HEALTH AND SAFETY PROCEDURE

PROCEDURE FOR WORKING AT HEIGHT

IN NHS BLACKPOOL AND NHS NORTH LANCASHIRE

No 25a

Document Reference: NHSB/SPD/RISK/16/2008

Author: Damian Gudgeon

Department: Risk Management

Date: May 2008

Review Date: November 2010

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 NHS Blackpool and NHS Document Reference Number: NHSB/SPD/RISK/09/2008
North Lancashire

Document Type: Policy Document Reference Number:

BPCT/SPD/RISK/08/08

Title: Procedure for working at Version Number: 01

height in NHS Blackpool and NHS
Lancashire Classification: Health and Safety

Author(s): Title(s): Risk Auditor Department(s): Risk Management

Damian
Gudgeon

Date of Issue: Replaces Version Number: 0

August 2008
Review due:
August 2011 Description of Amendments: New Legislation

Ratified by: Title: Signature: Ratified Date:

Joint Health and Safety
Blackpool PCT Committee and Senior
Management Forum
North Joint Health and Safety
Lancashire
Committee
Teaching PCT

Document Review History

Review Date: Version Number: Approved Reviewer:
27//05/08 Damian Gudgeon

Procedure For Working At Height In NHS Blackpool and NHS North Lancashire
May 2008
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NHS Blackpool and NHS Document Reference Number: NHSB/SPD/RISK/09/2008
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1.0 PURPOSE
Incidents involving employees Working at Height has consistently over the last
10 years, been responsible for the largest number of fatalities in the workplace.
As a direct result the Work at Height Regulations 2005 where introduced to
protect employees and others against risks to the health while working at
height. During 2006 -2007 45 fatalities occurred as a direct result from working
at height. Due to the nature of reporting it is unclear how many major injuries
have occurred as a result of employees falling from height when at work.
This policy outlines the steps to be taken by NHS Blackpool and NHS North
Lancashire to ensure that all employees, clients, members of the public and
contractors do not work at height where it can be avoided and where it cannot
suitable and sufficient controls are introduced following the appropriate
hierarchy. To achieve this, the corner stone of this policy requires a suitable and
sufficient risk assessment to be completed for all tasks which require working at
height.

2.0 DUTIES
2.1 Consultation

All staff employed by the Trust will be affected therefore, the Trust and Staff
representatives have had all information made available to them and have been
consulted through the Joint Health and Safety Committee.

3.0 SCOPE
This policy applies to all employees and staff and contractors working for the
undertakings of either NHS Blackpool or NHS North Lancashire.

4.0 EQUALITY IMPACT ASSESSMENT

This document has been impact assessed by the author and members of Joint
Health and Safety Committee. No issues in relation to equality, diversity,
gender, colour, race or religion are identified as raising a concern.

5.0 Procedure
Historically working at height was generally only recognised as a problem in the
construction and skilled trade industries, this was largely due to the “two metre
rule” which exists within the then relevant Approved Code of Practice
concerning falls or falling objects. However due to the number of deaths and
major injuries of employees falling less than two metres the “two metre rule”
was repelled and replaced by more open definition contained within the Working
at Height Regulations 2005.

Procedure For Working At Height In NHS Blackpool and NHS North Lancashire
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Death and serious permanent injury does result when people fall from low
heights in environments not considered to be particularly at risk, these include
offices, store rooms and canteens. That is the main reason why whenever any
employee is working where they can fall a distance likely to cause personal
injury appropriate precautions must be taken to ensure safety.

5.1 Risk Assessment

In the event of working at height being unavoidable, a suitable and
sufficient risk assessment must be completed. This will identify all the
necessary control measures.

Risk assessments may be generic, covering the same task on a number

of occasions and in a number of locations, but if there are significant
changes to the task, location, personnel or the equipment used then a
specific assessment must be completed for that task.

When considering the use of a generic risk assessment the following

factors must always be taken into account

• the task
• equipment used
• competency of the personnel

These points must always be relevant to the work being undertaken.

The Work at Height Regulations 2005 provides a hierarchy of control

measures for determining an appropriate level of control. It is vital that this
hierarchy is followed systematically and only when it is not reasonably
practicable to introduce the controls must the next level down be
considered. It is not acceptable to accept controls form lower down the
hierarchy (e.g. step ladders or kick stools) in the first instance. The
hierarchy has three basic steps to consider in order.

