROTECTION ....................................................................................................................... 15
11. REFERENCE.................................................................................................................................... 15
APPENDIX 1 – PERMIT TO WORK FLOW CHART ................................................................................... 17
APPENDIX 2 - EQUALITY IMPACT ASSESSMENT PART 1 INITIAL SCREENING ....................................... 18

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1. INTRODUCTION

The content of this document has two clear purposes. It is a Trust policy covering the
guidelines, regulations, and duty of care for all staff and contractors undertaking work on
Trust properties in relation to the use and operation of Permit to Work.

The policy describes the commitment of the Trust to provide a safe environment for
patients and staff. As part of the Trust’s duty of care, it also applies to all employees of the
Trust, agency staff, students and persons affected by our safety arrangement, that is,
patients, visitors, contractor’s staff and anyone else who has cause to be on the Trust’s
sites. A Permit to Work procedure is a formal written system used to control certain types
of work, which are potentially hazardous. Its aims are to ensure that proper consideration is
given to the risks of specific work and who the work effects. This will ensure that the risks
are dealt with prior to work commencing.

It also serves as a policy detailing the Trust’s requirements of those contracting companies
during preparation for undertaking work to Trust land, buildings, plant and equipment and
for the full duration of the work. This document shall be issued to all contracting companies
as a part of their approval process and available by request from the Trust in electronic
format. Contracting companies are expected to ensure that all personnel under their
employ who are to be engaged on Trust work are trained on the requirements of this policy.
Non-compliance with Statutory Regulations or with Trust policies by a contracting company
or any of its employees shall lead to the suspension of operations at no cost to the Trust.

Nothing within this policy is to be construed as relieving a Contractor of any of his Statutory
obligations under the Health and Safety at Work Act 1974, the Management of Health and
Safety at Work Regulations 1999, or any other current and relevant Legislation, Regulations
or Approved Codes of Practice.

2. PURPOSE

This policy lays down the mandatory requirements of the Trust for work activities within the
Trust’s Estates & Facilities, and applies to all sites, premises and equipment within the Trust,
or where the Trust provides a service from, at which new construction, refurbishment and
maintenance work is undertaken or any other contracted services provided.

As part of the Trust’s duty of care, this policy also applies to all employees of the Trust,
agency staff, students and persons affected by the Trust’s safety arrangement, that is,
patient, visitors, contractor’s staff and anyone else who has cause to be on the Trust’s sites.
This policy outlines the guidelines, regulations and duty of care for all contractors
undertaking work on Trust property.

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Nothing in these guidelines absolves contractors or their respective sub-contractors, their

employees and the self-employed from their duty to comply with all relevant Health and
Safety legislation.

3. DUTIES AND RESPONSIBILITIES

3.1 The Trust Board

The Trust Board has a generic responsibility for all aspects of Health & Safety. Contractors
working on Trust property pose a significant risk and the Trust Board, therefore, has a
responsibility to ensure that there is an approved Policy for the Permit to Work System
available to minimise that risk.

3.2 Chief Executive

The Chief Executive is responsible for ensuring that there is a suitable management structure
in place to manage the Policy for the Permit to Work System and its associated procedures.
Responsibility for this is delegated to the Director of Estates and Facilities.

3.3 Director of Estates and Facilities

The Director of Estates and Facilities is accountable to the Chief Executive and Trust Board for
ensuring that all who undertake work in connection with the development, maintenance or
disposal of Trust’s assets do so in accordance with the requirements set out within this
policy. They are also responsible for ensuring services provided by external providers are
appropriate, effective, efficient, safe and compliant with current statutory Legislation,
Regulations and NHS Good Practice Guidance including Health and Safety and Infection
Prevention and Control and that the risks are identified and managed as part of the Trust
Governance Framework.

3.4 All Directors and Deputy Directors

All Directors and Deputy Directors have a responsibility for ensuring that their Divisional
wards and department managers are aware of the Policy & Procedures for the Permit to
Work System and enforce its use within their own areas of responsibility.

3.5 Deputy Director of Estates and Facilities

The Deputy Director of Estates and Facilities is accountable to the Director of Estates and
Facilities for ensuring that this policy and appropriate procedures and systems are in place to

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ensure that all contractors’ activities are conducted safely and in compliance with current
legislation, regulations and good practice.

