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1 . HEALTH AND SAFETY MANAGEMENT SYSTEM REQUIREMENTS
1.1 General Requirements ............................................................................. 5
2 . POLICY
2.1 Safety, Health and Environment Policy Statement ................................... 6
2.2 University Policy Procedures and Guidance ............................................ 7
2.3 School / Directorate Policies .................................................................... 7
3 . PLANNING
3.1 Hazard Identification ................................................................................ 8
3.2 Risk Management – University.................................................................
8
3.2.1 Risk Assessment ................................................................................................... 8
3.2.2 Communication of the findings of the Risk Assessment ....................................... 9
3.2.3 Monitoring the effectiveness of controls ................................................................ 9
3.2.4 Review of Risk Assessments ................................................................................ 9
3.3 Risk Management – Fire ..........................................................................
9
3.4 Risk Management
– Contractors ..............................................................
10
3.5 Environmental Aspects ............................................................................ 10
3.5.1 Identifying environmental aspects ...................................................................... 11
3.4.2 Determining significant environmental aspects .................................................. 11
3.6 Legal and other requirements .................................................................. 11
3.7 Objectives and programmes .................................................................... 12
4 . IMPLEMENTATION AND OPERATION
4.1 Roles and Responsibility – General
4.1.1 Figure 3 University Health, Safety and Environment Management Committees .. 15
4.1.2 Figure 4 Roles and Responsibilities of the Vice Chancellor ................................. 16
4.1.3 Figure 5 Roles and Responsibilities of Heads of Schools and Directorates ......... 17
4.1.4 Figure 6 Roles and Responsibilities of Managers and Supervisors ..................... 18
4.1.5 Figure 7 Roles and Responsibilities of Staff and Students ................................... 19
4.2 Roles and Responsibility – Other
4.2.1 Lay Member of Council ......................................................................................... 20
4.2.2 Chair of the Safety, Health and Environment Committee ..................................... 20
4.2.3 Director of Human Resources, Safety, Health and Environment .......................... 20
4.2.4 Director of Occupational Safety, Health and Environment Unit (OSHEU) ............ 20
4.2.5 OSHEU Health and Safety Advisors ..................................................................... 20
4.2.6 OSHEU Environmental Safety Advisor ................................................................. 20
4.2.7 Departmental Safety Officers (DSO) ..................................................................... 20
4.2.8 Departmental Eco-Champions .............................................................................. 20
4.2.9 Radiation Protection Advisor (RPA) ...................................................................... 20
4.2.10 Radiation Protection Supervisor (RPS) ................................................................. 20
4.2.11 Biological Safety Advisor (BSA) ............................................................................ 21
4.2.12 Biological Safety Officer (BSO) ............................................................................. 21
4.2.13 Maintenance Engineer (ESTAT) ........................................................................... 21
4.2.14 Asbestos Responsibility Person (ARP) ................................................................. 21
4.2.15 Deputy Asbestos Responsible Person (DARP) .................................................... 21
4.2.16 Asbestos Register Keeper..................................................................................... 21
4.2.17 Authorised Asbestos Managers (AAM) ................................................................. 21
4.2.18 Director Campus Services Division (CSERV) ....................................................... 21
4.2.19 Cleaning Services Officer (ESTAT) ....................................................................... 21
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4.2.20 Purchasing Manger (PURCH ................................................................................ 21
4.2.21 Safety Representatives ......................................................................................... 21
4.2.22 Employee Representatives ................................................................................... 22
4.2.23 Student Representatives ....................................................................................... 22
4.3 Competency, Training and Awareness
4.3.1 Methods for identifying training needs .................................................................. 22
4.3.2 Corporate induction ............................................................................................... 22
4.3.3 School / Directorate Induction ............................................................................... 22
4.3.4 Job / Task specific training .................................................................................... 22
4.3.5 Heads of School and Directorate Meetings........................................................... 22
4.3.6 Departmental Safety Officer Briefings ................................................................... 23
4.3.7 Eco Champion Briefings ........................................................................................ 23
4.3.8 Contractor Competency ........................................................................................ 23
4.4 Communication, Participation and Consultation
4.4.1 Methods of Communication................................................................................... 23
4.4.2 Management Communication Streams ................................................................. 23
4.4.3 Advisory Communication Streams ........................................................................ 23
4.4.4 Participation and Consultation .............................................................................. 23
4.5 Documentation and Records
4.5.1 University Health and Safety Policy ...................................................................... 23
4.5.2 University Health and Safety Management System .............................................. 23
4.5.3 University Policies and Guidance .......................................................................... 24
4.5.4 School / Directorate Policies ................................................................................. 24
4.5.5 General Risk Assessments ................................................................................... 24
4.5.6 Fire Risk Assessment ............................................................................................ 24
4.5.7 Health Records ...................................................................................................... 24
4.6 Operational Controls
4.6.1 Operational controls within Schools and Directorates .......................................... 24
4.6.2 Specific Operational Controls ................................................................................ 24
4.6.2.1 Asbestos .................................................................................................... 24
4.6.2.2 Electrical Wiring (fixed) .............................................................................. 24
4.6.2.3 Fire Detection ............................................................................................ 24
4.6.2.4 Fire Fighting Equipment ............................................................................ 25
4.6.2.5 Legionella .................................................................................................. 25
4.6.2.6 Lifting Gear ................................................................................................ 25
4.6.2.7 Pressurised Vessels .................................................................................. 25
4.6.2.8 Storage of Chemicals ................................................................................ 25
4.6.2.9 Hazardous Waste ...................................................................................... 25
4.6.2.10 Biodiversity Issues ..................................................................................... 26
4.7 Emergency Preparedness
4.7.1 Identification of potential emergency situations – Central University Major
Incident Planning ................................................................................................... 26
4.7.2 Identification of potential emergency situations – School/Directorate
Contingency Plans ................................................................................................ 26
4.7.3 Fire ....................................................................................................................... 26
4.7.4 Personal Emergency Evacuation Plans (PEEPs) ................................................. 26
4.7.5 Fire Wardens ......................................................................................................... 26
4.7.6 Evacuation Chairs ................................................................................................. 27
4.7.7 Exposure to Hazardous Chemicals ....................................................................... 27
4.7.8 First Aid ................................................................................................................. 27
4.7.9 General Emergency Contacts ............................................................................... 27
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5 . CHECKING
5.1 Proactive Monitoring and Measuring
