Management and control of contractors policy

1 Introduction

The trust utilises contractors to carry out various types of work. This can range from very simple work such as window cleaning, servicing of equipment, maintenance and repair of buildings to larger construction-type projects for new buildings. The term “contractor” does not exclusively refer to maintenance or building workers.

When contractors are engaged to work on trust premises the trust has a legal duty to safeguard the health, safety and welfare of those in its employment and also of those not in its employment. There is a duty to liaise with and monitor the work of contractors for the safety of all including the contractor’s staff, trust staff, patients, visitors and others who may be affected by the contractor’s activities. The contractor also holds similar obligations and it is a legal duty that all parties work together to ensure that any workplace in the trust remains safe and that risks to health and safety are reduced as far as reasonably practicable. Further duties are detailed in regulations 11, 12 and 15 of the Management of Health and Safety at Work Regulations (1999).

Some contract work falls within the definition of ‘construction’ and as a client the trust recognises it has responsibilities under the construction (design and management) Regulations (CDM 2015) which entails:

checking the competence of all appointed contractors
ensuring there are suitable management arrangements for the agreed work including the provision of welfare facilities for contractors or staff
allowing sufficient time and resources for all stages of the agreed work
providing pre-construction information to designers and contractors

Some construction work will fall within the requirements of Part 2, regulation 6 of the CDM regulations and are notifiable to the health and safety executive. This policy is not intended to cover the detailed Health and Safety arrangements for such projects which will be determined on a case by case basis and for which responsibility would be shared with the principal designer and principal contractor. These projects are managed by the estates department who will appoint an agent for all major projects.

2 Purpose

The purpose of this policy is to ensure that the activities of contractors who are engaged by the trust are effectively managed to reduce the risk of harm to themselves, to others and to the environment. This policy provides guidance to all the trust staff who are involved in the appointment of contractors.

3 Scope

This policy details the trusts’ policy for the health, safety and welfare aspects of managing contactors. It does not provide details of other aspects of contract management.

Any proposal to use a contractor may have an impact on compliance with statutory health and safety duties. Whilst most contractor appointments will be undertaken by the estates department, contractors may also be appointed by others in the trust including corporate departments and clinical staff. All staff are required to follow this policy and staff who appoint a contractor should be familiar with their level of authority to appoint contractors. It is likely that the CDM Regulations will only apply to some contract work that is managed by the estates department. All contract work associated with property or technical installations should be referred to the estates department.

In any client or contractor relationship, both parties have duties under Health and Safety law. Similarly, if the contractor employs sub-contractors to carry out some, or all of the work, all parties will have some health and safety responsibilities. Contractors are responsible for ensuring compliance with health and safety matters within their working area.

Some of the duties associated with the management of contractors overlap with those of other policies and procedures, for example, management of asbestos containing materials. This policy must be read in conjunction with other relevant trust policies some of which are listed in section 9 and 10 of this policy.

4 Responsibilities, accountabilities and duties

The trusts’ management have a duty, so far as it is reasonably practicable to ensure that there is a regime in place for the management of contractors.

4.1 Chief executive

The chief executive has overall responsibility for health and safety which includes ensuring that legal duties are met, and adequate resources are made available for the trust to meet its obligations for managing contractors. Whilst the responsibility for managing contractors is delegated to other officers in the trust the accountability remains with the chief executive.

4.2 Health and safety lead

The health and safety lead has the responsibility for overseeing compliance with health and safety legislation throughout the trust and for providing advice and guidance to trust staff on the management of contractors.

4.3 Head of estates and facilities

The head of estates and facilities has the responsibility for ensuring all contractors under his control are managed in accordance with this Policy and that training, advice and guidance is provided to estates and facilities staff on the management of contractors.

4.4 Directors, deputy care group directors and service managers

Directors, deputy care group directors and service managers are responsible for ensuring that this policy is implemented in areas under their control and for providing advice and support to staff who appoint contractors.

4.5 Estates managers

Estates managers are responsible for managing any work under their control where contractors have been appointed. They have the responsibility for ensuring that an evaluation of the proposed contractors work is carried out to assess the potential hazards and determine any precautions that may need to be taken and to ensure that safe systems of work are employed.