The Deputy Director shall ensure the Director of Estates and Facilities is kept informed at
reasonable time intervals as to the effectiveness of the arrangements for the management of
contractors and shall report any serious deviations to and when they arise. The Deputy
Director of Estates and Facilities shall ensure that regular audits are undertaken regarding the
Policy & Procedures for the Permit to Work System, including regular checks on adherence to
the Trust Policies and Procedures.

The Deputy Director shall ensure permit to work register is maintained, which will define all
specific staff who can issues permits to work (issuing officers) and include names of relevant
Authorised Persons (AP’s), Competent Persons (CP’s), and the systems they control.

3.6 Departmental/Estates and Facilities Managers and Authorised Persons

The above staff are the most likely to commission staff and contractors in their day to day
duties in the Trust and, as such, carry a responsibility to be aware of, and familiar with the
Policy & Procedures for the Permit to Work System. They should make every endeavor to
ensure that they, and staff under their control, comply with the relevant documentation.

They all hold a responsibility to ensure that specific work undertaken by their Staff and
Contractors is undertaken safely and in accordance with applicable legislation regulations and
good practice.

It is the responsibility of the person commissioning or managing the contractors to ensure

that pre-commencement meetings are held prior to the start of any work. During the
meeting the contractor must provide details of how they intend to carry out any work and
the risks associated with that work, to ascertain whether any precautions need to be taken
before or during the work. Permit to work systems may be required for some types of work;
these methods of work must be agreed and documented prior to commencement of the
work.

Each manager in areas where contractors are working must be made aware of any hazards
and risks presented by the work and relevant safety measures, as well as ensuring
contractors are made aware of risks that may be present in the area they are working.

Where there is the potential for the work to impact on the delivery of patient care or where
the work takes place in the proximity of a clinical area, advice must be sought from the Trust
Infection Control Team.

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3.7 Issuing Officer

Employees of the Trust Estates & Facilities directorate once suitably trained and authorised
in writing by the Deputy Director of Facilities, can issue permits. They are defined in this
policy as Issuing Officer. The Issuing Officer will be duly authorised to only issue permits that
they are competent and trained/qualified to issue.

3.8 Authorised Persons

The Director of Estates & Facilities will formally appoint in writing the Authorised Person
(AP) to appropriate defined systems and installations. The AP shall be responsible for
ensuring that all the actions to achieve a Safe System of Work have been completed. The
Authorised Person will be the Issuing Officer for Permits.

3.9 Competent Persons

The Competent Persons (CP) shall be responsible for undertaking specified duties on the
plant and apparatus and will be the person issued the Permit to Work, the limits of these
duties will be clearly defined in accordance with an Authorised Person’s instructions. While
carrying out these duties the Competent Persons must ensure that all safety measures are
taken to prevent danger, avoid injury and prevent damage to equipment.
The responsibilities of Competent Persons are to be fully conversant with the nature and the
extent of the work to be done, to read the contents and confirm to the person issuing the
safety document that it is fully understood, during the course of the work, adhere to, and
instruct others under their charge to adhere to, any conditions, instructions or limits
specified on the safety document, retain the safety document and (where appropriate) keys
in safe custody, and correctly implement any management procedure to achieve this, warn
all persons as quickly as possible to withdraw from, and not to work on, the equipment
concerned until further notice if, during the course of work, a hazard which could result in
danger arises or is suspected. The situation shall be reported immediately by the Competent
Persons to an Authorised Person and to comply with these ‘Safety Rules’ when carrying out
work whether instructions they are issued orally or in writing.

3.10 Other Staff

All employees who may be required to organise, work alongside, or assist contractors have a
responsibility to co-operate with their line manager in using the Trust’s Policy & Procedures
for the Permit to Work System and to participate, where required in any relevant training.

All staff have a duty to look after their own safety and that of others affected by their acts or
omissions, and therefore must co-operate with management in following agreed procedures
when contractors are undertaking work on behalf of the Trust.

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3.11 Health and Safety Adviser

The Health and Safety Manager will work closely with those responsible for the Policy &
Procedures for the Permit to Work System in the provision of advice and practical assistance
in all matters for health and safety.

3.12 Fire Safety Adviser

The Fire Safety Manager will work closely with those responsible for the Policy & Procedures
for the Permit to Work System in the provision of advice and practical assistance in all
matters relating to fire safety.

3.13 Local Security Management Specialist

The Local Security Management Specialist will work closely with those responsible for the
Policy & Procedures for the Permit to Work System in the provision of advice and practical
assistance in all matters relating to Security Management.