5.1.1 Workplace Inspections .......................................................................................... 28
5.1.2 Occupational Hygiene Monitoring ......................................................................... 28
5.1.3 Internal Audits ....................................................................................................... 28
5.1.3.1 Annual Returns .......................................................................................... 28
5.1.3.2 OSHEU General Internal Audit .................................................................. 28
5.1.3.3 OSHEU Radiation Audits .......................................................................... 28
5.1.3.4 OSHEU Laser Audit .................................................................................. 29
5.1.3.5 Health Surveillance ................................................................................... 29
5.1.3.6 Control of Legionella ................................................................................. 29
5.1.4 Second Party Duty of Care Audits ......................................................................... 29
5.1.5 External Audit ......................................................................................................... 29
5.1.6 Monitoring of Utilities .............................................................................................. 29
5.1.7 Monitoring of Waste ............................................................................................... 29
5.2 Reactive Monitoring and Measuring
5.2.1 Accidents, Incidents and near misses ................................................................... 30
5.2.2 Investigation of ‘Major’ Accidents, Incidents and Near Misses ............................. 30
5.2.3 Investigation by Trades Union Representatives ................................................... 30
5.2.4 Reporting of Injuries Diseases and Dangerous Occurrences ............................... 30
5.2.5 Occupational Hygiene ........................................................................................... 30
6 . MANAGEMENT REVIEW
6.1 Management Review – Central University
6.1.1 Inputs to the Review .............................................................................................. 31
6.1.2 Outputs from the Review ....................................................................................... 31
6.2 Management Review – Schools and Directorates
6.2.1 Inputs to the Review .............................................................................................. 31
6.2.2 Outputs from the Review ....................................................................................... 32
_ _ _ _ _ _ _ _ _ _ _ _
Appendix 1: Communication and Consultation Streams
Appendix 2: List of Key Committees and their composition
Appendix 3: Management System Document History
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1. GENERAL REQUIREMENTS
The following Health, Safety and Environmental Management System has been developed in order to implement the Safety, Health and Environmental Policy
Statement of Cardiff University and is based on the requirements of BS OHSAS
18001:2007 and ISO 14001.
The management system is intended to provide the university with the elements and structure required for effective management of its health, safety and environmental obligations to its staff, students and visitors who could be exposed to hazards associated with the university’s activities. Furthermore, the management system is designed to cover operations both on-site and offsite when controlled by the university’s employees. The scope includes the academic colleges and professional service directorates, excluding environmental management for those based at the University Hospital of Wales site.
Figure 1: Schematic representation of the University
Safety, Health and Environment Management System
This section involves top management review in safety, health and environmental performance at University level and School / Directorate level in order to take action to continually improve performance
This stage of the system requires the University and its
Schools and Directories to set out its commitment to the management of safety, health and environment.
This section established the objectives and processes for achieving policy commitments and involves planning for hazard control which includes hazard identification, risk assessment, legal requirements and setting of objectives.
This section involves checking that policy and plans have been implemented through the monitoring of safety, health and environmental performance via workplace inspections, audit, accident / incident data and investigation and routine monitoring.
This section defines how processes and plans will be implemented and includes roles and responsibilities and how the university delivers its safety, health and environmental management
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UNIVERSITY OCCUPATIONAL SAFETY, HEALTH AND
ENVIRONMENT POLICY STATEMENT
N.B. The University is in the process of revising its safety, health and environmental policy. The University’s current policy statement can be found at: Cardiff University Safety Health and Environment Policy
The management system as outlined within this document constitutes the organisation and arrangements the university has in place for managing its safety, health and environmental obligations.
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Code Procedure
2.1 UNIVERSITY SAFETY, HEALTH AND ENVIRONMENT POLICY
The University has developed a safety, health and environment policy statement which is authorised by the Vice Chancellor and is supported in its delivery by the University Safety, Health and Environment Management System.
This policy statement shall be reviewed annually.
2.2 UNIVERSITY POLICIES, PROCEDURES AND GUIDANCE
It is the responsibility of administrative Directorates to draft policies procedures and guidance in relation to how the university manages it safety, health and environmental obligations.
Each School and Directorate is required to comply with University policies, procedures and guidance
Safety, health and environmental policies, procedures and guidance can be found through the OSHEU website: http://www.cardiff.ac.uk/osheu/.
2.3
SCHOOL / DIRECTORATE POLICIES
Each School and Directorate is required to have in-place a local health, safety and environmental policy and procedures (which are in-line with the overarching
Safety, Health and Environment Policy and management systems of the
University) and which describes the specific arrangement and systems within the School / Directorate for the operational control of hazards.
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Introduction:
It is critical to the health and wellbeing of staff, students and visitors that hazards associated with the university’s operations are identified, risk assessed and that appropriate control measures are put in-place in order to reduce the risk of harm. The University must also ensure that it has identified all its environmental aspects. The identification of control measures for each hazard/aspect will involve consideration according to the hierarchy of controls as laid out in University guidance :
(http://www.cardiff.ac.uk/osheu/complete_risk_assessment/index.html)
.
In addition the university is committed to complying with (at least) its statutory obligations and as such has developed a register of legal requirements affecting its operations.
Furthermore, the university has developed systems of monitoring and performance review (sections 5 and 6) which assess the university against identified indicators and drives continual improvement through the setting of objectives.
Code Procedure
3.1 HAZARD IDENTIFICATION
It is the responsibility of Heads of Schools and Directorates to ensure that all significant hazards arising out of the School / Directorate operations are identified and subsequently, risk assessed and controlled as far as reasonably practicable.
In practice day to day responsibility for this lies with Managers and Supervisors who must identify all significant hazards associated with their operations. Methods to do this include: a) systematic analysis of the task by the manager / supervisor and / or competent person (for risk management procedure see: http://www.cardiff.ac.uk/osheu/safety/generalsafety/index.html ) b) advice given by the Occupational Safety, Health and Environment Unit
(OSHEU) (see: OSHEU webpage http://www.cardiff.ac.uk/osheu/ ) c) information provided on suppliers data sheets d) systematic inspection of the workplace.
In addition it is expected that the School/ Directorate compiles a hazard map of its significant hazards in order to evaluate control of the hazards and compliance with statutory requirements ( see the OSHEU Hazard map example )
3.2 RISK MANAGEMENT- Cardiff University:
3.2.1 Risk Assessment
It is the responsibility of Heads of Schools and Directorates to ensure that all significant hazards arising out of the School / Directorate operations undergo a suitable and sufficient risk assessment and measures are identified to control and minimise the risk as far as reasonably practicable to staff, students, visitors and the environment.
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3.2.3
3.2.2
3.2.4
In practice day to day responsibility for this lies with Managers and Supervisors who must ensure that risk assessments of operations under their control are undertaken by a competent person or overseen by a competent person. Methods to do this include: a) Cardiff University guidance on completing a risk assessment (for risk management procedure see: http://www.cardiff.ac.uk/osheu/safety/generalsafety/index.html ) b) Cardiff University risk assessment template ( see Risk Assessment
Template )
N.B
For non-routine activities it is the responsibility of the manager / supervisor of the activity to gain a full understanding of the nature of the hazards associated with the activity and ensure that a suitable and sufficient risk assessment is undertaken prior to the activity commencing. Examples of non-routine activity include visits by school parties; temporary alterations to working environments / procedures, utility disruptions, extreme weather conditions