• Avoid
• Prevent
• Minimise

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Hierarchy General Guidance Examples

Avoid
Use work equipment or other
measures to Prevent falls
where working at height
cannot be avoided
Where you cannot eliminate
a risk of a fall use work
equipment or other
measures to minimise the
distance and consequences
if a fall should occur
If you don’t have to go up there
don’t.
Can an existing safe place at
height be used?
Adopt a more suitable method
of working.
Selection of suitable
equipment
Give collective measures
priority over personal
Mitigate the consequences of
a fall
Prevent any person falling a
distance liable to cause injury
Have measures in place to
arrest a fall
Airbags
Can the work be done from
ground level?
Can the work be lowered to
ground level
Lower shelves
Remove desks from in front of
windows to allow access to
window opening devices
An existing building or
structure including its means of
access and egress.
Tower scaffold
Ladders
Kick stools
landing mats
nets
fall arrest equipment,
rope access.

The risk assessment form for completing work at height assessments is

found in Appendix 1.

When selecting suitable work equipment on the risk assessment form an

explanation of why the controls are or are not being used must be placed
in the appropriate box when systematically moving down the hierarchy of
choice.

If yes is ticked a brief explanation of the controls to be used must be

placed in the box. If no is ticked then an explanation of why that control is
not suitable must be placed in the appropriate section.

The hierarchy on the form must be followed in the same systematic

manner as previously mentioned.

Employees who work at height must be informed and or trained in the

use of the work equipment and awareness of working at height. Ticking
that employees are trained on the risk assessment form will help
significantly reduce the likelihood score on the assessment of risk.

NHS Blackpool and NHS North Lancashire risk assessment risk level
estimator should be used when assessing residual risk after control

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measures have been introduced. The consequence score rating must

always remain at 5 as it is foreseeable that fatalities can occur on falls
less than 2 metres. The introduction of suitable work equipment and the
provision of a competent well trained workforce will have a significant
effect on reducing the likelihood score and thus the residual risk score on
the quantification of risk on the assessment.

Risk assessments must be reviewed annually or whenever there is

significant change in the task, equipment, after an accident or on the
introduction of new legislation or guidance.

5.2 Step Ladders

Step Ladders have not been banned in the workplace. The use of step
ladders in an office environment can be justified being at the bottom of
the hierarchy.

Before considering the use of steps to access items which may be stored
in high places priority must be given to the relocation of items into areas
in which the use of such steps is not required. This may be on lower
shelves. Only when it is reasonably practicable not to achieve this must
height access equipment be considered.

If step ladders are to be used providing the user must be trained and
instructed in the selection and safe use of the ladders and systems must
be in place to ensure step ladders are maintained and inspected every
six months. A ladder inspection checklist is included in Appendix 1. Step
ladders do not prevent a fall or mitigate a fall but if used by trained
operators in appropriate circumstances i.e. low risk and for short
durations, their work can be justified. All departments that have step
ladders must operate a ladder register Appendix 2, detailing the date of
purchase, date and frequency of maintenance, defects reported, repair
work etc. All step ladders must have an identifiable number. All step
ladders must be stored correctly. Consult the manufacturer’s instructions
for methods of safe storage.

When using step ladders ensure the following

• all four legs are in contact with the ground

• place the stepladders with the rungs facing the work activity and not
side on as this is less stable
• Ensure the ladders are the correct length. Do not overreach
• Do not use the top three (including the top step) rungs of the
stepladder unless it has a suitable hand rail. This should ensure a
handhold is readily available
• Always use appropriate footwear

Procedure For Working At Height In NHS Blackpool and NHS North Lancashire
May 2008
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NHS Blackpool and NHS Document Reference Number: NHSB/SPD/RISK/09/2008
North Lancashire

Where ever ladders or step ladders are in use throughout NHS Blackpool
and NHS North Lancashire copies of the following documents must be
read and understood by all staff using the relevant equipment.

