College of Medical and Dental Sciences
Executive Summary of 2012/2013 Health and Safety Action Plan
The system in the College of Medical and Dental Sciences where individual School Action Plans feed
into and are informed by an overarching College Action Plan has proved to be successful and will be
continued in the 2013/14 plan.
Similar headings will be used to ensure all areas have been considered and there is continuity and
consistency in our efforts to improve health, safety and environmental standards in the College.
Although not specifically written in the action plan for 2012/2013 notable successes for the College
over the last year include the introduction of two way radios to facilitate more effective
management of emergency evacuations and the hosting of a successful ‘mini-environment day’ in
the College in January.
Review of achievement 2012/2013 (On reflection, the number of targets set for 2012-2013 was on
the high side. A more holistic approach has been taken for the production of the 2013-2014 plan)
 Out of 23 targets 10 have been completed.
 9 are in progress and will be carried over to the 2013/2014 plan.
 4 have yet to be progressed.
Successes
 The standard of housekeeping remains high; this is in part due to the introduction of
Laboratory Managers across the College, inherent in their job description is a responsibility
to monitor and manage basic H&S/general housekeeping issues within their geographical
area.
 PEEPS policy has been approved by College Board and the necessary requirements
implemented.
 Health surveillance for over 200 staff entering BMSU is now assured
 The Energy Reduction plan was completed in good time.
Targets currently in progress
 The improvement of PI engagement in health and safety through the PDR process is an issue
which needs to be incorporated in to the revised PDR process in order to ensure appropriate
checks are made by senior management within Colleges and constituent Schools. We
suggest that this is an issue which requires input at University level to ensure a consistent
approach is achieved across all Colleges.
 The fire drill procedure guidance was overtaken by the introduction of 2 way radios to assist
in emergency evacuations of the Medical School Building and IBR, this new development
needs to be added to the guidance which can then be finalised.
 Induction and other training are in progress but engagement of office staff has been slow.
Alternative methods for implementing the training need to be identified which will hopefully
increase participation and uptake.
Targets not achieved
 The College Health and Safety Advisor has not been able to progress the appropriate
website training to enable necessary editing and maintenance of the H&S Website, however
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this has not resulted in a lack of updates to the website which have been delivered by using
alternative resources within the College as a short term solution. It is recognised however
that the website does need a more thorough review and update.
Following a review of the current procedures for checking action points identified via safety
inspections, it is clear that the current system for the review the actions deemed as urgent
works reasonably well. The system for assessing action points with a medium to long term
timeframe is not functioning as effectively as we would like. Further work is required to
investigate more effective methods of ensuring all action points are cleared in the
designated timelines.
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College of Medical
and Dental Sciences
Health and Safety Action Plan 2013-2014
ITEM
Audit of GM animal work in preparation for HSE
inspection
 School BSO’s to update list of projects
 Cross check lists with BMSU projects

Arrange a pre-inspection of transgenic work
Policies and procedures
 Local guidance for Fire Drills in the College to be
finalised
 Formal procedure for following up action points
from inspections to be established
Training
 Safety training for office staff to be introduced
 Raise profile of POD among office staff
 Ensure Heads of Operations are aware of
safety training opportunities
Communication/Recordkeeping /IT
 Re-establish communication with UHBFT Health
Person(s) Responsible
Target date
31st October 2013
School BSO’s
College HSA &
University BSO
College HSA & Head of
Infrastructure & Estates
College HSA
December 2013
HSA/TM’s/Head of
Infrastructure & Estates
December 2013
HSA/Head of
Infrastructure & Estates
January 2014
College HSA/ Head of
December 2013
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6 monthly progress statement/date of
completion
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and Safety Unit by setting up an
Operational/Functional Committee
Initial scoping meeting held
Follow up meeting planned
Update website by arranging training for HSA
Database for accidents and incidents to be
established
Electronic record of safety training for Technical
Management Team and College Safety Coordinators to be established
Develop a repository of searchable repository of
COSHH assessments for use by College staff and
students
Establish a robust connection between College
H&S co-ordinators and specialists in the Central
H&S Unit
Ensure appropriate structures are put in place to
guarantee lines of communication with HBRC
and other HTA licensed areas in order to share
compliance and best practice
Infrastructure and
Estates
HSA
September 2013
December 2013
December 2013
HSA
January 2014
HSA/TMs/Medical
Education Team
January 2014
Head of Infrastructure
and Estates/HSA
March 2014
Head of Infrastructure
and Estates /Director of
HBRC /HSA/HTA
Designated Persons
June 2014
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College of Medical and Dental Sciences
Executive Summary of the 2013/2014 Action Plan
In 2013/2014 the College of Medical and Dental Sciences remains committed to maintaining and improving the
management of and operational standards for health and safety across all our activities.
Following a review of the 2012/2013 action plan and reflecting on the success of targets set against targets achieved
we believe we were perhaps over ambitious on the number of targets set and the spread of activity covered.
This year a more holistic approach has been taken. The plan is an overarching one, covering the schools and is a
consolidation of the following:
 Action points carried over from last year’s plan that were either outstanding or still in progress at the end of
the year.

Items arising from the review of the School Action plans.

Items such as the audit of transgenic animal assessments which required because of the proposed
HSE/DEFRA inspection.