Communication of the findings of the risk assessment:
It is the responsibility of Managers and Supervisors to communicate the findings of the risk assessment to all staff and students who may be affected by the operation in order that they may have the information to work safely or be aware of the hazards and actions of others. Methods for doing this include: a) providing and discussing the full assessment with the operator and/or b) extraction of the salient points from the assessment into Standard
Operating Procedures for relevant staff/students to follow c) providing staff / students with relevant training and awareness
N.B. at all times a current risk assessment should be available on request to
demonstrate that a suitable and sufficient assessment of the risk has been undertaken.
Monitoring of the effectiveness of controls:
To ensure the effectiveness of the control measures the university has established proactive and reactive methods.
Proactive:
It is the responsibility of managers and supervisors to ensure that: a) workplace inspections are carried out in accordance with University policy and procedures b) where appropriate preventative maintenance regimens are implemented, documented and monitored c) periodic review of the risk assessment to ensure that it remains relevant.
Reactive: a) review of causal factors in relation to incidents b) in response to complaints from interested parties and/or findings from audits and assessments.
Review of risk assessments:
To ensure that the risk assessments remain relevant, Managers and Supervisors must ensure that the risk assessment is reviewed: a) in light of an incident b) as a result of change in the operation (procedure, personnel or organisational) c) in light of new information relating to the operation d) at least every 3 years unless the nature of the hazard or activity is such that it requires more frequent assessment.
3.3
RISK MANAGEMENT - FIRE
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The University has established various mechanism to support the management of risk from fire: a) The University has a competent person based in OSHEU with responsibility for advising the university on fire related matters. b) Every building within the university’s portfolio has undergone fire risk assessments. These assessments are subject to regular review by
OSHEU. c) All staff receive fire awareness briefings. d) Where appropriate, and through risk assessment, procedures are present in Schools and Directorates to control the risk of fire. e) Maintained fire fighting equipment is strategically positioned throughout the university f) Each School and Directorate has nominated fire wardens whose role is to monitor the workplace for potential situation that may cause / exasperate fire and to assist in the emergency evacuation of buildings. g) The university has installed and maintains fire detection systems throughout its buildings (typically to L2 Standard). h) Each School and Directorate is responsible for ensuring that workplace inspections are undertaken (see Safety Health and Environmental
Monitoring Policy ) i) Each School and Directorate is responsible for ensuring that there are procedures in place to routinely check portable electrical appliances owned by the university for electrical safety ( see Portable Applicance Testing
Policy )
3.4 RISK MANAGEMENT- Contractors
Risk assessment
It is the responsibility of Managers and Supervisors to ensure that contractors under their control are competent to undertake the tasks assigned to them and ensure that the operations of the contractor do not adversely affect the university and that the hazards owned by the university are communicated to the contractor.
In order to do this, Managers and Supervisors must: a) ensure that contractors under their control have undertaken a suitable and sufficient risk assessment of the operation which takes into account the operations of the university. b) Ensure the contractors have the correct level of competency to carry out the assigned task. c) ensure that contractors have relevant procedures in place to undertake the work appropriately and minimise risk. d) ensure that contractors are aware of and have access to information required for them to complete a suitable and sufficient risk assessment. e) routinely monitor the performance of the contractor through inspection of the workplace.
N.B. for advice on University preferred / approved contractors please contact
ESTATES and PURCHASING.
3.5 ENVIRONMENTAL ASPECTS
The elements of an organization's activities, products and services that can interact with the environment are called environmental aspects. Examples include a discharge, an emission, consumption or reuse of a material, or generation of noise.
The University should identify the environmental aspects it can control and those that it can influence. The University will not communicate its environmental aspects externally.
It is the responsibility of Heads of Schools and Directorates to ensure that all environmental aspects arising out of the School / Directorate operations are identified and subsequently, risk assessed and controlled as far as reasonably practicable.
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3.5.2
3.5.1
In practice day to day responsibility for this lies with Managers and Supervisors who must identify all environmental aspects associated with their operations.
Methods to do this include: a) systematic analysis of the task by the manager / supervisor and / or competent person ( see Risk Assessment Guidance Notes) b) through advice given by the Occupational Safety, Health and Environment
Unit (OSHEU) (see: OSHEU webpage http://www.cardiff.ac.uk/osheu/) c) information provided on suppliers data sheets d) systematic inspection of the workplace.
In addition it is expected that the School/ Directorate compiles a Environmental
Aspects Register, it is recommended that this is done as part of the hazard map of its significant hazards in order to evaluate control of the hazards and compliance with statutory requirements ( see the OSHEU Hazard map example )
Identifying Environmental Aspects
The University will identify its environmental aspects, within the scope of its environmental management system, that are associated with its past, ongoing and planned activities. In doing this, the University will consider normal and abnormal operating conditions including start-up and shut-down maintenance and emergency situations and accidents. Inaddition to those environmental aspects the University can control directly, it should also consider aspects that it can influence, e.g. those related to products and services used by the University and those related to products and services it provides.
The process of identifying environmental aspects will benefit from the participation of those individuals who are familiar with the School/Directorate activities. The following should be considered in identifying environmental aspects:
— emissions from air,
— releases to water,
— releases to land,
— use of raw materials and natural resources (e.g. land use, water use),
— local/community environmental issues,
— use of energy,
— waste.
Determining significant environmental aspects
It is the responsibility of Heads of Schools and Directorates to ensure that all significant environmental aspects arising out of the School / Directorate operations undergo a suitable and sufficient risk assessment and measures are identified to control and minimise the risk as far as reasonably practicable to the environment.
In practice day to day responsibility for this lies with Managers and Supervisors who must ensure that risk assessments of operations under their control are undertaken by a competent person or overseen by a competent person. Methods to do this include: a) Cardiff University guidance on completing a risk assessment ( see Risk
Assessment Guidance Notes) b) Cardiff University risk assessment template ( see Risk Assessment
Template )
3.6 LEGAL AND OTHER REQUIREMENTS
3.6.1 The university is committed to (at least) comply with its statutory and other requirements affecting it. To that end the university has developed and maintains a register of legal and other requirements to which the university must conform. It is the responsibility of the Head of each School and Directorate to identify and address those requirements which affect areas under their control.
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3.6.2 It is the responsibility of OSHEU to lead in identifying changes to legal and other requirements and to disseminate relevant information to Schools and Directorates through appropriate communication routes (see: Section 4.4). It is the responsibility of each School and Directorate to ensure that any changes in legal requirements are identified and addressed.
The University’s register of safety, health and environmental legal requirements is held by OSHEU. All Schools and Divisions must have a register of local legal requirements; these registers will inform the overarching University register.
3.7 OBJECTIVES AND PROGRAMMES
In order to achieve continual improvement in the management of health, safety and environment throughout the university, systems have been developed to identify, establish and agree objectives and targets [and subsequent programmes to monitor and achieve the objectives] at central university level and at each School and Directorate level.
The objectives at university level and School/ Directorate level will take into account legal and other compliance. Furthermore, in order to be monitored effectively the objectives will be Specific, Measurable, Attainable, Relevant and Time-bound
(SMART).
In practice corporate university objectives are consulted on and agreed at the
University Safety, Health and Environment Committee through advice and guidance from the Safety, Health and Environment Advisory Group and through the
Environmental Management Systems Steering Group. The composition of the key
Committees and Groups in the university management system is given in Appendix
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Figure 2: Schematic representation of the management of safety, health and environmental objectives and programmes
University Council