Additionally copies of these documents must be located in

each department. These documents can be obtained from HSE BOOKS
or from the Risk Management Department.
• Safe Use of Ladders and Step Ladders INDG 402
• Top Tips for Ladder and Step Ladder Safety INDG405

All step ladders used for the purposes of NHS Blackpool and NHS North
Lancashire must be the British Standard for stepladders BS / EN 131 or
BS 2037 (aluminium) BS 1129 (wood) and must all be class 1
(industrial).

5.3 Inspections
All equipment used for working at height must be inspected by a
competent person. This inspection must be vigorous as well as visual.
Inspections must be carried out on step ladders and kick stools at the
following intervals
• After installation or assembly
• If exposed to conditions likely to cause deterioration.
• After any incident or report of near miss
• After exceptional circumstances which may jeopardise the safety of
the equipment.
• Annual check.

A simple visual check can be completed by all users prior to use the
simple check is looking for the following defects:

• Missing damaged or worn anti –slip feet on metal and fibreglass

ladders (these are essential for good grip)
• Items stuck in the feet such as swarf, stones grease or dirt,
preventing the feet from making contact with the ground
• Mud grease or oil either on the rungs or the stiles (the slides)
• Cracks in the rungs or stiles of the ladder
• Missing broken or weakened rungs
• Missing or damaged tie rods
• Check metal ladders for cracked or damaged welds and missing or
loose screws or rivets

After the inspection has been completed any concerns regarding the
safety of the equipment must be reported immediately to your line
manager and the equipment immediately labelled as defective and de

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NHS Blackpool and NHS Document Reference Number: NHSB/SPD/RISK/09/2008
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commissioned. Do not use faulty or defective equipment under any

circumstances.

NHS Blackpool and NHS North Lancashire shall ensure that no

equipment used for working at height leaves the organisations
undertakings without it being accompanied by the last inspection report.
Equally no equipment used for working at height must be brought into
NHS Blackpool and NHS North Lancashire for use as a result of its
undertakings unless it is accompanied by the last inspection report.

5.4 Kick Stool Safety

The kick stool is versatile piece of work equipment. Kick stools can
provide a means of access to high shelves and should only be used
when other methods of control have been exhausted i.e. relocation of
files on high shelves.

Before using a kick stool for the first time be aware of how it works.

To enable the stool to be relocated, it is based on a number of castors

which collapse on to a rubber base ring when any weight is placed on the
stool providing a solid platform.

Inspect every kick stool before use. If there are any defects cracks or
damage do not use and decommission the equipment immediately. Take
particular notice of the surface to ensure it is free from contaminants
such as dirt or fluids.

Before moving the kick stool be sure there are no obstacles in the path. It
is safe to move the kick stool with the foot using a short light kick aimed
at the base of the kick stool.

Ensure the stool is in the right position; minor adjustments can be done
by hand.

Do not attempt to mount a moving kick stool.

Once the stool is stationary step firmly up one foot at a time. Hold any
item to be lifted with both hands making sure you stand in the centre of
the stools platform.

When you are comfortable reach up to complete the required task.

Never lift any large or heavy objects, if you are unsure hand any item to a
second person before mounting / dismounting the stool.

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Do not over stretch or stand on one foot it is important to keep both feet
firmly on the stool at all times.

Dismount slowly and carefully one foot at a time do not jump off the stool.

Do not use a kick stool if you are wearing high heel shoes.

All kick stools must meet the British Standards of BS 7377 or BS / EN

131.

6.0 IMPLEMENTATION

6.0.1 For risk management to be effective within the Trust, this policy
has a structured and supportive approach for the implementation of
training and will demonstrate the Trust' s commitment that all staff are
taking positive steps and working in partnership with each other, patients
and stakeholders to provide a positive risk management culture within
the organisation.

To achieve this, the Risk Management policy will be;

• reviewed annually and approved by the Health and Safety

Committee and Senior Management Forum.
• circulated to all Managers, with specific responsibilities detailed in
the document.
• available to all staff in all departments and practices.
• available to all stakeholders on request ( in an appropriate format )
• available to Independent Contractors for information.
• available on the intranet.

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6.1.1 Implementation of the policy

The Risk Management Department will provide support and

guidance to all staff to implement the policy.

To support the implementation of the policy, risk management

must be:

• included in the job descriptions for all staff;

• incorporated into KSF and PDP objectives for all staff on an
annual basis;
• part of the mandatory induction programme for all new staff;

A Risk Management Bulletin will be published on a 4 monthly basis and

available on the Intranet.