3.14 Infection, Prevention and Control Team

The Infection, Prevention and Control Team is responsible for providing advice on matters
relating to infection, prevention and control and the risks which could arise as a result of
construction work in clinical areas. The Infection, Prevention and Control Team will be
responsible for performing audits in clinical areas during the construction/alteration work to
ensure that the highest standards of infection, prevention and control are maintained
throughout the work.

3.15 Contractors

Contractors are responsible for ensuring compliance with all Health and Safety procedures
and legislative requirements. Contractors working on premises, which are leased out, to
another Trust must, in addition to the Trust procedures, set out in this policy, follow any
relevant policies on Health and Safety Management that the occupying Trust has in place.
Non-compliance with any of these policies may result in termination of the contract. The
Contractor must also ensure that they do not interfere with the day to day operation of the
departments or site.

All contractors either visiting or working on any of the Trust’s properties will ensure all his
employees on the Trusts site have either Reset Certification Scheme (RCS) ID badges or ID
badges which includes company name, employees name and photograph and must have a
Contractors pass or a Permit to Commence Work document supplied by the Trust.

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Additional permits are in existence to cover different types of work activities on various
specialist / hazardous pieces of equipment or systems. The Trust's Representative who is
responsible for a given project/work will under normal circumstances is the first person to
contact in respect of any necessary Permits and any issues associated

Risk Assessments Method Statements and Safe Systems of Work are the responsibility of
the Contractor unless work is being carried out jointly with Trust personnel. In such cases
the safe system of work must first be approved by the Trust's representatives.

If the Main Contractor intend to use any other sub-contractors or self-employed individuals
to provide services to the Trust these must also be registered with RCS and follow all
instruction as required by the Trust for the Contractor and be approved by the Trust. They
can register and subscribe themselves as companies or individuals.

The Contractor will also ensure that his activities will not endanger members of the public
or Trust employees working in the location of the works and will ensure that all accidents or
incidents are reported to the relevant member of the Trust Compliance Team.

4. PERMIT TO WORK (PTW) PROCEDURE

On arrival at site the Contractor must follow the Trust’s Policy and Procedure for the
Management of Contractors together with the agreed methods of work. (See Appendix 1)
Prior to starting work the Contractor must attend an agreed location in order to sign in and
obtain the relevant identification, information relating to the Contractor and their location
of work must be entered onto the RCS system. All Contractors working on behalf of
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust will be expected to have
attended Contractor Induction.

Contractor or Staff who are appointed as Competent Persons will be the person issued the
Permit to Work.

The Permit-to-Work System is not simply permission to carry out high hazard and complex
or dangerous work, but is essentially part of a procedure that provides planning and
instructions on how a potentially high hazard complex and dangerous work can be carried
out safely. They are required if there is a risk of serious injury which cannot be adequately
controlled by normal physical safeguards. Permits specify the work to be done and
precautions to be taken and provide a clear record that all foreseeable hazards have been
considered. The risk assessments and method statements will indicate the level of permit.

The issue of a Permit does not, by itself, make the work safe. This can only be achieved by
those preparing for and those carrying out the work. The Permit is a document that
authorizes competent people with the appropriate skills experience and knowledge to carry
out Specific work, limited by a specific area.

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The Issuing Officer signs that all the necessary precautions for achieving Safety from the
System have been complied with and will be secure for the duration of the work activity.
Hence, the Issuing Officer/ Authorised Person must carry out a comprehensive assessment
of all the risks associated with undertaking a particular job at a particular time and the
context of the work to ensure safe systems of work.

4.1 Types of Permits

The Trust Operates three specific types of permits that cover the full range of work
required on an Acute Hospital site.

Visitor and Contractor Safety Register is the simplest form of permit and are used for
general business visitors not undertaking work on the building fabric. Visitors and Contractors
shall comply with all relevant Health & Safety Law, Trust and company Health & Safety rules,
and have an understanding of the fire procedures for the premises and provide copies of
current public and employer liability insurance and a method statement for work being
undertaken.

Permit to Commence Work allows contractors to undertake low risk works to the building
fabric.
This type of permit can only be issued via the Estates & Facilities Directorate on each of the
three main sites. The RESET Certification login asks the contractor a number of questions
which forms a permit to commence allowing work to be carried out from up-loaded risk
assessments and method statements. If the RESET system has not had the work up-loaded
then it will ask the contractor to contact the Estates team before work commences.