Endorse and support the university objectives

Overseeing monitoring and review of the objectives
Safety, Health and Environment
Advisory Group
Identifies and advises the
Committee on SMART objectives and programmes in-line with

Legislative requirements

Broader University objectives

Communication from interested parties

Continual improvement
Governance and Compliance Committee
Safety, Health and Environment Committee

Consultation and agreement on objectives and development of implementation programme.

Periodic monitoring of objectives to ensure that they are on target and realistic
Occupational Safety, Health and Environment Unit
(OSHEU)

Communication and monitoring of University objectives to each School and directorate through:

Briefings at local Safety, Health and Environment
Committees

Six monthly briefings to the Departmental Safety Officers

Briefing to Departmental Eco Champions (through
PAFRS)

Annual meetings between Director/Deputy Director of
OSHEU and Head of School/Directorate

Ad hoc advice

Audit

OSHEU Liaison Officers
Environmental Steering
Group
Development of central
University SMART objectives as a result of communication from interested parties
School and Directorate Committee
Development of local SMART objectives in-line with

University objectives

Legal requirements

Results of internal monitoring

As a result of communication from interested parties
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Introduction:
To ensure the effective management of health, safety and environment within the university; the university has put in place structures to make certain that roles and responsibilities are defined and understood, there are mechanisms to identify training and awareness needs so that staff and students have the knowledge they need to work safely, and that required resources are identified and available.
In addition the university has mechanisms for the control of documents relating to the management system to ensure that they are relevant and readily available and has established various communication systems including paper based, electronic and verbal to ensure that relevant information can be exchanged and consultation with staff, students and representative bodies (e.g. Trades Unions) is achievable.
Furthermore, the university has put in place strategies and systems for actions in the event of emergencies.
Code Procedure
4.1 ROLES AND RESPONSIBILITIES - GENERAL
Council, as the governing body of the University, bears ultimate responsibility for the health and safety of the University’s students, staff and visitors and for managing the University environment responsibly. 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
Roles and responsibilities are highlighted in the following figures:
Figure 3: University health, safety and environment management
Committees
Figure 4: Roles and responsibilities of the Vice Chancellor
Figure 5: Roles and responsibilities of Pro Vice Chancellors
Figure 6: Roles and responsibilities of Heads of Schools and
Directorates
Figure 7: Roles and responsibilities of Managers and Supervisors
Figure 8: Roles and responsibilities of staff and students.
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Figure 3: University safety, health and environment management committees
Council
As the governing body of the University,
Council bears ultimate responsibility for the health, safety and environment of the
University’s students, staff and visitors see: http://www.cardiff.ac.uk/govrn/governance/ind ex.html
Ordnance 3
Governance Committee
For terms of reference for the Governance
Committee see: http://www.cardiff.ac.uk/govrn/governance/ind ex.html
Ordnance 10
Safety, Health and Environment Committee
For terms of reference for the Safety, Health and Environment Committee see: http://www.cardiff.ac.uk/govrn/governance/ind ex.html
Ordnance 10
Schools and Directorates
Heads of Schools and Directorates are responsible for the day to day organisation and management of safety, health and environment in areas under their control.
Sub Committees
Committees and Working Groups as required by the Safety, Health and Environment Committee.
A register of current sub committees and corresponding terms of reference can be accessed through OSHEU
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Figure 4: Roles and Responsibilities of the Vice Chancellor within Cardiff
University’s Health, Safety and Environmental Management System
Carry out an annual top management review of university health, safety and environment performance and set future SMART objectives including:

Results of audits and compliance

Relevant communication from

Authorise and promote the
University Safe, Health and external parties

Extent to which objectives have
Environment Policy.

Ensure the implementation of the been met

Status of investigations

Health, safety and environmental
Safety, Health and Environment
Policy. performance

Changing circumstances

Recommendations for
 improvement
Management review
Safety, Health and Environment
Policy
Checking and corrective action
Planning
Implementation and operation

Ensure adequate resources are provided to meet health, safety and environment requirements.

Ensure the University holds a register of legal and other requirements to which it must comply.

Ensure that health, safety and environmental objectives are developed.

Ensure that there are mechanisms to identify significant hazards and environmental aspects determining controls.
Ensure there are systems to monitor:

Objectives

Compliance with legal and other requirements

Accident/incident investigations

Nonconformity against the standard

Health safety and environmental performance

Ensure that the organisational structure is appropriate to manage health, safety and environment.

Ensure training programmes exist so that staff and students can adequately carry out their health, safety and environmental responsibilities.

Ensure that there are adequate communication and consultation channels with staff and students.

Ensure adequate effective emergency arrangements.
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Figure 6: Roles and Responsibilities of Pro Vice Chancellors and Chief
Operating Officer within Cardiff University’s Health, Safety and Environment
Management System
Carry out an annual top management review of university health, safety and environment performance of the Schools / Professional
Services and set future SMART objectives including:
 Results of audits and compliance

Relevant communication from external partiesExtent to which objectives have been met
 Status of investigations

Health, safety and environmental performance

Changing circumstances
 Recommendations for improvement
Management review
Checking and corrective action
Ensure there are systems to monitor:
 School/Professional Services
Objectives

Compliance with legal and other requirements
 Accident/incident investigations
 Nonconformity against the standard

Health safety and environmental performance
Safety, Health and Environment
Policy
Planning
Implementation and operation

Ensure you are aware of your health, safety and environmental responsibilities as indicated within the
University Safety, Health and
Environment Policy and Management
System
 Demonstrate commitment to Health,

Safety and Environment
 Be aware of the Health, Safety and environment legal requirements affecting you

Ensure systems are in place throughout the College / Professional
Service to ensure all hazards have been risk assessed and all
Environmental aspects (hazards) have been identified and measures are in place to control the hazard
 Ensure that there are mechanisms in place to identify appropriate Health, Safety and
Environmental training needs to ensure staff/students are competent to undertake tasks.

Establish mechanisms for effective communication and consultation with staff/students throughout the College /
Professional Service.
 Ensure there is a system in place for the management of documentation relating to
Health, Safety and Environment.
 Ensure the potential for emergency situations has been identified and the appropriate responses are in place
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Figure 6: Roles and Responsibilities of Heads of Schools and Professional
Services within Cardiff University’s Health, Safety and Environment
Management System
Carry out an annual top management review of university health, safety and environment performance and set future SMART objectives including:
 Results of audits and compliance
 Relevant communication from external parties

Extent to which objectives have been met

Status of investigations
 Health, safety and environmental
 performance

Changing circumstances
Recommendations for improvement
 Ensure you are aware of your health, safety and environmental responsibilities as indicated within the
University Safety, Health and
Environment Policy
 Demonstrate commitment to Health,
Safety and Environment
 Ensure the policy has the appropriate management structure to manage
Health, Safety and Environment.
 Authorise and ensure it is disseminated with the intent that everyone knows their Health, Safety and Environment obligations
 Ensure it is reviewed annually
Management review
Safety, Health and Environment
Policy
Checking and corrective action
Planning
Implementation and operation
 Be aware of the Health, Safety and environment legal requirements affecting you

Ensure all specific hazards have been risk assessed and all Environmental aspects have been identified and measures are in place to control the hazard.
Ensure there are systems to monitor:

School/Directorate Objectives
 Compliance with legal and other requirements
 Accident/incident investigations

Nonconformity against the standard
 Health safety and environmental performance
 Ensure that there is a mechanism in place to identify appropriate Health, Safety and
Environmental training needs to ensure staff/students are competent to undertake tasks.
 Establish a mechanism for effective communication and consultation with staff/students.

