Facilities Management Department
Routine Audit and Monitoring of Health and Safety
management functions.
The responsibilities and monitoring approaches contained within this guide
are to be followed by all Facilities Management (FM) staff in support of the FM
Health and Safety Policy.
A duty holder has been identified for each activity together with guidance as to
who will provide support in carrying out the related tasks.
The ‘Duty holder’ will be responsible to the Director of FM , via their Section
Managers, for: The implementation and maintenance of the auditing and monitoring
processes contained within this guidance.
The allocation of suitably trained, experienced and qualified competent
staff to fulfil the responsibilities identified.
Reporting to the Director of FM the findings of the audits and reviews
within their respective areas.
1. H&S core policy review:
Duty holder: Director of FM
a. Annually:
i.
Check currency of guidance and procedures.
ii.
Check representative selection of links on website.
b. Carried out by:
Health and Safety Manager liaising with Deputy Health, Safety and
Environment Manager with FM IT support.
2. Legionella management. (Annex O):
Duty Holder: Duty Holder: FM Chartered or Incorporated Building
Services/Plant Engineer.
a. Currency of policy procedures and guidance.
FM Senior Building Services Engineer - Appointed by Duty Holder
b. Routine testing and monitoring of systems in accordance with L8
ACoP.
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Contractors and FM Services Staff depending on current FM
Services adopted approach.
Monitored by FM Services Contracts Manager supported by FM
Projects technical input as required.
c. Monitoring of out of term operational works requisition returns from
Imago for student accommodation under their control.
Imago Health and Safety Coordinator with support from FM
Services Contracts Manager and FM Helpdesk.
d. Annual physical checks on representative sample (say 10%) of
storage arrangements to monitor contractors’ or operatives’
performance.
In house FM Projects staff supported by FM Services if necessary.
Monitoring initiated via planned preventive maintenance system
works requisition, to incorporate any ad-hoc reports from
operatives.
e. Annual review of extent of systems being managed and check of
records pertaining to all systems.(Up to date lists include new
buildings etc.).
FM Services Contracts Manager initiated by PPM job card.
3 yearly review of Legionella relevant policies and procedures. FM
Health and Safety Manager, Building Services, Health, Safety and
Risk Management Coordinator and appropriate FM Services
Managers with Deputy Health, Safety and Environment Manager.
Possibility of cross sectional auditing process utilising FM Projects
managers and Imago expertise.
3. Asbestos Management. (Annex X).
Duty Holder: FM Maintenance Officer.
.
a. Currency of policy, procedures and guidance.
FM Maintenance Officer initiated by PPM system.
b. 3 monthly monitoring of checks being carried out and current results
posted on University intranet utilising reminders issued through
PPM system.
Building Services, Health, Safety and Risk Management
Coordinator with support from FM Services Maintenance Manager
or equivalent Prompted by PPM system.
c. Annual review of procedures and management arrangements. (Incl.
competence of staff allocated roles and responsibilities).
FM Health and Safety Manager supported by FM Services
Supervisors and FM Projects Small Works Manager.
d. Annual review of training of operational staff
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i.
General awareness training.
FM Health and Safety Manager
ii.
Staff trained to check condition of ACM left in situ.
FM Services Maintenance Manager supported by Corporate
Services Manager (Training database desktop review).
Initiated through ppm system.
iii.
Staff trained to access contaminated areas
FM Services Maintenance Manager supported by Corporate
Services Manager (Training database desktop
review).Initiated through ppm system.
e. Quarterly check of accessibility of Register from external
departments. (Incl. link from security).
Building Services, Health Safety and Risk Management
Coordinator.
f. Annual check of general departmental training records.
Corporate Services Manager supported by FM Health and Safety
Manager.
4. Pressure Systems. (Annex B).
Duty Holder: FM Chartered or Incorporated Building Services/Plant
Engineer.
a. Currency of policy procedures and guidance and 3 yearly review.
FM Senior Building Services/Plant Engineer - To be nominated by
Duty Holder
b. Existence of written authority for Authorised Person(s) – Pressure
Systems.
Corporate Services Manager – Training database desktop review.
c. Annual review of currency of certification, log books pertaining to
Pressure systems and use of permit system.
FM Health and Safety manager
d. Close monitoring of all Pressure systems during permitted work.