The RESET certification Scheme is mandatory on all Trust sites. Information on the Scheme
can be found in the Policy and Procedures for the Management of Contractors.

Should the RESET system not be available, or an infrequently used specialist contractor is
commissioned, then the commissioning officer is to issue a paper permit to commence and
obtain certification of competency to carry out task, method statements and risk assessments
from the specialist contractor prior to work commencing and record these for future audit
purposes. This permit will only be issued if valid job specific risk assessments and method
statements have been completed and approved by the Estates designated officer prior to the
start date when the work is to commence.

High Risk Permits are issued to all Staff and Contractors undertaking specific or high risk
works on Trust premises. This type of permit is normally issued by Authorised Persons.
Access to this permit is via the Estates & Facilities Directorate on each of the three main
sites.
Depending on the nature of the tasks to be undertaken and the risks associated with them it
may be necessary to initiate one or a number of other supplementary permits for the duration
of the task to be undertaken. Accordingly, the main Contractors permit to commence work
and/or RAMS (Risk Assessment and Method Statement) shall lead to the issue of other
specialist Permits to Work as required depending on the nature of the task to be undertaken.

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The following attachments will be provided with the High-Risk Permit where appropriate:

Working Instructions (Method Statement & usage of equipment for carrying out of the work
Works Assessors Report (A risk assessment, which will highlight any problems that may arise,
as well as providing information or any additional safety requirements).
COSHH Requirements (Highlighting areas of risk that may arise due to work being carried out
or materials being used).

Types of High Risk Permits are;

 Hot Working Permit (Soldering, Welding Plastic, arc, gas, etc.)

 Fire alarm Isolation Permit (requires 48hr notice prior to work being commenced).
 Medical Gases Pipeline Systems (MGPS) Permit (high & low risk Permit for working on
MPGS to include all work associated with the pipeline /plant and alarm systems. Permit
can only be issued to the contractor or staff if s/he has successfully completed the
competent person (CP) paperwork for that site and has been entered onto the CP
register for working on MGPS).
 Confined Spaces Permit (access Permit for any work in a defined Confined Space).
 Pressure Systems Permit (work carried out on Boiler plant, Steam services, Refrigeration
where system working pressure is in excess of 0.5 Bar. Permit can only be issued to the
contractor or staff if s/he has successfully completed the competent person (CP)
paperwork for that site and has been entered onto the CP register for working on
Pressure Systems)
 Excavation Permit (Permit issued prior to any Excavation Work).
 Electrical Low Voltage LV Permit (Permit can only be issued to the contractor or staff if
s/he has successfully completed the competent person (CP) paperwork for that site and
has been entered onto the CP register for working on Low voltage systems). Electrical
Isolation for Passenger & Goods Lifts will be carried out under the LV Permit.
 Electrical High Voltage HV (Permit can only be issued to the contractor or staff if he/she
has successfully completed the competent person (CP) paperwork for that site and has
been entered onto the CP register for working on High voltage systems).
 Asbestos Permit (all works in connection to Asbestos, removal, encapsulation or
exposure. Permit can only be issued to the contractor or staff if s/he has successfully
completed the competent person (CP) paperwork for that site and has been entered
onto the CP register for working on asbestos).
 Water Systems Permit (Permit can only be issued to the contractor or staff if s/he has
successfully completed the competent person (CP) paperwork for that site and has been
entered onto the CP register for working on the water system specified).
 Ventilation Systems Permit (Permit can only be issued to the contractor or staff if s/he
has successfully completed the competent person (CP) paperwork for that site and has
been entered onto the CP register for working on the specific Ventilation System).

This list is not exhaustive and there may be other tasks deemed to require a Permit to Work.

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4.2 Objections or Work outside the Scope of the Permit

Objections on Safety Grounds

Where a Permit to Work is issued, the Competent Person who receives it may object to any
work instructions that accompany the permit on the grounds of Safety. If an objection is
raised then it should be discussed with the Permit Issuing Officer in the first instance: - The
Issuing Officer is obliged to discuss any queries regarding instructions on the grounds of
safety.

Work outside the Scope of the Permit

If during the course of work which is covered by a Permit to Work the Competent Person
discovers further work or variations to existing work instructions are required, the Permit Issuing
Officer must be contacted and all work halted until a decision is reached (a new Permit will need
to be issued with the cancellation of existing Permit).

