Health and Safety Policy

Transcription

1 Health and Safety Policy Document control This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of the document are not controlled. Ref Number: Version: 1 Status: Pending Author: H Davey Approval Governing Body Date Approved 22 March 2016 body Date Issued 22 March 2016 Review Date March 2018 Contact for Review: Corporate Affairs team Page 1 of 21

2 Prepared by This Policy has been prepared and reviewed by the CCG Corporate Affairs team. Impact Assessment Consultation Authorised by SERCO ASP Health and Safety Team Pending approval by the Governing Body What is it for? Who is it aimed at and which settings? Evidence Other relevant approved documents References See section 6 Statutory or Evidence Base Training and competences Monitoring and Evaluation This policy will be monitored and reviewed for effectiveness by the Corporate Affairs team on a regular basis. Appendix 1. Health & Safety General Risk Assessment 2. Equality Impact Assessment Page 2 of 21

3 Contents Section Title Page 1.0 Introduction Scope of this Policy 5.0 Duties and Responsibilities Organisation of Health and Safety Local Arrangements for Health and Safety Statutory or Evidence Bases Dissemination and Implementation Overall responsibility for the Document Monitoring and Review 11 Appendix 1- Health and Safety General Risk Assessment 1 Appendix 2 - Equality Analysis Initial Assessment 21 Page of 21

4 1.0 INTRODUCTION 1.1 NHS South Norfolk Clinical Commissioning Group (CCG) is committed to providing safe, effective and supportive services and has developed a comprehensive risk management strategy. The CCG believes that its workers are their most important asset and as such accept responsibility for ensuring, so far as is practicable, the health, safety and welfare of all our patients, service users, workers and others who may be affected by our activities. 1.2 The CCG recognises that the maintenance of a safe place of work and safe working environment is critical to continued success and accordingly, we view our responsibilities for health, safety and welfare as the upmost important objective. The CCG recognises the need for development of effective Health and Safety management. The CCG s policy is to comply with relevant legislation as a minimum, and exceed this wherever possible to improve the health, safety and wellbeing of any person (staff, patient, visitor, agency or contractor) who may be affected by the organisations work activities. 1. The CCG requires all workers to equally accept their responsibilities as part of the development of a true safety culture. The organisation aims to ensure the achievement of high standards in relation to the provision of health and safety arrangements and the continued development of the safety culture. 1.4 The nature of our activities means that a wide range of risks exist, but through the implementation of this policy, directors, managers and workers will ensure that all significant risks to health are reduced so as far as is practicable. The management of health and safety is an integral part of every manager's role. All managers are required to adopt the approach laid out in the Management of Health and Safety at Work Regulations These state the need for hazard identification, risk assessment and the implementation of control strategies aimed at reducing accidents, injuries and ill health. It is also an integral component of the Code of Conduct for NHS Managers 2002, which applies to all NHS managers. Managers should be familiar with the NHS Health, Safety and Welfare at Work 2010 Essential Guidance 1.5 The requirements of the Health and Safety at Work etc Act 1974 and other related and relevant legislation and guidance will form part of the minimum standards to be achieved. These standards aim to ensure the health, safety and welfare of workers, patients, service users, members of the public and others who use the organisation s facilities and services. This will include the provision of: a safe working environment safe entry and exit to all workplaces adequate occupational health and welfare facilities safe systems of work safe plant and equipment adequate training, information, and supervision for employees whilst at work. Page 4 of 21

5 1.6 The CCG is committed to the continuing development of arrangements to support health and safety, and a proactive safety culture. The CCG will ensure that sufficient resources are available to fulfil these objectives. 1.7 Through the provision of training, information, and supervision, the organisation will ensure that all workers are competent to maintain high standards of health and safety in all of our activities. 1.8 The CCG will actively seek the participation of all workers, including formally through recognised workers organisations, to ensure appropriate arrangements are made for consultation and monitoring. In addition, any issues relating to health and safety should be brought to the attention of managers as soon as possible so that an early remedy can be sought. 1.9 The effectiveness of this policy will be monitored and reviewed by the Corporate Affairs team. Matters of particular concern will be reported on to SERCO ASP Risk Support Services by the Corporate Affairs team. Safety aims and objectives will be set and performance will be monitored against these objectives This policy supports managers to manage health and safety within their areas of responsibility, which includes assessment and monitoring of the effectiveness of control measures introduced to reduce identified risks to acceptable levels. Managers will ensure that any changes to policy or procedures are brought to the attention of all workers Workers are reminded of their statutory duty, to take reasonable care for the health and safety of themselves and others who may be affected by their actions. This includes co-operating in procedures introduced in the interests of health and safety and not interfering with or misusing anything provided in the interests of health and safety. Only with the co-operation and involvement of every worker can the requirements of this policy be met Expert health and safety advice is provided by the SERCO ASP Risk Support Services and other agencies as appropriate. It is recognised that there are links between health and safety, governance, quality and risk management and effective liaison and co-ordination of efforts in all these areas will be maintained to ensure safety of all service users, workers and visitors. 2.0 SCOPE OF THIS POLICY 2.1 This policy applies to all employees, Interim and Consultancy staff, Governing Body members whilst conducting CCG business, volunteers and, and all other people working at the CCG s premises regardless of role or occupational responsibility. 2.2 This policy should be read in conjunction with all of the organisation s Health and Safety related policies, and in conjunction with specific occupational or departmental Health and Safety documentation including policies and procedures. Page 5 of 21