Authorised Person(s) – Pressure Systems.
e. Gas cylinder storage and associated equipment and systems – 6
monthly recorded monitoring checks.
Suitably competent and trained Person – Gas storage systems.
Nominees to be appointed by Duty Holder in consultation with
Maintenance Manager.
(Training and competence currently held within FM Services
Mechanical section).
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f. Appropriate use of permits
i.
Contractors’ staff
Monitoring by Project Manager supported by Building Services, Health, Safety
and Risk Management Coordinator where appropriate.
6 Monthly audit and report
Building Services, Health, Safety and Risk Management
Coordinator
ii.
Direct Labour
FM Services Maintenance Manager supported by Line
Manager and Supervisory staff.
6 Monthly audit and report
Building Services, Health, Safety and Risk Management
Coordinator
g. Existence of equipment lists and currency of records, certification
etc.
FM Services Contracts Manager.
h. Annual audit of certification by Competent Person Pressure
Systems. (Insurance Inspector).
FM Health and Safety Manager.
5. Electrical management of HV and LV electrical systems. (Annex I - J)
Duty Holder: FM Senior Authorised Person Electrical
a. Annual Review of currency of policy, procedures and training.
FM Services Senior Authorised Person Electrical. (Currently FM
Services Maintenance Manager)
b. Monitoring of operatives compliance with declared health and safety
arrangements.
Project Manager/Supervisor or Authorised Person supervising
works.
c. Appropriate use of permits.
i.
Contractors’ staff
Monitoring by Project Manager supported by Building
Services, Health, Safety and Risk Management Coordinator
where appropriate.
ii.
FM Services
FM Services Maintenance Manager supported by Line
Manager and Supervisory staff.
6 Monthly audit and report by Building Services, Health,
Safety and Risk Management Coordinator
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d. Suitable and &Sufficient risk assessments (and method statements
where appropriate) for work.
Supervisor or Project Manager as appropriate.
6. Confined Spaces and controlled areas: (Annex F).
Duty Holder: Assistant Director FM Services
a. Annual review of currency of policy procedures and guidance.
Assistant Director FM Services supported by FM Health and Safety
Manager.
b. Ad-hoc checks of operatives and contractors working in such areas.
All managers as prescribed in departmental guidance plus
monitoring by Health and Safety Manager and Building Services,
Health, Safety and Risk Management Coordinator.
c. Routine 6 monthly desktop review and report of permit use.
Building Services, Health, Safety and Risk Management
Coordinator.
d. Annual survey of Signage for confined spaces and controlled areas.
FM Services Maintenance Manager prompted by works docket from
PPM system.
e. Currency of training of staff authorised to manage work in confined
spaces, including issuing permits.
Section and Sub-section Supervisors/Managers with support of
Corporate Services Manager.
7. Management responsibilities.
Coordinator: Corporate Services Manager
a. Review of individuals’ recorded ability to discharge their managerial
and supervisory responsibilities in accordance with FM H&S Policy
and this guidance.
i.
Annually utilising Personal Development Review process
when appropriate.
All line managers.
ii.
Stress issues. Training attendance of staff within sections.
All line managers supported by Corporate Services Manager.
iii.
Annual review of currency of educational and training
requirements for Supervisory positions, including
responsibilities defined within this guidance.
All line managers utilising Personal Development Process
plus Corporate Services Manager support as appropriate.
.
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iv.
Reporting strings. Annual review of currency and
appropriateness of reporting lines and procedures.
Corporate Services Manager supported by Senior
Management Team.
8. Operational safety risk assessment availability, suitability and
sufficiency.
(Physical, and preparedness for emergencies).
Duty Holder: FM Services Building Services, Health and Safety Risk
Management Coordinator.
a. Biennial review of existence of and suitability/sufficiency of
appropriate Risk and COSHH assessments.
Operative and line manager for every task as appropriate.
Building Services, Health, Safety and Risk Management
Coordinator for monitoring and reporting.
b. Existence of generic Risk Assessments for emergency operations.
(Partial buildings collapse, isolating and accessing underground
services, leaks, electrical outages etc.)
Maintenance Manager with the support of Line Managers and Duty
Holders responsible for the areas of operation.
c. Annual review of efficacy and implementation of arrangements.