4.2 Safety Documentation

Additional Documents
Attached to the Permit for Work may be additional instructions, other than the work
instructions, concerning work procedures, materials to be used, testing required during work,
safety procedures or COSHH requirements etc.

Safety Document
Competent Persons shall not start or restart work under a safety document issued to another
Competent Person.

Clearing of Safety Documents

Competent Persons clearing a safety document should do so only after all persons working
under the safety document have been withdrawn from, and warned not to work on, the
equipment concerned. Where appropriate they ensure that all tools, equipment and loose
material have been removed, guard and access doors replaced and the workplace left tidy.

Safety Document Working Party

The Working Party can be of any size (i.e. 1 to 21) and may consist of other Competent
Persons, Responsible Persons, specialist fitter’s etc. Members of a Working Party carrying
out work instructions which are covered by a Permit for Work are to take working
instructions from the Competent Person who has received the Permit for Work. Every
member of a Working Party has a responsibility to safeguard the Health & Safety of
themselves, other employees and anyone else who may be affected by works in progress.
The job will be stopped immediately if any work is found to be being performed outside the
scope of the permit. An incident will be raised and a reapplication for a permit to work will
be surrendered inclusive of a new risk assessment and method statement.
The job will be stopped immediately if it is found that unsafe practices are being performed

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against health & safety and against the contractor’s method statement. An incident form will
be submitted to the sites health & safety advisor and the contractor may be banned from
site.

5. TRAINING/ SUPPORT

All Issuing Officers will be trained to standards appropriate to the discipline and in line with
the appropriate Health Technical Memorandum HTM for specialist services and appointed in
writing to perform the task of issue of Permits by the Deputy Director of Estates & Facilities.

6. MONITORING COMPLIANCE WITH THE PROCEDURAL DOCUMENT

Who will carry out How Reviewed/

What is being Monitored How often
the Monitoring Where Reported to
The Monitor and Deputy Director of Annually Action plan with
Compliance and Estates & Facilities timeline. To the Director
Effectiveness of this of Estates & Facilities
Policy
Review of Policy Head of Estates & Yearly or when Approval from Estates &
Facilities Compliance significant Facilities SMT, Estates
change to and Facilities Health &
process Safety Committee, Trust
Health & Safety
Committee
Monitor Head of Estates & Annually Action plan with
Approved Facilities Compliance timeline. To the Director
Contractors of Estates & Facilities
Health and Safety Ad Hoc Report any issues to
Adviser Estates managers and
contractors supervisors
Monitor Competent Head of Estates & Annually Action plan with
Persons Register Facilities Compliance timeline. To the Director
of Estates & Facilities

Audit Permits Senior Authorised 6 Monthly Action plan with

Person or AE for timeline. To the Director
Discipline of Estates & Facilities

7. DEFINITIONS

AP - Authorised Person
CP - Competent Person
PTW - Permit to Work
RCS – Reset Certification Scheme

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8. EQUALITY IMPACT ASSESSMENT

The Trust aims to design and implement services, policies and measures that meet the diverse
needs of our service, population and workforce, ensuring that none are disadvantaged over
others. Our objectives and responsibilities relating to equality and diversity are outlined within
our equality schemes. When considering the needs and assessing the impact of a procedural
document any discriminatory factors must be identified.

An Equality Impact Assessment (EIA) has been conducted on this procedural document in
line with the principles of the Equality Analysis Policy (CORP/EMP 27) and the Fair
Treatment for All Policy (CORP/EMP 4).

The purpose of the EIA is to minimise and if possible remove any disproportionate impact
on employees on the grounds of race, sex, disability, age, sexual orientation or religious
belief. No detriment was identified. (See Appendix 2)