Ensure there is a system in place for the management of documentation relating to
Health, Safety and Environment.
 Ensure the potential for emergency situations has been identified and the appropriate responses are in place
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Figure 6: Roles and Responsibilities of Managers and Supervisors within
Cardiff University’s Health, Safety and Environment Management System
Carry out an annual review of the groups performance:

Results of audits and 
Ensure you are aware of your Health, compliance

Relevant communication from
Safety and Environmental responsibilities as indicated within the external parties

Extent to which objectives have
School/Directorate Safety, Health and
Environment Policy

Demonstrate commitment to Health, been met

Status of investigations

Accident/Incident rate

Changing circumstances

Recommendations for
Safety and Environmental improvement
Management review
Safety, Health and Environment
Policy
Checking and corrective action
Planning
Implementation and operation

Be aware of the Health, Safety and
Environmental legal requirements affecting you

Ensure all specific hazards have been risk assessed and measures are in place to control the hazard and identify and assess all environmental aspects

Ensure that the findings of the risk assessments are communicated to relevant persons

Be aware of the School/Directorate
Health and Safety objectives

Ensure that incidents are investigated and any remedial action is carried out

Ensure that the workplace under your control is inspected in accordance with the
University Monitoring Policy
(see

Ensure that there is a mechanism in place to identify appropriate Health and Safety training needs to ensure staff/students under your control are competent to undertake tasks

Establish a mechanism for effective communication and consultation with staff/students under your supervision

Ensure appropriate measures are in place for controlling significant hazards

Ensure preparedness for emergency situations and that staff/students under your control are aware of them
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Figure 7: Roles and Responsibilities of Staff and Students within Cardiff
University’s Health, Safety and Environmental Management System

Receive information from the management review of

Ensure you understand your Health,
Health, Safety and
Environmental performance
Safety and Environmental role and responsibility within the School /
Directorate
Management review
Checking and corrective action
Safety, Health and Environment
Policy
Planning
Implementation and operation

Ensure understanding and compliance with the control measures identified in the risk assessments

Ensure understanding of the objectives of the School /
Directorate

Ensure unsafe situations are reported

Assist in workplace inspections as required

Assist in corrective action as required

Ensure correct use and storage of hazard control

Adhere to instructions given for safe working

Ensure that information of what to do in the event of an emergency is known

Participate in communication and consultation on Health, Safety and
Environment matters

Be aware of hazards within the workplace
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4.2.10
4.2.7
4.2.8
4.2.9
4.2.4
4.2.5
4.2.6
Code Procedure
4.2 ROLES AND RESPONSIBILITIES – OTHER
4.2.1
The following staff have specific roles, responsibilities and authorities pertaining to the Health, Safety and Environmental Management System .
Lay member of Council: acts as a health and safety champion who is a member of Council who sits on the Safety, Health and Environment Committee.
4.2.2
4.2.3
Chair of the Safety, Health and Environment Committee: responsibility for ensuring that the Committee acts in accordance with Ordinance 10.1.
Director of Human Resources, Safety, Health and Environment: represents safety, health and environment at University Board, is a member of the;
Health, Safety and Environment Committee and has overall responsibility for the provision of professional advice and guidance to the University on matters relating to safety, health and environment.
Director of Occupational Safety, Health and Environment Unit (OSHEU): is responsible for the day to day management of OSHEU in support of the
University safety, health and environment management systems
OSHEU Health and Safety Advisors: Are responsible for the provision of professional advice and guidance to the university, maintaining the Health and
Safety Management System and associated documentation.
OSHEU Environmental Safety Advisor: Is responsible for the provision of professional advice and guidance to the university, maintaining the
Environmental Management System and associated documentation in collaboration with colleagues in the University Estates Division. In addition
OSHEU are responsible for managing hazardous chemical and clinical waste streams.
Departmental Safety Officers (DSO):
Each School and Directorate has a nominated Departmental Safety Officer who is responsible for assisting with the management of health and safety and who acts as a liaison between School / Directorate and OSHEU.
Departmental Eco Champions
Each School and Directorate has a nominated Departmental Eco Champion who is responsible for disseminating information from the central University to the School/Directorate and for assisting with the management of environmental issues at School/Directorate level and who acts as a liaison between School /
Directorate and OSHEU.
Radiation Protection Advisor (RPA):
The Radiation Protection Adviser act as competent advice for the University in accordance with the Ionising Radiation Regulations. The current RPA is based in OSHEU and their responsibilities can be accessed at: http://www.cardiff.ac.uk/osheu/resources/OSHEU%20Guidance%20Document
%20RP1.doc
Radiation Protection Supervisor (RPS):
The role of a department radiation protection supervisor is to supervise the arrangements set out in the local rules. It may not always be necessary for the
RPS to be present in the department when work with ionising radiation is in progress; this will depend on the competency and experience of the workers, the work in progress and alternative arrangements that have been made for action in the event of an emergency. The duties of RPS can be accessed at : http://www.cardiff.ac.uk/osheu/resources/OSHEU%20Guidance%20Document%
20RP1.doc
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4.2.19
4.2.20
4.2.21
4.2.17
4.2.18
4.2.11
4.2.12
4.2.13
4.2.14
4.2.15
4.2.16
Biological Safety Advisor (BSA):
The Biological Safety Advisor acts as competent advice for the University in regard to the management and risk control of biological agents. The current
BSA is based in OSHEU and their responsibilities can be accessed through the
OSHEU Website.
Biological Safety Officer (BSO)
In those Schools in which work with biological agents and genetic manipulation is carried out, the Head of Department must appoint suitably experienced and senior member(s) of staff to advise and assist in the control of hazards associated with the work.