Health and Safety Manager with assistance of Building Services,
Health, Safety and Risk Management Coordinator.
d. Currency of training and staff competency.
Line managers supported by Corporate Services Manager.
e. Delivery or arrangement of appropriate training.
FM Health and Safety manager.
f. Availability of Safety data sheets, COSHH assessments etc.
Line Manager
9. Occupational Health related risk assessments and associated
monitoring processes
Duty Holder: FM Services Health and Safety Manager.
a. LEV maintenance and performance monitoring, including fume
cupboards.
FM Services Contracts Engineer.
b. Biennial review of existence of and suitability/sufficiency of
appropriate COSHH assessments.
Operative and line manager for every task as appropriate.
Building Services, Health, Safety and Risk Management
Coordinator for monitoring and reporting.
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c. Annual review of efficacy and implementation of arrangements
for COSHH compliance.
Health and Safety Manager with assistance of Building Services,
Health, Safety and Risk Management Coordinator.
d. Currency of staff training and competency.
Line managers supported by Corporate Services Manager
e. Noise and Vibration risk assessment co-ordination
Building Services, Health, Safety and Risk Management
Coordinator
10. Machinery maintenance schedules including cranes and their use.
Duty Holder: FM Services Maintenance Manager.
a. Annual audit of currency of policies, procedures and guidance.
FM Services Maintenance Manager
Health and Safety Manager annual audit of certification for installed
equipment.
b. Lifting beams and associated supporting structures (including
temporary structures),
FM Project Managers monitor contractors’ arrangements for
temporary or construction works under their control.
FM Services Contracts Manager for routine inspection, testing and
maintenance.(Lifts and lifting equipment)
c. Lifts, associated equipment and control mechanisms
FM Project Managers monitor contractors’ arrangements for
temporary or construction works under their control.
FM Services Contracts Manager for legislative and routine
inspection, testing and maintenance once equipment is handed
over.
Health and Safety Manager annual Audit of certification by
Competent Person(Insurance Inspector)..
d. Work Equipment including cranes.
i.
Cranes and lifting operations
FM Services contract or line manager as appropriate.
ii.
Lifting strops, chains, ropes etc.
Services Contracts Manager for legislative and routine
inspection, testing and maintenance.
Workshop or section Supervisor responsible for ensuring that
items are on the register, are adequately maintained and
available for inspection by competent persons.
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iii.
Provision and Use of Work Equipment Regulations
implementation. (Including LOLER as appropriate).See
also cranes and lifting operations.
Workshop or section Supervisor responsible for ensuring that
items held are on the register, are adequately maintained
and available for inspection by Competent Person (Insurance
Inspector)..
11. Work at Height arrangements (Annex M)
Duty Holder: Assistant Director FM Services.
.
a. Adoption and implementation of University policy and procedures.
i.
ii.
Day to day management.
Line managers ultimately reporting to Assistant Director FM
Services.
Annual auditing and reporting of effectiveness, adoption
and implementation of processes.
Health and Safety manager with support of Building
Services, Health, Safety and Risk Management Coordinator.
b. Roof access and associated fall prevention/arrest provision.
Duty Holder: FM Projects Maintenance Officer.
i.
Annual audit of currency of policy procedures, guidance
and arrangements .
FM Projects Maintenance Officer.
ii.
Maintenance and recording of fall arrest and fall prevention
equipment, systems and fastenings. (Hooks, fastenings,
runners, edge protection mountings etc).
FM Services Buildings Technician supported by Building
Services, Health, Safety and Risk Management Coordinator.
c. Work at Height compliance, including appropriate use of permits,
recording staff competence etc.
All supervisory and management staff plus ad-hoc monitoring by
Health and Safety Manager.
d. Monitoring of currency of training. (Access equipment, standing
authority to access roofs etc. etc.)
Section and Sub-section Supervisors/Managers with support of
Corporate Services Manager.
e. Access equipment register and maintenance schedules.
i.
Ladders, steps and associated equipment.
1. Pre-use equipment inspections and checks.
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Operative with advice from Line Manager as
appropriate.
2. Routine periodic maintenance and inspections.
Supervisor responsible for workshop or staff utilising
equipment.