For contract work which is of a low hazard, the application of generic risk assessments may be appropriate to reduce the risks to an acceptable level. More specific method statements or risk assessments will be required for work which is of an unusual, irregular or non–routine nature. The application of a permit to work system may be required for work which has a high hazard potential.

4.6 Staff who appoint contractors

All staff who appoint contractors have a responsibility to ensure that contractors are managed in accordance with this policy.

5 Procedure or implementation

Where the CDM regulations do not apply, for example, the work is non-notifiable, any health and safety or other arrangements will need to be determined specifically for the needs of the proposed work for example, maintenance of equipment, installation of data circuits and so on. The staff member appointing the contractor will be responsible for co-ordinating the work by the contractor with any other parties and will carry out the following as appropriate:

define the work that has to be done including the task, the place of work and any associated issues
consider the hazards that are likely to be introduced by the contractors work and any risks arising from trust activities affecting the contractors
contact the service or departmental manager where the work is to take place to ascertain whether any precautions need to be taken
determine whether it is reasonably practicable to segregate the contractors work from other activities taking place either by scheduling the work out of hours or by physical separation
identify potential contractors and evaluate their competence to carry out the work safely
ensure that any design or specification work undertaken by the trust or on behalf of the trust is undertaken by competent persons who are able to eliminate hazards and control risks within the design and meet health and safety obligations
obtain detailed work plans from the contractor and review the contractors risk assessments and method Statement for the work
ensure that health and safety requirements are included in any written contract or agreement
undertake or review risk assessments for the workplace to determine any new or changed risk controls to be introduced for the duration of the work
ensure that a responsible person is appointed to meet the contractors representatives and if required that they receive an induction and are briefed with essential health, safety and emergency information
if the work is particularly hazardous for example, roof work, it will be necessary to ensure that there are arrangements for issuing permits to work and as such advice must be sought from estates
where practicable, monitor the execution of the work to ensure that is being carried out safely
lead a contract review and where required, involve other trust staff in particular security, fire and health and safety staff to ensure that any potential problems are identified

Where the CDM regulations apply, for example, If it is likely that any agreed works will exceed 30 working days or more than 500 person days of construction work, this will fall within the additional requirements described in part 2, regulation 6 of the CDM regulations (notifiable projects) and the estates manager may appoint an agent who will be required to take the actions below:

coordinate arrangements for the appointment of a competent principal designer and principal contractor taking into account guidance on competency set out within the approved code of practice to the CDM regulations
take responsibility for ensuring that the work does not begin until there is an adequate construction phase plan in place and suitable welfare facilities for workers
ensure that the health and safety executive are sent an F10 form before the construction phase begins

The regulations contain sufficient information to assist with an assessment of a contractor’s competence and information that may need to be provided to a contractor. The estates notice to contractors- workplace responsibilities also provides essential information relating to the control of contractors.

The estates department holds and maintain specific guidance for estates related work which is available to estates staff. The documents listed below are available as standard operating procedures on ‘L’ drive, estates shared, or contracts procedures or health and safety:

precautions for the use of acetylene
permit to work procedures

6 Training implications

There are no specific training needs in relation to this policy.

7 Monitoring arrangements

7.1 Appointment of competent contractors

How: Review of contract agreements.
Who by: Head of estates or health and safety lead.
Reported to: Health and safety forum.
Frequency: Annually.

7.2 Policy implementation

How: Regular checks.
Who by: Head of estates or health and safety lead.
Reported to: Health and safety forum.
Frequency: Quarterly.

8 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

8.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

8.1.1 How this will be met

No issues have been identified in relation to this policy.

8.2 Mental Capacity Act 2005

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

8.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1).