7.0 MONITORING

Compliance to this Procedure shall be monitored by the Joint Health and

Safety Committee via review of the Untowards Incident Reporting
process.

8.0 PERFORMANCE INDICATORS

Compliance to Working at Height Regulations 2005 (SI 2005 No 735)

RIDDOR provision and use of Work Equipment Regulations 1998
(PUWER) Construction (Health, Safety and Welfare) Regulations 1996

9.0 REFERENCES AND BIBLIOGRAPHY

Work at Height Regulations2005 SI 2005/735
The Work at Height Regulations 2005 a brief guide INDG 401
HSG 33 Health and Safety in Roofwork
HSE Topic Inspection Pack Working at Height
HSG 150 Health and Safety in Construction

10.0 ASSOCIATED DOCUMENTS

Document Title
25 Working at Heights

Procedure for Working at Height in the Works Dept

25b

Procedure For Working At Height In NHS Blackpool and NHS North Lancashire
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11.0 PEER REVIEW

The document, entitled Procedure for Working at Height In NHS

Blackpool and NHS North Lancashire has been peer reviewed by the
following people:

Name (print) Post held Date Signature

Wendy Swift (BPCT) Chief Executive 27/05/08

Keith Savage Head of Governance 27/05/08

Helen Skerritt Associate Director of adult provider services 12/06/08

Liz Holt Associate Director of children provider 12/06/08

services

Debbie Mathlouthi Risk Auditor 27/05/08

Brenda Hargreaves Head of community nursing 27/05/08

Tracey Keith CDNA staff side 27/05/08

Colin Norris Unison staff side 27/05/08

Ruth Roberts (NLPCT) Director of Provider Services 27/05/08

Tricia Cross Infection Control Nurse 27/05/08

Donna Taylor Infection Control Nurse 27/05/08

12.0 APPENDICES
APPENDIX 1 Ladder Registration
APPENDIX 2 Ladder Checklist

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 Appendix 1

Ladder Register

Department …………………………………….

Identity Date of
Material Type Location Inspected Dates
Number Registration
 Appendix 2
Ladder Checklist

Department Location of Ladder

Ladder Identification
Number
single extension Substance of wood aluminium
Type of Ladder
step platform Ladder fibreglass steel
Date and Time of
Name of Inspector
Inspection
Date and Time of Date and Time of
Last Inspection Next Inspection
Ladder Inspection Y N Comments
Is the ladder id prominently displayed on the ladder
Is the ladder free from modification, such as shortening, being
painted etc
Are the stiles (uprights) free of cracks, damage or excessive wear
particularly at the head or foot of the ladder
Are all the rungs (steps) clean and free of cracks, damage or
excessive wear
Are all the rungs (steps) and fittings in place (e.g. slip resistant feet
on metal ladders etc)
Are the rungs and stiles secure and free from movement
Are all tie rods in place free from damage and secure are all rivets
and bolts tight and in place.
Are all side guides in place free from damage and secure are all
rivets and bolts tight and in place.
Are all rung locks in place free from damage and secure are all
rivets and bolts tight and in place.
Are all hinges in place free from damage and secure are all rivets
and bolts tight and in place.
Are all pail shelf in place free from damage and secure are all rivets
and bolts tight and in place.
Are all spreader braces in place free from damage and secure are
all rivets and bolts tight and in place.
Is the ladder free from distortion or warping
Is the ladder free from cracks, corrosion or dents etc
Are all fittings such as ropes, pulleys or hinges free from wear or
damage
For fixed ladders in the workplace currently in use
Is it positioned correctly (1 out for every 4 up; approx 75% pitch)
Is it positioned on a firm level surface
Is it correctly footed and / or secured (tied off) to prevent it slipping
or moving
Does it extend1.05m (3.5ft) above the platform it is being used to
access or is an alternative handhold provided on the landing
surface
Has the ladder passed inspection and is fit for use
If the answer to any of the above questions is NO the ladder should be immediately de
commissioned and a notice placed upon it stating “DO NOT USE THIS LADDER” and all faulty
reported. This ladder must not be used until all the faults have been corrected.

Signature of Person Completing Inspection