3. Currency and content of Access Equipment Register.
Supervisor responsible for Workshop in which main
user groups operate.
4. Annual monitoring and auditing equipment register
currency and accuracy.
FM Services Buildings Technician with assistance
from respective Supervisors.
5. Staff training and competency management.
Line managers utilising Training database.
ii.
Safety lines, harnesses, karabiners and associated
fixings/equipment inspections.
1. Pre-use checks
Trained operative prior to each use.
2. Periodic legislative checks and inspections of
equipment, mountings and structural equipment (edge
protection, eye bolts, etc.). Initiated through PPM
system.
FM Services Building Technician, utilising specialist
contractors as appropriate.
3. Staff training and competency management.
Line managers utilising Training database. Support by
FM Corporate Services Manager.
12. Personal Protective Equipment – Suitability, availability and
use.(Annex N)
Duty holders: FM Health and Safety manager equipment quality.
FM Services Maintenance Manager. Availability and
use of equipment.
i.
Day to day operational use in accordance with procedures
and guidance..
Line managers and Supervisors.
ii.
Monitoring above.
Section Managers with support of Building Services, Health,
Safety and Risk Management Coordinator
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iii.
Auditing effectiveness and implementation of procedures.
Health and Safety Manager.
13. Driving related work. (Annex AA)
Duty Holder: Director or Deputy Director FM Projects.
a. Day-to-day compliance, monitoring and management of
departmental procedures.
Line managers with FM Helpdesk support.
b. Monitoring of staff registered to drive University owned or
leased/hired vehicles.
Corporate Services Manager with Helpdesk support.
c. Auditing and reporting implementation and effectiveness of policy
and guidance.
Health and Safety Manager with Corporate Services Manager
support.
14. First Aid provision.
Duty Holder: FM Director with Health and Safety Manager support.
a. Monitoring numbers and provision of First Aiders and reviewing risk
assessment, including liaison with University Health, Safety and
Environment Manager
Health and Safety manager with support of local line managers and
Health, Safety and Environment office.
b. Provision of First Aid boxes and contents.
Supervisors with support of Local First Aiders and Drivers for
vehicle kits.
c. Monitoring and maintaining contents and inspections of First Aid
boxes.
First Aiders.
Line managers for content of kits in vehicles.
15. Accident and Near Miss Investigation and Reporting.
Duty Holder: Deputy Director FM Projects
a. Accidents involving FM employees and Agency staff, near miss
incidents and dangerous occurrences reports.
i.
ii.
Initial report following accident and actions to assist or
mitigate/prevent further harm.
Person involved where appropriate with immediate
supervisor.
Initial investigation to prevent further occurrences in similar
circumstances.
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Person involved where possible, immediate Supervisor and
Supervisor’s Line Manager. Health and Safety Manager (or
in their absence the Building Services Health, Safety and
Risk Management Coordinator) to be notified immediately
where the accident leads to the person being absent from
work or requiring medical assistance other than basic first
aid.
iii.
Follow up investigations, processing accident reports,
liaison with Health and Safety Office and reporting statistics
to departmental Health and Safety Committee.
Health and Safety Manager.
b. Accidents involving Contractors and self-employed workers.
i.
Processing reports and monitoring adequacy of operatives’
employer’s actions.
Appropriate FM Project Manager with support of Health and
Safety Manager.
ii.
Incorporating details into and maintaining/monitoring FM
database .
Health and Safety Manager.
16. Gas installation and maintenance management. (Annex D and E)
Duty Holder: Senior Chartered/Incorporated Building Services/Plant
Engineer
a. Installation compliance with statutory requirements.
Competent Projects Engineer.(Building Services/Plant Engineer.
To be nominated by Duty Holder.
b. Managing routine statutory compliance inspections and
maintenance scheduling.
FM Services Contracts Engineer with support of competent Projects
Engineers.
c. Competence of operatives working on gas installation.(Including
(CORGI or CAPITA Registration.).
Assistant Director FM Services for FM staff.
Projects Manager responsible for monitoring contractors’ staff
competence
17. Permit use generally.
Duty Holder: Assistant Director FM Services
a. Auditing accuracy of permits documentation.
FM Health and Safety manager.