Items arising from communication with external bodies such as the re-establishment of the Joint
UHBFT/UOB Safety Group.
The slight difference in approach will, we believe, better serve a College of the size and complexity of Medical and
Dental Sciences.
The attached priority objective table is taken from the overarching plan, the first action being the most urgent, in
this case the audit of the College’s transgenic assessments in preparation for the proposed HSE inspection.
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College of Medical and Dental Sciences
Health and Safety Action Plan 2013 -2014
Further JSAC Questions
To demonstrate the effectiveness of the chain of command especially at PI/Supervisor level with the respect to the
following issues;
Being aware of the legal and University requirements in their respective areas of research
This is done in a number of different ways:
 There are established policies and procedures to reflect legal and University requirements.
 The College of Medical and Dental Sciences Safety Executive (CSEC) meets termly to ensure compliance with
requirements. In addition each constituent School of the College has established a School Safety Executive
Committee which reports into CSEC
 All new lab staff and students attend Laboratory Safety training and also Chemical Safety training both of
which include current legislation, University and College requirements.
 There are regular in- depth inspections of individual PIs and their research groups which includes a
discussion of legal and University requirements with respect to health and safety. This type of inspection
mirrors the approach taken by HSE inspectors and has been well received by the PIs and their teams we have
visited to date
Ensuring those with supervisory roles are trained to carry out risk assessments and are competent to supervise
others.
There are different arrangements for the various types of risk assessments the College of Medical and Dental
Sciences is required to produce:
 All new staff receive training on the principles of risk assessment and are taken through a sample risk
assessment for biological hazards and a ‘COSHH’ assessment.
 PIs are expected to complete GM assessments themselves however the GM pro forma is structured in such
a way as to provide guidance to new PIs and assist more established staff in the preparation/review of these
risk assessments.
 Biological assessments and COSHH assessments can be delegated to Research Fellows and Technicians. The
quality of COSHH assessments has been found to be variable and so a COSHH assessment workshop has
been set up to help Technicians in particular. A COSHH sub group has been formed to monitor and advise on
the quality of COSHH assessments produced by research / technical staff
Being able to identify and manage the risks associated with the research
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Given the training outlined above, PI’s and Supervisors should be able to identify the hazards and assess the
risks they encounter in their work.
Hazards and risks would also be discussed at induction training.
Support is given to researcher groups by the Technical Management Team and cadre of Laboratory
Managers. In addition there is a well-established network of Safety Co-ordinators located throughout the
College who also contribute to the support systems.
There is a lot of information on the Health and Safety Unit web pages and more local information is given on
the College of Medical and Dental Sciences web pages, links to these are given at the safety training sessions
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Ensuring that all people under their direction have adequate information about the risks and the risk controls that
apply to their work and that these people have relevant training and appropriate supervision arrangements are in
place.
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A primary function of the College Health and Safety Advisor is to ensure relevant information is disseminated
effectively to research groups. In addition they will review and, where necessary, summarise new
policies/initiatives in order to ensure they are presented in such a way as to engage staff/students and
facilitate recognition of how such policies impact on our core business activities.
In laboratories and offices new staff and students are usually assigned a ‘mentor’ to supervise them until
they are deemed competent.
In the College High Risk Containment Level 3 Laboratories (CL3) arrangements are written in the form of
Codes of Practice and workers are not given access to a CL3 laboratory until they are judged to be
competent. There are similar requirements in Radiation Laboratories and Liquid Nitrogen Facilities.
Undergraduate project students are supervised constantly and are not allowed to work out of hours unless
granted permission by the School Technical Manager for specified low risk work.
Monitoring workplace safety compliance and the action taken if deficiencies are found such as unsafe acts or
conditions, failure to follow safe systems of work, lack of planned maintenance or inadequate facilities
Monitoring compliance is undertaken in a number of ways:
 There is programme of termly local inspections, the results of which are communicated to the College
Safety Executive Committee
 As mentioned earlier a team representing the College Safety Executive Committee conduct in depth
inspection of individual research groups.
 Any failures flagged up are followed to ensure issues have been remedied.
 For repeated non-compliances, situations of imminent danger or serious breaches of H&S rules/regulations
there is an enforcement procedure similar to the HSE system. In essence the College can either issue an
improvement notice, whereby staff are advised that activities must cease until prescribed remedial actions
are taken to a standard approved by senior managers within the College, or a prohibition notice which
requires immediate cessation of work, the relevant area is secured and a detailed investigation is
undertaken. In the five years since this was established it has only issued one improvement notice.
Issues for University to deal with
An issue the College believes would be best dealt with at University level is the engagement of PI’s in health and
safety via the new PDR process. We believe this would provide a useful vehicle for ensuring greater engagement and
establish an effective process for monitoring compliance in conjunction with local College procedures.
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College of Medical and Dental Sciences
2013-2014
1
2
Priority objectives
Audit of GM animal work in
preparation for HSE inspection
Update Policies, procedures
and guidance specifically:


Guidance for fire drill
The follow up of actions
arising from inspections
By whom
School BSO’s
College HSA,
University BSO,
Head of
Infrastructure
and Estates
College HSA
TMs, Head of
Infrastructure
and Estates
By when
31st
October
Success criteria
Satisfactory
compliance with
the GMO(CU)
Regulations
December
2013
Fire drills are
carried out in all
buildings.
Action points
from
inspections are
completed
Communication
of H&S
improved within
the college and
between the
College and H&S
Unit
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Communication/recordkeeping/
IT specifically:
 re-establish joint
UHBFT/UoB safety group
 update H&S web pages
 create database for
accidents and incidents
 Electronic record of M, LM
and Safety co-ordinator
training
 Develop a COSHH
assessment database
 Establish a robust
connection between
College and HSU specialists
College HSA
TMs, Head of
Infrastructure
and Estates
December
2013 March
2014
4
Introduce safety training for
office staff
College HSA,
Head of
Infrastructure
and Estates
December
2013
Steve Johnson
Sue Chalder
September 2013
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Improved safety
awareness for
office staff
Notes