Maintenance Engineer (ESTAT)
The University’s Maintenance Engineer is responsible for maintaining the energy systems of the University. The current Maintenance Engineer is K. Sims
Asbestos Responsible Person (ARP) – Mr Stephen Duddridge (Director
Estates Development) is responsible for developing and ensuring compliance with the Estates Asbestos Management Plan , produced in response to regulation 4 of the Control of Asbestos Regulations (CAR).
Deputy Asbestos Responsible Persons (DARP) – Mr Paul Yeoman (Deputy
Director Estates Development and Mr Richard Williams (Assistant Director
Estates Maintenance) will act as deputies in the event of the ARP absence.
Asbestos Register Keeper (ARK) – The Estates Safety Compliance Officer,
(Martin Thomas) is responsible for maintaining the Asbestos Register and is the person to whom all documents required by the register must be sent.
Authorised Asbestos Managers (AAM) – only those persons authorised by the Asbestos Responsible Person may manage work involving the maintenance or removal of asbestos containing material (ACM).
Schools and Directorates are responsible for the provision of information (via the
Asbestos Responsible Person) regarding the risk of exposure to asbestos containing material to contractors under their control.
Director Campus Services Division (CSERV)
The Director of CSERV is responsible for the coordination of the University
Transport strategy and related action plan.
Cleaning Services Officer (ESTAT)
The cleaning services officer is responsible on a day to day basis of managing the domestic waste and recycling contract.
Purchasing Manager (PURCH)
The Purchasing manager is responsible for providing information relating to the purchase of sustainable goods for the University and for maintaining the SPAF.
Safety Representatives: within the university there are a number of Safety
Representatives who represent the health and safety interests of Trades Union members. Each of the three recognised trades unions is represented on the
Safety, Health and Environment Committee. A list of the current Safety
Representatives are available through OSHEU or Human Resources:
Employee Representatives: There are nominated staff representatives who represent the health and safety interests of staff members. These nominated persons are members of the University Safety, Health and Environment
Committee.
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4.2.22
4.2.23
Student Representatives: There are nominated student representatives who represent the health and safety interests of Cardiff University Students. These nominated persons are members of the University Safety, Health and
Environment Committee.
4.3.4
4.3.5
4.3.6
4.3 COMPETENCY, TRAINING AND AWARENESS
4.3.2
4.3.3
4.3.1
The University has developed various mechanisms for the identification of training and awareness needs and methods of training delivery.
Methods for identifying training needs include: a) appraisal b) job role c) task analysis d) risk assessment e) incident investigation
The University has identified a minimum level of health and safety training in-line with the job role.
The matrix of training requirements per job role can be accessed at OSHEU
Training Policy http://www.cardiff.ac.uk/osheu/safety/generalsafety/index.html
Corporate Induction:
The university requires all new members of staff (or staff that have moved Schools
/ Directorates) to attend the corporate induction which highlight s the University’s safety, health and environmental management system and highlights the health, safety and environmental responsibilities of the university and of individuals. It is the responsibility of OSHEU to deliver the health, safety and environmental aspects of the corporate induction.
School / Directorate Induction:
Each School and Directorate is responsible for the local health, safety and environmental induction for new members of staff and students and should include local rules and site specific information. A checklist of the general subjects that may be included in the induction can be accessed at: School/Directorate Induction
Checklist .
Job / task specific training
It is the responsibility of the manager / supervisor of the task to ensure that the person(s) undertaking the operation have sufficient knowledge to minimise the health, safety and environmental risk whilst carrying out the task. Methods to do this include: a) ensure understanding of the associated risk assessment b) ensure understanding of the associated procedures c) ensure any specific training needs that have been identified with the task have been completed prior to the task being carried out.
Heads of School and Directorate Meetings
The Director (or Deputy Director) of OSHEU shall meet with all Heads of Schools and Directorates annually to brief on updates and forthcoming relevant issues, to discuss the performance of areas under their control and to agree objectives inline with broader University objectives.
Departmental Safety Officer Briefings
OSHEU shall meet with University Departmental Safety Officers twice annually in order to brief on updates and forthcoming relevant issues and initiatives and consult on these topics.
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4.4.1
4.4.2
4.4.3
4.4.4
4.3.7
4.3.8
Eco Champion Briefings
A programme of eco-champion meetings will be agreed each year to disseminate energy and environmental information to the School and Directorate Eco
Champions.
Contractor Competency:
It is the responsibility of managers and supervisors of tasks under their control to ensure that contractors undertaking tasks on behalf of Cardiff University are competent to do so. A procedure to establish contractor competency and monitor performance can be accessed through ESTAT.
4.4 COMMUNICATION, PARTICIPATION AND CONSULTATION
Methods of Communication: The University has established and utilises various means to communicate health, safety and environmental information throughout the university and to the wider community. Methods include: a) University electronic notice board b) E-mail c) Intranet d) Paper correspondence e) Staff / student inductions f) Senior manager forums g) Departmental Safety Officers h) Eco Champions i) Trades Unions j) Management meetings (including the University Safety, Health and
Environment Committee) k) School / Directorate management meetings. l) School / Directorate team meetings
Management Communication Streams: A schematic representation of management communication streams is given in Appendix .
Advisory Communication Streams: A schematic representation of advisory communication streams is given in Appendix .
Participation and Consultation: The University recognises the importance of participation and consultation (including its statutory obligation) and uses the various means illustrated above to ensure that a comprehensive consultation process is achieved with all relevant parties.
4.5.1
4.5.2
4.5.3
4.5 DOCUMENTATION AND RECORDS
Control of major documents relating to the Health, Safety and Environmental
Management System are as follows:
University Safety, Health and Environment Policy