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b. Currency of procedures, guidance and routine monitoring of the
implementation and adoption of the appropriate applicable Safe
Systems of Work, including permits to work or access.
Building Services Health, Safety and Risk management Coordinator
supported by the Health and Safety Manager.
18. Fire and emergency lighting
a. Installations and Maintenance of Infrastructure Systems
Duty Holder: Senior FM Electrical or Building Services
Engineer
i.
Installation to appropriate standards
FM Project Manager in consultation with University Fire
Officer.
ii.
Routine inspection and testing of installed fire alarm and
emergency lighting installations.
FM Services Electrical/Contracts Engineer arranges and
monitors contractors’ performance.
Assistant Director FM Services annually audits the records
and certification produced.
iii.
Recording and reporting obvious mechanical damage or
tampering related to sensors (including bags over
detectors) noted as part of FM annual plant room audit.
Building Services Health, Safety and Risk management
Coordinator with Trades Union Health and Safety
Representative.
iv.
Fire Door inspections
1. Currency of fire door inspection register and link to
PPM system.
FM Projects Maintenance Officer
2. Ensuring checks and reports are current in
accordance with works requisitions.
FM Services Maintenance Manager
v.
Fire alarm systems isolation requests.
Audited by FM Building Services Health, Safety and Risk
Management Coordinator as part of 6 monthly permit auditing.
b. FM Equipment
Departmental duty holder; FM Services Maintenance Manager.
i.
Fire extinguisher inspection.
University Fire Officer
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ii.
Annual inspection forming part of FM annual plant room
auditing.
Building Services Health, Safety and Risk management
Coordinator with Trades Union Health and Safety
Representative.
iii.
Check drivers’ fire extinguisher training.
Section Supervisor with reference to Training database.
iv.
Presence of fire extinguisher in vehicle
Driver during daily checks and Supervisor during weekly
checks.
c. Operational fire issues, including Fire drills
Coordinator: FM Health and Safety manager
v.
Undertaking weekly monitoring checks/tests of local fire
alarm and detection system and its connection to the
Security gatehouse.
Fire Marshall for building(s) as nominated.
vi.
Monitoring of fire drills and responses within individual
buildings.
Nominated building Fire Co-ordinator or Fire Marshal
vii.
Overarching auditing and monitoring of fire drills and record
keeping.
University Fire Officer.
viii.
Storage of flammable Liquids
1. Annual inspection and report on of all FM storage
arrangements.
FM Services Maintenance Manager with technical
assistance from University Fire Officer if required.
vi.
FM Projects Maintenance Officer supported by FM
Services staff.
19. Manual Handling operations.
Duty Holder: FM Health and Safety manager
a. FM Staff
i. Suitability of staff allocated to tasks.
Line Manager
ii. Competency and training of operatives
Supervisor Responsible for each section or group.
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iii. Monitoring of records regarding operatives’ training
FM Services HR Coordinator
iv. Annual audit of currency of Training database.
FM Corporate Services Manager
v. Monitoring performance of staff and H&S issues.
b. Contractors’ staff monitoring.
FM Project Manager monitoring of contractors’ arrangements
including compliance with risk assessment and method statements.
20. DSE Work Station Assessments.
Duty Holder: Director of FM Services supported by FM Health and
Safety manager
a. Maintenance and content of Self Assessment Guidance and
database.
FM Health and Safety manager supported by FM Services HR
Coordinator and Section Assessors.
b. Currency of Section assessments and local advisors
Line Managers supported by Nominated Section Assessors
c. Currency and accuracy of self-assessment database and links to
Training database.
FM Services HR Coordinator
d. Annual audit of currency of Training database.
FM Corporate Services Manager
21. Health and Safety of staff in areas not under FM control.
Duty Holder: Assistant Director FM Services
a. FM Services Staff
i.
Coordination of inter-departmental procedures
Assistant Director FM Services supported by FM
Maintenance Manager
ii.
Vicarious liability for staff in areas not under the direct
control of FM staff.
Section Supervisors liaise with departments and tenants as
appropriate and allocate work to suitably competent staff and
afford adequate information is given.
b. Contractors’ staff
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i.
Coordination of FM and departmental procedures and
liaison with departmental staff and tenants.
FM Projects and Services Project Manager as appropriate.
All Managers, Supervisors and Line Managers.
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