9 Links to any associated documents

10 References

Construction (Design and Management) Regulations (CDM 2015)
Management of Health and Safety at Work Regulations (1999)
Health and Safety at Work Act (1974)

11 Appendices

11.1 Appendix A Contractor competency assessment

Contractors should be selected based on technical competence, experience and suitability for the work to be done. Any trust staff authorised to appoint contractors are to carry out an assessment process, and dependent on the risk, may involve a review of information from the contractor which includes:

track record of experience in similar contracts
membership of reputable trade bodies or approved contractor schemes
legally required registrations, for example, gas safe register
evidence of health and safety policies and practices
recent health and safety performance, number of accidents
qualifications, training and skills of staff and managers
selection procedures for sub-contractors
example safety method statements and risk assessments for similar work
arrangement for consulting their workforce

References from previous clients. The HSE’s notices and prosecution database (HSE website (opens in new window)) should also be reviewed to determine if the potential contractor has been subject to any formal legal sanction.

The contractor’s status as a member of a trade or professional body or an approved contractor scheme should be verified directly with the body to ensure the membership is current and covers the work being offered by the trust.

11.2 Appendix B Essential information provided to or from contractors

To enable contractors to take account of all issues affecting health and safety estates need to be contacted to establish that if required within their tender the contractor will be requested to provide essential and, as applicable, health and safety information including:

for any design or specification work already undertaken, any information about risks which could not be eliminated at the design stage
any restrictions on the time or location in which work is to be done
access, parking and road traffic rules
information about other people who could be present in the premises or could be at risk in the vicinity for example, service users, staff, children, the elderly, and the disabled
restrictions which apply to the storage of goods, materials, skips, site huts and storage containers
rules regarding the storage of waste awaiting collection and, where applicable for removal of waste from site
smoking restrictions
any particular trust procedures about work on electrical installation and the use of electrical equipment
requirements for work on gas systems
general trust fire procedures about the need to maintain escape routes and access to fire equipment and any specific rules in relation to the project
procedures requiring the use of personal projective equipment (PPE) when required as a result of the hazards of the work for example, hearing protection, head protection, safety footwear, and hi visibility clothing
any particular hazards within the premises such as the presence of asbestos with work areas likely to be used by contractors, fragile roofs, overhead or underground services, confined spaces, and reversing vehicles at loading bays. anticipated hazards from the work activities undertaken or other contractors, machinery or hazardous substances
restrictions on the introduction of certain high hazard equipment or processes except where agreed in advance and subject to a permit to work for example, radioactive sources, cartridge tools, hot work, lifting equipment
restrictions and procedures about the use of hazardous substances (COSHH) or the generation of noise
procedures about wat height including roof work, scaffolds, mobile elevating work platforms and suspended access equipment when applicable
any restrictions on the use of trust facilities for example, toilets, washing facilities, restaurants or eating areas, equipment such as fork lift trucks
requirements for supervision and quality assurance
restrictions, procedures or arrangements on the use of sub-contractors
the need for contractors to provide their own first aid arrangements or the availability of our first aid facilities and staff
any specific qualifications required for particular parts of the job
if deemed applicable, security clearance arrangements
requirements to report all accidents and incidents to the trust project manager
the contact details of the trust representative(s) responsible for coordinating the work who can be contacted for further information
provide the contractor with the trust notice to contractors workplace responsibilities guidelines available from estates.

11.2.2 Receiving information from contractors

Once the contractor is selected agreed work plans will need to be discussed and the contractors risk assessment and method statement reviewed.

Any risks created by the contractor affecting other persons on the premises or work area will need to be taken account of in the trust’s own management arrangements for the duration of the agreed work.

11.2.3 Authorisation and permits

Arrangements must be in place, planned for contractor’s staff or representatives to sign in on arrival and out when leaving as required through obtaining a contractor pass issued from estates.

Additional precautions may be required for particularly hazardous work when a permit to work and detailed permit to work procedures issued by estates will be required. Hazardous work requiring a permit to work may include:

hot works
excavation
confined space work
work at heights
the use of mobile cranes
work on pitched roofs
work in a lift shaft or pit
work on electrical equipment and medical gases
working in a high risk or medium risk area.

The trust estates department is responsible for identifying work which will require a permit to work and completion of the document with details of the work to be undertaken, foreseeable hazards, the precautions to be implemented by the contractor and the start and finish time of the permit to work. Both parties are to sign to indicate that particular work methods and precautions have been agreed.