Master copy held and managed by OSHEU

Available as part of the University Health and Safety Management System through the OSHEU website and by request
University Health, Safety and Environmental Management System

Master copy held and managed by OSHEU

Available through the OSHEU website
University policies and Guidance

Master copies of the primary University safety, health and environmental
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4.5.4
4.5.5
4.5.6
4.5.7 policies and guidance are held and managed by OSHEU

Available through the OSHEU website
School / Directorate Policies

Each School and Directorate is responsible for the management and communication of their policies and guidance which are in line with
University policies and guidance .
General risk assessments

Risk assessment templates are controlled by OSHEU and are available through the OSHEU website.

Copies of risk assessments are controlled and managed by individual
Schools and Directorates at the relevant location.
Fire risk assessment.

Original copies of the fire risk assessments are managed and held by
OSHEU

Working copies of the fire risk assessment are held at the relevant location
Health Records.

Health records including health surveillance are managed and maintained by the Occupational Safety, Health and Environment Unit.

Records of personnel requiring health surveillance is held within the relevant School and Directorate.
4.6 OPERATIONAL CONTROLS
4.6.1 Schools and Directorates:
It is the responsibility of each School and Directorate to identify, implement and maintain controls for those hazards under its control. Furthermore, it is the
4.6.2
4.6.2.1
4.6.2.2
4.6.2.3
4.6.2.4 responsibility of each School and Directorate to monitor the effectiveness of the controls (see: section 5) in line with statutory requirements or in line with risk assessment review (see: section 3.1).
Specific operational controls: a) Asbestos
All of the buildings within Cardiff University’s portfolio have undergone Type 2 assessment for the presence of asbestos containing material.
Staff with specific responsibility for the management of asbestos containing materials are listed in section 4.2. b) Electrical wiring (fixed)
ESTAT is responsible for the routine maintenance and checking of the fixed wiring throughout the University. The day to day management of this is the responsibility of the University’s Maintenance Engineer. c) Fire detection
ESTAT is responsible for the routine maintenance and checking of the fire detection systems throughout the University. The day to day management of this is the responsibility of the University’s Maintenance Engineer. d) Fire fighting equipment
ESTAT is responsible for the provision and routine maintenance and checking of the fire fighting equipment throughout the University (with the exception of the residences). The day to day management of this is the responsibility of the
University’s Maintenance Engineer.
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4.6.2.8
4.6.2.9
4.6.2.10
4.6.2.6
4.6.2.7
4.6.2.5
CSERV is responsible for the provision and routine maintenance and checking of the fire fighting equipment throughout the University’s residences. The day to day management of this is the responsibility of the Facilities Manager. e) Legionella
The University has nominated a Legionella Responsible Person who is responsible for statutory requirements regarding the control of Legionellosis.
ESTAT are responsible for the management of controls relating to this risk within the water supply network throughout the University. The Responsible
Person is the University Maintenance Engineer.
It is the responsibility of each School and Directorate to put in place controls to manage the risk of Legionella via means other than the network supply (e.g. water containing equipment). To assist in the management of this risk the
School /Directorate should nominate a local Legionella Responsible Person. f) Lifting Gear
ESTAT is responsible for the provision of routine maintenance and checking of lifting gear throughout the University. The day to day management of this is the responsibility of the University’s Maintenance Engineer.
It is the responsibility of each School and Directorate to ensure there are procedures in-place to identify lifting gear, ensure that the lifting gear is registered with the Maintenance Engineer and that there are procedures inplace to ensure that lifting gear that is fit for purpose and used by appropriately trained staff and students. g) Pressurised Vessels
ESTAT is responsible for the provision of routine maintenance and checking of pressurised vessels throughout the University. The day to day management of this is the responsibili ty of the University’s Maintenance Engineer.
It is the responsibility of each School and Directorate to ensure there are procedures in-place to identify pressurised vessels, ensure that the pressurised vessel is registered with the Maintenance Engineer and that there are procedures in-place to ensure that vessels are fit for purpose and used by appropriately trained staff and students. h) Storage of Chemicals
It is the responsibility of each School and Directorate to identify, implement and maintain controls for Chemical storage to ensure where necessary suitable bunding is in place and adequate spillage kits are available. The surrounding drainage of any storage area should also be identified to ensure that controls are in place to prevent any accidental discharge to drain. i) Hazardous waste
It is the responsibility of each School and Directorate to identify, implement and maintain controls for the safe disposal of any hazardous wastes produced in their area. Hazardous wastes should be correctly segregated and contained following University Policy. See hazardous waste policy
( http://www.cardiff.ac.uk/osheu/environment/waste/envwaste.html
OSHEU are responsible for the coordination of collections with the University approved contractor for the disposal of Clinical, Chemical and elements of the WEEE waste stream. ESTAT coordinate the collections for battery and fluorescent tube waste. j) Biodiversity issues
ESTAT are responsible for the monitoring and maintenance of the Grounds and Gardens through the external contractor. This includes ensuring that the
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4.7.1
4.7.4
4.7.2
4.7.3
4.7.5
4.7.6 contractor complies with the University Biodiversity Statement and works with the University on issues identified by the planned Biodiversity Audit and subsequent action plan.
ESTAT is also responsible for the monitoring of the Tree Preservation Orders
(TPO’s) throughout the University Estate through the University contracted
Tree Surgeon, these are surveyed annually.
4.7 EMERGENCY PREPAREDNESS
The University has developed and maintains procedures for the identification of emergency situation and response to those situations associated with both specific activities and the wider workplace.
Identification of potential emergency situations – Central University Major
Incident Planning
The University has developed documented procedures to deal with emergency situations of varying significance in relation to the operations of the University.
These procedures are managed and maintained by GOVRN and are reviewed and re-distributed annually to all Heads of Schools and Directorates.
Identification of potential emergency situations – School / Directorate
Contingency Plans
It is the responsibility of each Head of School and Directorate to ensure that contingency plans in relation to emergency situations are drafted, enacted and reviewed inline with the University’s Major Incident Planning procedures.
Fire
The University Fire Policy and guidance can be found at: Fire Safety (Non Hospital
Based Sites) Policy a) All University buildings undergo fire risk assessments b) Early fire detection and alarm systems are installed in all occupied buildings and are routinely checked and maintained by ESTAT. c) All occupied buildings have a documented emergency evacuation plan. In practice this is satisfied by a ‘fire acting sign’. d) Appropriate emergency evacuation signage is installed throughout the university. e) Fire fighting equipment is installed throughout the University in –line with
University fire strategy. Management and maintenance of the fire fighting equipment is the responsibility of ESTAT. f) Manual Call Points (MCP) are installed throughout the University buildings. It is the responsibility of SECTY to routinely check the operation of the MCPs. g) Emergency evacuation drills are carried out on all University buildings. It is the responsibility of SECTY to organise and monitor the drills.
Personal Emergency Evacuation Plans (PEEPs)
Each School and Directorate shall prepare a PEEP for those staff and students requiring assistance during an emergency evacuation.
Fire Wardens
Each School and Directorate shall nominate an appropriate number of persons to take charge in the event of an emergency evacuation. These persons must be appropriately trained; the training is facilitated by OSHEU.
Evacuation Chairs
Where appropriate the University has installed evacuation chairs to be used in the event of an emergency evacuation. The responsibility for the management and maintenance of the chairs lies with ESTAT.
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4.7.8
4.7.9
4.7.7 Exposure to Hazardous Chemicals
It is the responsibility of the Head of each School and Directorate to ensure that local emergency procedures are in-place in the event of exposure to hazardous chemicals. In practice these should be identified through the risk assessment process and may include: a) Personal Protective Equipment b) Spill kits c) Drench showers
First Aid
Each School and Directorate shall nominate an appropriate number of first aiders to take charge in the event of injury or ill health. These persons must be appropriately trained; the training is facilitated by the School / Directorate. The policy and guidance relating to first aid can be found at: University First Aid Policy .
General Emergency Contacts
A list of emergency contact numbers are available within the front cover of the
University’s Communication Directory.
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28

