UNIVERSITY POLICY AND GUIDANCE
SAFETY, HEALTH AND ENVIRONMENTAL
MONITORING
Author(s)
Mike Turner
John Frayling
Policy Ratified
by
Safety Health and
Environment
Committee
Date
05/09
Area Applicable
Cardiff University
Review Year
2012
This policy and guidance has been Equality Impact Assessed
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DRAFT POLICY
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 Directorates are
relative to their overall safety, health and environmental objectives;

To comply with relevant safety, health and environmental legislation.

To assist Schools and Directorates 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, monitoring and auditing procedures and protocols;
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.
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g) Ensuring that the same management standards are applied to workplace
inspections, monitoring and audit as are applied to other management
functions
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 Directorates:
Ordinance 7 of the Cardiff University’s Rules of Governance state that the duties and
responsibilities of the Head of School 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 provided to meet the requirements of
the Monitoring Policy;
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 / Directorate 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
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m) Systems are in-place for maintenance of records detailing the inspections and
the completion of any remedial action;
n) The School / Directorate 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) Supporting the objectives of the Monitoring Policy;
b) Ensuring areas under their control are inspected on schedule;
c) Records of the inspections and remedial action plans are maintained;
d) Remedial actions are completed on schedule;
e) 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/Directorate, through the appropriate line
management, to ensure effective management of contractors under their control. As
such each School/Directorate 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. Independent Audits:
It is the responsibility of the University’s Occupational Safety, Health and
Environmental Unit (OSHEU) to provide University Council, the University 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.
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10. 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 /
Directorate as containing such significant hazards that entry by maintenance
staff or cleaners requires a written Permit to Work using the ‘Red Book
system’
Each School / Directorate 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
/ Directorate as containing significant hazards and which require Permit to
Work systems and written method statements for maintenance staff and
cleaners.
Each School / Directorate 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 / Directorate 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
11. Frequency of audit
The timing and frequency of audits will take into account inherent safety, health and
environmental hazards and the standard of safety, health and environmental
management currently in practice.
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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.
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Appendix A
Draft Monitoring Policy Guidance
1. Self Inspection – Schools and Directorates:
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:
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.
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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 over-familiarity.
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 /
Directorate. The auditors should be familiar with both the working practices of the
School / Directorate 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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