The contractor’s staff or representatives are required to keep a copy of the permit to work at the place of work for inspection by trust staff as required. On completion of work the permit to work must be signed off by both parties.

2.4 Contracts

In the conditions of contract or agreement the trust will stipulate that the contractor and all of their employees must:

adhere to the notice to contractors workplace responsibilities, as issued to contractors by estates and facilities, see appendix C. Note that additional precautions for contractors working in high and medium risk areas may also apply
comply with their own method statements or where this is not practicable for any reason to agree changes with the trust appointed project manager or other manager or staff connected with the appointment of the contractor
comply with all health and safety laws applicable to the work being undertaken

2.5 Briefing

As outlined in 2.3 above on arrival at the work site the contractor will need to be questioned or briefed by the trust appointed project manager or other manager or staff authorised with the appointment of the contractor in relation to the following, as applicable, matters:

parking arrangements
any hazards that the contractor may create for other building users for example, use of chemicals or flammable liquids, obstructing access, use of power tools
any hazards arising from trust activities on the particular day which may affect the work to be carried out
a reminder of the locations of any known asbestos containing materials that there are no known asbestos containing materials in the building, but if the contractor suspects anything during the course of the work to stop immediately and report back
agreed safe working method to protect the contractor and others
the importance of the contractor not doing any work that has not been previously agreed
the fire procedures including; raising the alarm, sound of the alarm, assembly point, exit routes, location of extinguishers, for use if trained
the need for the contractor to report any accidents or hazards
arrangements for waste removal if necessary
toilet location and any other welfare facilities the contractor is permitted to use
the need to sign in on arrival and sign out prior to leaving
identify any activities requiring a permit to work and ensure that it is issued before the contractor commences work

2.6 Monitoring

All work by contractors will need to be monitored periodically to:

review progress
check the quality of workmanship
check that workers on site are those expected and who have signed in
identify any problems or unanticipated risks at an early stage
check the work is restricted to the planned areas and creating additional risks by spreading beyond agreed areas or involving unauthorised work
check that method statements are being followed and that the contractor is complying with site rules and generally working in a safe manner

The degree of monitoring will depend on the type of work involved for example, regular contract work such as window cleaning may only need checking a few times a year whereas building alterations may require checking several times in a day therefore the frequency of monitoring is a matter of judgement for the trust appointed project manager or other manager or authorised staff connected with the appointment of the contractor.

2.7 Contract review

On completion of agreed works the trust appointed project manager or other manager or authorised staff connected with the appointment of the contractor is to ensure receipt of any required certification, operating instructions, product guarantees or any necessary health and safety information. The trust appointed project manager or other manager or authorised staff connected with the appointment of the contractor should also ensure that ongoing inspection and maintenance requirements of new equipment is identified and scheduled as required.

The trust project manager or other manager or authorised staff connected with the appointment of the contractor is responsible for leading a contract review process to evaluate satisfaction with a contractors work but also to identify any other concerns which may have arisen. The contract review process should cover the following particular areas:

quality of the work
compliance with health and safety rules within the method statement
effectiveness of communications, this includes with trust staff for example, fire, security, health and safety
any improvements required to this policy

The contract review process should always take place on completion of the agreed works or in the case of contracts for regular work every six months.

Where a contract review indicates that the contractor in question standards are below those required the trust project manager or other manager or staff connected with the appointment of the contractor is to bring this to the immediate attention of the head of estates and facilities in order to agree any action required to avoid using the contractor for future work for example, not to appoint the contractor to carry out any future work

11.3 Appendix C Notice to contractors workplace responsibilities

Appendix C Notice to contractors workplace responsibilities (staff access only) (opens in new window)

Document control

Version: 5.2.
Unique reference number: 181.
Approved by: Corporate policy approval group.
Date approved: 6 February 2024.
Name of originator or author: Head of estates and facilities.
Name of responsible committee or individual: Executive director of finance and estates.
Date issued: 8 February 2024 (extension).
Review date: 31 August 2024.
Target audience: All staff.

Page last reviewed: November 13, 2024
Next review due: November 13, 2025

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