UNIVERSITY POLICY AND GUIDANCE
SAFETY, HEALTH AND ENVIRONMENTAL
MONITORING
Document No
CU/09/MI/P/G/2.0
Area Applicable
All areas of the University
Approved by
Director of OSHEU
Review Year
2015
Document History
1
Author(s)
Revision
Number
Mike Turner, John Frayling
Date
Date 05/09
Amendment
Name
Removed: Based on a School /
Directorate rating system of Low,
Medium and High Risk, audits will be
scheduled to take place at required
frequencies. Where an audit identifies
significant problems it may be
appropriate to repeat the audit
outside the normal frequency to assess
and verify progress
Change: Directorate to Professional
Service
2.0
05 /13
Added: be agreed by the Health,
Safety and Environment Committee
based on a requirement to routinely
visit all Colleges and Professional
Services over a given timescale. This
may be influenced by
Added: Audits of specific themes may
be undertaken outside of the routine
frequency as appropriate
Added: 12. Independent External
audits
Various external interested parties will
audit the University for compliance
with statutory obligations and
conformity to the university
management system. These bodies
include:
 Health and Safety Executive
 Environment Agency
 Local Authority
 Certification bodies
3.0
12/13
Change: Definition of High Hazard
(Red) Areas: Areas which have been
identified through hazard assessment
by the School / Professional Service as
containing such significant hazards that
entry by maintenance staff or cleaners
requires a written Permit to Work using
the ‘Red Book system’.
Change to: Areas which have been
2
Mike Turner
Approved by
identified through hazard assessment
by the School / Professional Service as
containing such significant hazards that
entry by persons unaware/unfamiliar
with those hazards, for example
maintenance staff or cleaners,
requires a written Permit to Work using
the ‘Red Book system’.
And:
Change: Definition of Medium Hazard
(Amber) including Pool Rooms: Areas
which have been identified through
hazard assessment by the School /
Professional Service as containing
significant hazards and which require
Permit to Work systems and written
method statements for maintenance
staff or cleaners.
Change to: Areas which have been
identified through hazard assessment
by the School / Professional Service as
containing significant hazards and
which require Permit to Work systems
and written method statements for
persons unaware/unfamiliar with those
significant hazards, for example
maintenance staff or cleaners.
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Richard Steed
SAFETY, HEALTH AND ENVIRONMENTAL MONITORING
1. Legal Requirements:
The Health and Safety Executive (HSE) places significant emphasis on the
requirement for formal systems that cover inspection, monitoring and auditing
as essential features of the action required by organisations to satisfy their
statutory duties. Such systems are designed to prevent many of the failures
that lead to accidents, incidents and prosecutions.
The legal requirement to have in place formal systems to cover inspection,
monitoring and auditing may be found in the Health and Safety at Work Act
1974, the Management of Health and Safety at Work Regulations 1999 and
guidance such as the HSE publication HS(G)65 “Successful Health and Safety
Management”. Furthermore, the role and responsibility of senior management
in ensuring that periodic audits of the effectiveness of management structures
and risk controls for safety health (and environment) are carried out, is
explicit in the ‘Leading health and safety at work’ guidance issued by the
Institute of Directors. Moreover, individual members of the University’s
governing bodies and the University’s most senior staff may be guilty of
criminal offences if they neglect their obligations under safety, health and
environmental legislation
The Health and Safety Executive promote both “active and reactive
monitoring”.


Active monitoring systems which monitor the extent of compliance with
recognised standards; and
Reactive systems which monitor accidents, incidents and ill-health.
A low accident rate, even over a period of many years, is no guarantee that
safety, health and environmental risks are being effectively controlled. This
is particularly so in organisations such as Cardiff University where there is a
low probability of accidents and incidents but where major hazards are
present. In such cases historical accident data can be a deceptive indicator of
safety, health and environmental performance.
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2. Principal Objectives of the Policy:







To protect the safety and health and environment of Cardiff University
staff, students, visitors and any persons who may be affected by the
University’s activities;
To protect the physical assets of the University;
To protect the reputation of the University;
To provide information on where individual Schools and Professional
Services are relative to their overall safety, health and environmental
objectives;
To comply with relevant safety, health and environmental legislation.
To assist Schools and Professional Services in achieving continual
improvement in the management of safety, health and environmental
issues; and
by association, ensure the University’s continuing productivity
3. Responsibility of Council:
Cardiff University Council will have overall responsibility and accountability
for ensuring that safety, health and environmental risks are effectively
monitored, managed and that periodic audits of the effectiveness of
management structures and risk controls for safety health and environment
are carried out.
In practice the Council has delegated the authority for ensuring compliance
with its obligations to the Vice-Chancellor. The Vice-Chancellor has further
delegated authority to the Heads of Schools and to the administrative
Directors and this is consistent with the delegation of other responsibilities
within the University
4. Responsibility of the Vice- Chancellor:
a) Ensuring the implementation of the Monitoring Policy by securing the
commitment and co-operation of all University’s staff;
b) Allocating adequate personnel and financial resources;
c) Agreeing inspection,
protocols;
monitoring
and
auditing
procedures
and
d) Ensuring that adequate and appropriate information from the
monitoring and auditing systems is received in order to exercise
effective control over safety, health and environmental matters;
e) Agreeing arrangements for staff training, at all levels;
f) Regularly reviewing the University’s safety, health and environmental
performance, and agreeing any necessary action plans.
g) Ensuring that the same management standards are applied to
workplace inspections, monitoring and audit as are applied to other
management functions
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h) Ensuring that the organisational structure in place is appropriate to
manage health and safety matters related to workplace inspections,
monitoring and audit issues;
5. Responsibility of Heads of Schools and Professional Services:
Ordinance 7 of the Cardiff University’s Rules of Governance state that the
duties and responsibilities of Heads shall include:

to ensure on behalf of the University compliance with its obligations
with regard to the health, safety and welfare of staff and other persons
in or affected by the School and for the premises, plant and substances
therein.
This is consistent with the responsibilities set out in the University’s Safety,
Health and Environment Policy, including having responsibility for:
a) The implementation of the Monitoring Policy;
b) Ensuring
that
the
organisational
structure
within
the
School/Directorate is appropriate to manage workplace inspections;
c) Ensuring that adequate resources are
requirements of the Monitoring Policy;
provided
to
meet
the
d) Ensuring that the same management standard is applied to safety,
health and environment monitoring as to other management functions;
e) The quality of the inspection process meets an appropriate standard
(see inspection guidance appendix A);
f) Managers/ Supervisors are aware of their responsibility in ensuring
inspections are undertaken for areas under their control;
g) Agreeing who will carry out the inspection, monitoring and auditing;
h) Ensuring the suitable training, instruction and supervision for all
personnel so that they can competently carry out their responsibilities
within the Monitoring Policy;
i) Appropriate time is allocated for personnel involved in inspection,
monitoring and audit to complete their work;
i) There is a consistent approach across the whole School / Professional
Service and common problems identified in different areas receive
consistent action throughout the School / Directorate;
k) Inspections are completed on schedule;
l) Remedial action plans are completed on schedule; and
m) Systems are in-place for maintenance of records detailing the
inspections and the completion of any remedial action;
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n) The School / Professional Service Safety Health and Environment
Committee and Trade Union Safety Representatives are consulted on
the precise arrangements for self-inspection;
o)
Reviewing School/Directorate safety, health and environmental
performance
6. Supervisors and Managers are responsible for:
a)
b)
c)
d)
e)
Supporting the objectives of the Monitoring Policy;
Ensuring areas under their control are inspected on schedule;
Records of the inspections and remedial action plans are maintained;
Remedial actions are completed on schedule;
Inspection reports and/ or significant findings are reported to all
relevant parties.
7. Role of Staff and Students
All staff and students will be required to:

Support the objectives of the University’s Monitoring Policy.
8. Monitoring and Inspection- Contractors
It is the responsibility of each School/ Professional Service, through the
appropriate line management, to ensure effective management of contractors
under their control. As such each School/ Professional Service must monitor
and inspect areas where contractors under their control are operating to
ensure that appropriate safety health and environmental standards are being
met.
9. Frequency of inspection:
The timing and frequency of inspections should take into account inherent
safety, health and environmental risks and as a minimum will be based on the
University’s zoning system for high, medium and low hazard areas which is as
follows:
High Hazard (Red) Areas.Red Zone definition
Areas which have been identified through hazard assessment by the School /
Professional Service as containing such significant hazards that entry by
persons unaware/unfamiliar with those hazards, for example maintenance
staff or cleaners, requires a written Permit to Work using the ‘Red Book
system’.
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Each School / Professional Service is responsible for ensuring that work place
inspections are carried out at least once every 3 months. Suitable records
must be maintained for audit purposes.
Medium Hazard (Amber) Areas including Pool Rooms
Amber Zone definition
Areas which have been identified through hazard assessment by the School
/ Professional Service as containing significant hazards and which require
Permit to Work systems and written method statements for persons
unaware/unfamiliar with those significant hazards, for example maintenance
staff or cleaners.
Each School / Professional Service is responsible for ensuring that workplace
inspections are carried out at least once every 6 months. Suitable records
must be maintained for audit purposes.
Any other areas
Each School / Professional Service is responsible for ensuring that all areas not
falling within the University defined Red or Amber designation are subject to
a recorded hazard assessment to determine the frequency of inspection.
Should the assessment identify the area as having high or medium hazards
then the frequency should be as the previous categories. Should the hazard
assessment identify the area as ‘low’ then the workplace inspection frequency
should be at least once every 12 months
10. Independent Internal Audits:
It is the responsibility of the University’s Occupational Safety, Health and
Environmental Unit (OSHEU) to provide University Council, the University
Executive Board and senior staff essential information in order for them to
exercise effective control over safety, health and environmental
management.
This information will be provided through a planned
programme of integrated safety, health and environmental audits.
11. Frequency of audit
The timing and frequency of audits will be agreed by the Health, Safety and
Environment Committee based on a requirement to routinely visit all Colleges
and Professional Services over a given timescale. This may be influenced by
inherent safety, health and environmental hazards and the standard of safety,
health and environmental management currently in practice.
Audits of specific themes may be undertaken outside of the routine frequency
as appropriate.
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12. Independent External audits
Various external interested parties will audit the University for compliance
with statutory obligations and conformity to the university management
system. These bodies include:
 Health and Safety Executive
 Environment Agency
 Local Authority
 Certification bodies
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Appendix A
Monitoring Policy Guidance
1. Self Inspection – Schools and Professional Services:
Workplace inspections have long been recognised as a valuable tool available
to monitor the effectiveness of safety, health and environmental practices.
Inspection for safety, health and environmental purposes often has negative
implications associated with fault finding. A positive approach based on fact
finding will usually produce better results, and co-operation from those taking
part in the process.
The aim of self inspection is for the School / Directorate to assess its own
safety, health and environmental performance against agreed standards and
objectives in order to recognise achievement and, where necessary, to take
remedial action.
Schools / Directorates should be carrying out a range of different types of
checks as part of normal operating procedures. These may range from
informal assessment of researchers working methods by their supervisors to
planned formal inspections using standard inspection check-lists.
The Inspection Report should also contain a corrective action plan covering
each of the significant findings.
The Action Plan should detail:

The action recommended by the School / Directorate;

Who will be responsible for carrying out the action; and

A suitable timescale for corrective action to be completed taking into
account the nature of the hazard and the degree of risk.
2. Workplace inspection –Safety Representatives
It is acknowledged that recognised safety representatives are entitled to
inspect the workplace in accordance with the ‘Safety representatives and
safety committees’ guidance. These inspections should be seen as in addition
to and not in place of the routine inspection of the workplace by the School/
Directorate
3. Inspection Teams:
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Ideally, the inspection, which should be co-ordinated by
the person
responsible for the area(s), should be conducted by a team of two or three
people and include senior members of staff who are familiar with both the
working practices of the School / Directorate and the safety, health and
environmental standards relevant to the premises and activities.
In addition, consideration should be given to including personnel in the
inspection team who are independent of the area being inspected to give a
‘fresh pairs of eyes’ so that faults /issues are not overlooked through overfamiliarity.
4. Audit Teams
Ideally, the audit should be conducted by a team of two or three people
(including at least one competent auditor) and should include representatives
of the School / Professional Service. The auditors should be familiar with both
the working practices of the School / Professional Service and the relevant
safety, health and environmental standards relevant to the premises and
activities.
5. Hazard areas
Typical examples of area designation are as follows (the examples given
should not be considered exhaustive).
Red areas may include: radiation areas; genetically modified organism
laboratories; laser laboratories; x-ray laboratories; Nuclear Magnetic
Resonance rooms; certain microbiological laboratories; neurotoxin
laboratories; poisonous animal holding rooms; workshops.
Amber areas may include: general laboratories; kitchens; pool rooms;
refectories; libraries.
Other areas may include: clerical areas; personal offices.
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