.
Introduction
The University has established procedures for measuring and monitoring its health, safety and environmental performance on a routine basis. The performance monitoring and measuring will be conducted at both central
University level and at School and Directorate level and consists of proactive measures (which include workplace inspections, internal audits, occupational hygiene and health surveillance monitoring) and reactive measures (which include incident investigations and monitoring in response to identified issues).
Code Procedure
5.1
5.1.3
5.1.3.1
5.1.2
5.1.1
5.1.3.2
5.1.3.3
PROACTIVE MONITORING AND MEASUREMENT
Workplace Inspections
It is the responsibility of the Head of each School and Directorate to ensure that the workplace under their control is inspected regularly and in accordance with the University’s Monitoring Policy and guidance (see: University Safety
Health and Environmental Monitoring Policy and Guidance ). In practice it is the responsibility of managers and supervisors to ensure the workplace under their control is inspected and that issues raised as a result of the inspections are addressed within a timescale proportionate to the risk. Records of the workplace inspections should be retained within each School and Directorate.
Occupational Hygiene Monitoring
The University has an occupational hygienist based in OSHEU to provide competent advice and workplace monitoring (contact safety@cf.ac.uk
) for potential exposure to: a) certain chemical agents b) dusts c) noise d) temperature extremes e) light levels
Internal Audits
The University has developed a programme of internal audits to evaluate health, safety and environmental performance of Schools and Directorates.
The programmes are: a) Annual Returns
It is the responsibility of OSHEU to compile an annual return questionnaire designed to gauge the University’s health, safety and environmental management performance. It is the responsibility of each Head of School and
Professional Service to ensure that the University’s Annual Return performance report is completed and submitted within the specified timescale.
It is the responsibility of OSHEU to collate the data derived from the Returns and report to senior management. b) OSHEU General Internal Audit
It is the responsibility of OSHEU to undertake internal audits to evaluate compliance and health, safety and environmental performance and report the findings to senior management. c) OSHEU Radiation Audits
It is the duty of the Radiation Protection Adviser to organise / carry out periodic
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5.1.3.4
5.1.5
5.1.4
5.1.3.5
5.1.3.6
5.1.6
5.1.7 audits of the management of radio-chemicals throughout the University. The results of the audits are disseminated to individual Schools. A combined report is presented to the Ionising Radiation Working Group and to senior managers. d) OSHEU Laser Audit
It is the duty of the Radiation Protection Adviser to organise / carry out periodic audits of the management of laser installations throughout the University. The results of the audits are disseminated to individual Schools.
Health Surveillance
It is the responsibility of each School and Directorate to identify through risk assessment the requirement for health surveillance and to keep appropriate records (see: Guidance on COSHH Regulations )
It is the responsibility of the Health Centre to carry out baseline health checks for new staff and to undertake health surveillance on those staff identified as requiring it, to communicate to the Schools and Directorate any issues arising from the surveillance results and to keep records accordingly. (Health Centre numbers: Cathays Campus 74810; Heath Park 8955)
Control of Legionella
The University undertakes quarterly audits of its management systems for the control of legionella. These audits are managed by ESTAT.
Second Party Duty of Care Audits
The University undertakes periodic second party audits of hazardous waste contractors. The duty to undertake the audits lies with: a) Hazardous Chemical Waste – OSHEU b) Hazardous Waste (refrigerants, fluorescent tubes) – ESTAT c) Hazardous Waste (electrical) – Schools/ Directorates /OSHEU d) Hazardous Waste (clinical) - OSHEU
External Audit
The University is periodically audited by external bodies to assess its management systems. The external bodies include: a) Environment Agency – radiation management/waste disposal b) Environmental Health - food hygiene c) South Wales Fire and Rescue Service – fire management d) Zurich Insurance – general health and safety and business continuity
(fire safety) e) Counter Terrorism Security Advisors (CTSA) – control of chemicals and f) biological agents
Health and Safety Executive – random checks g) Health Inspectorate Wales - medical exposure and medical practice.
h) British Standards Institution – ISO 14001 i) Bureau Veritas
Monitoring of Utilities
ESTAT monitor through metering the energy usage throughout the University and individual buildings. Information is provided to Schools and Directorates on Building energy usage on a regular basis.
Monitoring of Waste
The University, through its domestic waste and recycling contractor, will plan to provide information on weights of domestic waste and recycling.
The University will also monitor, through the contractor, the disposal of hazardous chemical and clinical waste in line with its objective to continue to improve recycling and encourage waste minimisation wherever reasonably practicable.
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5.2
5.2.2
5.2.3
5.2.1
5.2.4
5.2.5
REACTIVE MONITORING AND MEASUREMENT
Accidents, Incidents and Near Misses
It is the responsibility of managers and supervisors to ensure that all accidents, incidents and near misses in areas under their control are reported using the
University reporting mechanism (see: Reporting an Accident/Incident ) and are investigated to identify root causes and appropriate remedial action is undertaken to prevent recurrence. The findings from the collated data are reported to senior managers.
Investigation of ‘Major’ Accidents, Incidents and Near Misses
OSHEU will investigate any accident, incident or near miss which has been assessed as being of major significance. The findings from the investigations are reported to senior managers
Investigation by Trades Union Representatives
The University recognises that Safety Representatives have the right to investigate incidents whether highlighted by a Trades Union member or not. To that end access to the incident data-base is available to University recognised
Trades Union Representatives on request .
Reporting of Injuries Diseases and Dangerous Occurrences
It is the responsibility of OSHEU to assess and, when appropriate, report to the
Health and Safety Executive any incident that falls under the requirements of the Reporting of Injuries Diseases and Dangerous Occurrences Regulations.
Occupational Hygiene Monitoring
OSHEU carries out occupational hygiene monitoring in response to an incident and on request by managers and supervisors of the issues as highlighted in section 5.1.2.
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Introduction
The University has developed systems to undertake (at least) annual management reviews of health, safety and environmental performance both at the central University level and at individual School and Directorate level.
The annual performance report is submitted to the university top management through the management structure as shown in Figure 3.
6.2.1
6.1.1
6.1.2
Code Procedure
6.1 MANAGEMENT REVIEW
– CENTRAL UNIVERSITY
6.2
A management review of safety, health and environmental performance will be carried out through the University Safety, Health and Environment Committee, which in-turn will report to University Council.
Inputs to the review: a) results of the internal audits and evaluation of compliance b) results of consultation with Trades Union, student and employee representatives c) relevant communications from external parties, including complaints d) health, safety and environmental performance of the University e) status of corrective and preventive actions (to include follow up actions f) from previous management reviews) changing circumstances and developments, including legal and other requirements. g) Extent to which the University objectives have been met h) Opportunities for continual improvement
Outputs of the review: a) changes to health, safety and environmental performance of the
University b) revised objectives c) allocation of resources as required
MANAGEMENT REVIEW
– SCHOOLS AND DIRECTORATES
Each School and Directorate will carry out an annual review of their safety, health and environmental performance. The review will be undertaken by the
School / Directorate top management.
Inputs: a) results of the internal audits and evaluation of compliance b) results of consultation with staff and students c) relevant communications from external parties, including complaints d) health, safety and environmental performance of the School and
Directorate e) status of corrective and preventive actions (to include follow up actions from previous management reviews) f) changing circumstances and developments, including legal and other
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6.2.2 requirements affecting the School / Directorate. g) extent to which the School / Directorate objectives have been met h) opportunities for continual improvement
Outputs: a) changes to health, safety and environmental performance of the School
/ Directorate b) revised objectives c) allocation of resources as required
Each School and Directorate is required to undertake an annual management review of health, safety and environmental performance. This review should be conducted by the School / Directorate top management.
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Appendix 1: Communication and Consultation Streams
Council
Receives briefings from the University
Safety, Health and Environment Committee via the Governance Committee
Governance Committee
Receives information from the University
Safety, Health and Environment Committee and disseminates to Council
Safety, Health and Environment
Committee
Committee membership includes:

Trades Unions,
 staff representatives
 student Representatives
 management representatives

Heads of Schools representative (1 from each Electoral Group)

Lay member of Council

Cardiff and Vale Health Board
Schools and Professional
Services
Communication / consultation through briefings with DSOs and local health, safety and environment committee
Student Body
Minutes available to all staff through:
S:\COMMON\MINUTES
SHEA Group
Receives guidance from
OSHEU and advises the
Safety, Health and
Environment Committee
General staff

Trades Union branch meetings

Other means as indicated in section 4.4.1
University Board
Advisory to the Vice
Chancellor and receives guidance and performance reports from OSHEU on a quarterly basis
34
Version 01; Revision 03

Appendix 3: Management System Document History
Revision
Number
01
02
03
Date
June
2010
30/08/
10
04/03/
2014
Amendment Compiled by
Initial issue Mike
Turner
Katrina
Henderson
/
Added to Section 3.5: ‘The University will not communicate its environmental aspects externally’
Mike
Turner
Scope of management system added to
Section1.
Peter
Thorne
Legal register removed from document and appendices renumbered.
Reference to generic HSE risk assessment guidance removed from
Section 3.2.
Approved by
35
Version 01; Revision 03