9. ASSOCIATED TRUST PROCEDURAL DOCUMENTS

CORP/HSFS 1 - Health and Safety Policy

CORP/HSFS 3 - Lone Workers Policy
CORP/HSFS 5 - Aggressive and Violent Behavior towards Staff Policy
CORP/RISK 30 - Risk Identification, Assessment and Management Policy
CORP/HSFS 7 - Control of Substances Hazardous to Health (COSHH) Guidance
CORP/HFSF 10 (A) – Asbestos Policy
CORP/HSF 10 (B) – Asbestos Management Plan
CORP/HSFS 14 - Fire Safety Policy (Note: to be read in conjunction with CORP/COMM 2 -
Smoke Free Policy) PLUS Protocol 1 - Fire Prevention; Protocol 2 - Fire Risk Assessment;
Protocol 3 - Fire Stopping; Protocol 4 - Fire Doors and Fire Door Assemblies
CORP/RISK 15 – Serious Incidents (SI) Policy
CORP/HSFS 16 - Mobile Communications Policy
CORP/HSFS 17 A - Waste Management Policy
CORP/HSFS 17 B - Waste Management Manual
CORP/HSFS 18 – Water Safety Policy
CORP/HSFS 21 - Ionising and Non-Ionising Radiations Safety Policy
CORP/HSFS 22 - Electronic Door Access Control and System Policy
CORP/HSFS 27 - Electrical Safety Policy
CORP/HSFS 28 - Window Management Policy
CORP/FAC 3 - Medical Gas Systems Policy (can also be accessed via Patient Care 'Medicines
Management' section)
CORP/EMP 4 – Fair Treatment for All Policy
CORP/EMP 27 – Equality Analysis Policy

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10. DATA PROTECTION

Any personal data processing associated with this policy will be carried out under ‘Current data
protection legislation’ as in the Data Protection Act 2018 and the General Data Protection
Regulation (GDPR) 2016.

For further information on data processing carried out by the trust, please refer to our Privacy
Notices and other information which you can find on the trust website:
https://www.dbth.nhs.uk/about-us/our-publications/information-governance/

11. REFERENCE

HSE.GOV. (1997). Confined Spaces Regulations 1997. [ONLINE] Available at:

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

HSE.GOV. (2014). Construction (Design and Management) Regulations (CDM) 2015.

[ONLINE]Available at:
http://www.hse.gov.uk/construction/cdm.htm

HSE.GOV. (2014). Control of Asbestos Regulations 2012. [ONLINE]Available at:

http://www.hse.gov.uk/asbestos/regulations.htm

HSE.GOV. (2014). Health & Safety at Work Act 1974. [ONLINE]Available at:
http://www.hse.gov.uk/legislation/hswa.htm

HSE.GOV. (2015). Health and Safety (First Aid) Regulations1981. Third edition.
[ONLINE]Available at: http://www.hse.gov.uk/pUbns/priced/l74.pdf

HSE.GOV. (1999). Ionising Radiation regulations 1999. [ONLINE]Available at:

http://www.hse.gov.uk/pUbns/priced/l121.pdf

HSE.GOV. (1998). Lifting Operations & Lifting Equipment Regulations (LOLER) 1998.
[ONLINE]Available at: http://www.hse.gov.uk/pUbns/priced/loler.pdf

HSE.GOV. (1999).Manual Handling Operations Regulations 1999, (as Amended) (MHOR)

[ONLINE] Available at: http://www.hse.gov.uk/foi/internalops/ocs/300-399/313_5.htm

HSE.GOV. (2015). Personal Protective Equipment at Work Regulations 1992. Third edition.
[ONLINE]Available at: http://www.hse.gov.uk/pUbns/priced/l25.pdf

HSE.GOV. (2013). Provision & Use of Work/Equipment Regulations 1998. [ONLINE]Available

at: http://www.hse.gov.uk/pubns/indg291.pdf

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 CORP/HSFS 31 v.2
HSE.GOV. (2013). Reporting of Injuries, Diseases and Dangerous Occurrences Regulations
(RIDDOR) 2013. [ONLINE]Available at: http://www.hse.gov.uk/riddor/

HSE.GOV. (2015). The Electricity at Work Regulations 1989. [ONLINE]Available

at: http://www.hse.gov.uk/pUbns/priced/hsr25.pdf

Legislation .GOV. (2014). Defective Premises Act 1972. [ONLINE]Available at:

http://www.legislation.gov.uk/ukpga/1972/35/section/4

Legislation.GOV. (2002). Electrical Safety, Quality and Continuity Regulations 2002.

[ONLINE]Available at:
http://www.legislation.gov.uk/uksi/2002/2665/pdfs/uksi_20022665_en.pdf

Legislation.GOV. (2016). Electromagnetic Compatibility Regulations 2016. [ONLINE]Available

at: http://www.legislation.gov.uk/uksi/2016/1091/pdfs/uksi_20161091_en.pdf

Legislation.GOV. (1972). Highly Flammable Liquids and Liquefied Petroleum Gases Regulations
1972. [ONLINE]Available at:
http://www.legislation.gov.uk/uksi/1972/917/pdfs/uksi_19720917_en.pdf

Legislation .GOV. (2014). Management of Health and Safety at Work Regulations 1999.
[ONLINE]Available at: http://www.legislation.gov.uk/uksi/1999/3242/contents/made

Legislation.GOV. (2000). Pressure Systems Safety Regulations 2000 Pressure Systems Safety
Regulations 2000. http://www.legislation.gov.uk/uksi/2000/128/contents/made

Legislation.GOV. (1998). The Noise at Work Regulations 1989. [ONLINE]Available at:

http://www.legislation.gov.uk/uksi/1989/1790/contents/made

Legislation.GOV. (2005). The Working at Height Regulations 2005. [ONLINE]Available at:

http://www.legislation.gov.uk/uksi/2005/735/contents/made

Legislation .GOV. (2014). The Workplace (Health, Safety and Welfare) Regulations 1992.
[ONLINE]Available at: http://www.legislation.gov.uk/uksi/1992/3004/contents/made

This list is not exhaustive and is the responsibility of Staff and Contractor to ensure that they
are conversant with all relevant legislation.

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 CORP/HSFS 31 v.2

APPENDIX 1 – PERMIT TO WORK FLOW CHART

Do I need a permit to work?

Does task/activity involve isolation, hazardous activity, alteration or work

on building fabric?

No Yes

Visitors pass to be issued Permit to commence work

required
Assessment and method statement are to
be provided by the service contractor.

Is the contractor signed up to RESET?

No
Yes
Check certification and
competence to conduct task, if RESET- Verification of Examples of the permits
satisfactory, a paper permit is to contractor competency required:-
be issued LV-HV Pressure
Systems Medical Gases
Hot work
Confined space
High risk permit required?
Working at height/roofs
Excavations
Yes Asbestos
Refer to the Trust Permit
Request made to relevant Trust Authorised or to Work Policy for all other
No Nominated Person will process the permit with permits
minimum notice of 10 working days

‘Trust Representative’ will process permit. The ‘contract administrator’ will sign for
receipt of the permit. The ‘authorised person’ will then sign the permit. The ‘competent
person’ will sign for receipt of the permit

If the intended isolation will have an impact outside of the ‘footprint’ of the
refurbishment, the ‘Trust Representative’ will inform the affected areas with the
cooperation of the person requesting the permit.

Permit cancelled by ‘Authorised Person’

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 CORP/HSFS 31 v.2

APPENDIX 2 - EQUALITY IMPACT ASSESSMENT PART 1 INITIAL SCREENING

Service/Function/Policy/Project/Strategy Division Assessor (s) New or Existing Service or Policy? Date of
Assessment
Permit to Work Policy and Procedures Estates and Facilities Directorate Neil P Donegan Existing Policy 14/09/2020
CORP/HSFS 31 v.2
1) Who is responsible for this policy? Estates and Facilities Directorate
2) Describe the purpose of the service / function / policy / project/ strategy? To ensure compliance with the Health and Safety at Work Act and all other related
legislation in relation to staff and contractors undertaking hazardous works
3) Are there any associated objectives? Legislation, targets national expectation, standards: Trust wide staff and contractors specific objectives to comply with
the Health and Safety at Work Act and all other related legislation when undertaking hazardous work on all Trust sites.
4) What factors contribute or detract from achieving intended outcomes? – Trust staff and contractors awareness.
5) Does the policy have an impact in terms of age, race, disability, gender, gender reassignment, sexual orientation, marriage/civil partnership,
maternity/pregnancy and religion/belief? Details: [see Equality Impact Assessment Guidance] – No
 If yes, please describe current or planned activities to address the impact [e.g. Monitoring, consultation] – N/A
6) Is there any scope for new measures which would promote equality?
7) Are any of the following groups adversely affected by the policy? No
Protected Characteristics Affected? Impact
a) Age No
b) Disability No
c) Gender No
d) Gender Reassignment No
e) Marriage/Civil Partnership No
f) Maternity/Pregnancy No
g) Race No
h) Religion/Belief No
i) Sexual Orientation No
8) Provide the Equality Rating of the service / function /policy / project / strategy – tick () outcome box
Outcome 1  Outcome 2 Outcome 3 Outcome 4
*If you have rated the policy as having an outcome of 2, 3 or 4, it is necessary to carry out a detailed assessment and complete a Detailed Equality Analysis form – see CORP/EMP 27.
Date for next review: October 2023
Checked by: Sean Tyler Date: 16/09/2020

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