6 .0 DUTIES AND RESPONSIBILITIES.1 The CCG accepts ultimate and overall responsibility for all matters relating to health and safety. The CCG s Governing Body is responsible for ensuring the health and safety policy is implemented, communicated and carried out through the appropriate management and committee channels.2 The CCG has delegated responsibility for ensuring the programme of health and safety work is implemented across the organisation, and ensuring policies are in place to cover:- Recording and investigating accidents and near misses including the requirements of the Reporting of Injuries, Diseases, Dangerous Occurrences Regulations 201 (RIDDOR) Fire precautions and fire drills Emergency and evacuation procedures First aid Liaison with ; the landlord and agents of the landlord providing services on the premises Maintenance of records. The Corporate Affairs team, supported by NHS Property Services, has operational management responsibility for:- Fire precautions and fire drills Emergency and evacuation procedures First aid Liaison with ; the landlord and agents of the landlord providing services on the premises Maintenance of records Recording and investigating accidents and near misses including the requirements of the Reporting of Injuries, Diseases, Dangerous Occurrences Regulations 201 (RIDDOR).4 Expert, competent health and safety advice and support is currently provided by SERCO ASP Risk Support Services..5 Directors and Managers are responsible for ensuring that the Health and Safety policy is adhered to in their area of activity and that work activities are carried out, in so far as is practical, safely and without risk to health. Responsibilities include:- Ensuring effective communication of health and safety matters within their area of responsibility Releasing staff for health and safety training and involvement in health and safety development activities Ensuring that hazards are identified, risk assessments completed and acted upon Ensuring that staff are aware of their responsibilities and meet these responsibilities for their own health and safety and that of others Ensuring that their staff work co-operatively with the Health and Safety Advisor in the discharge of the health and safety work programme Page 6 of 21

7 .6 Employees have a legal duty, and are expected to:- Take reasonable care of their own health and safety and that of other persons affected by their acts or omissions Co-operate with the CCG s Corporate Affairs team to enable to carry out its responsibilities Make proper use of health and safety facilities provided and attend and participate actively in health and safety training as required Comply with the requirements of health and safety policies and procedures Inform their line manager without delay of any work situation that might present a serious and/or imminent danger. In addition individuals should also notify any shortcomings in the health and safety arrangements to their line manager..7 Contractors and Partners The CCG will require all commissioned healthcare providing services to NHS patients and service users to have a suitable and sufficient health and safety policy and robust health and safety management procedures. This will include written standard operating procedures, safe systems of work and permits to work where required for the activity undertaken. The CCG will also require to carry out investigations into any patient safety or health and safety incident or accident and to fully participate and share in learning outcomes.8 Health and Safety Representatives / Representative of Employee Safety (ROES) Health and Safety representatives may be appointed by trade unions to represent an identified group of workers in the workplace. Representatives of Employee Safety (ROES) can only be used where employees are not covered by a Trades Union body. (see The Health and Safety (Consultation with Employees) Regulations 1996) They have the right to consult with managers and SERCO ASP specialist advisors on health and safety matters. They can make inspections of the workplace (by giving reasonable notice to the organisation), investigate incidents / accidents and complaints by workers about health and safety matters. 4.0 ORGANISATION OF HEALTH AND SAFETY 4.1 The CCG considers and monitors the organisation s approach to managing health and safety and advises the Governing Body on appropriate matters. This assists the CCG to comply with health and safety regulations, NHS Fire code and to achieve requirements within the Risk Management Strategies. 4.2 The Governing Body agenda should include an item to allow communication and consultation at a local level with regard to local health, safety and welfare arrangements. Page 7 of 21

8 4. Specialist Advice Health, safety, fire and security advice is provided by the SERCO ASP Risk Support Services. Liaison between the organisation and SERCO ASP on health and safety matters will be between the Corporate Affairs team and the SERCO ASP Safety Manager. 5.0 LOCAL ARRANGEMENTS FOR HEALTH AND SAFETY 5.1 The local arrangements for Health and Safety are detailed below in alphabetical order. Additional information relating to risk assessment may be found in Appendix Business Continuity Please refer to the CCG s Business Continuity Plan. 5. Claims Management Please refer to local line management for local arrangements and the CCG Claims Handling Policy and Procedure. 5.4 Competent Health & Safety advice All employees have access to SERCO ASP Safety Team directly for competent advice and further details may be found at Contractors Contact NHS Property Services the local Estates provider for further information via main reception 5.6 Consultation with employees As per local arrangements, further details are available from the Corporate Affairs team. 5.7 Conflict Resolution Conflict Resolution training is available from SERCO ASP Safety Team. 5.8 Control of Substances Hazardous to Health COSHH risk assessments are undertaken by local risk assessors with additional assistance from SERCO ASP Safety Team. See Appendix Display Screen Equipment (DSE) Managing the risks associated with Display Screen Equipment (DSE) are detailed in Appendix 1 General Risk Assessments 5.10 Driving for work Managing the risks associated with employees who drive to work are detailed in Appendix 1 General Risk Assessments Emergency Planning The CCG has a Business Continuity Plan in place. Page 8 of 21

9 5.12 Fire Safety including Fire Risk Assessments Refer to NHS Property Services for further information and a copy of the fire risk assessment. See Appendix First Aid Local arrangements are based on risk assessment (see Appendix 1), and are assessed as low risk. Information regarding the location of first aid boxes is included on Health and Safety posters which are displayed in all common areas including the reception area and staff kitchen. First Aid boxes are maintained by nominated First Aiders and are available in shared locations as well as in the CCG s Kitchen facility Health & Safety Further advice and support may be obtained from the SERCO ASP Safety Team. Further details may be found at:- Additional Health & Safety information in an A to Z format may be found at: Health & Safety Audits May be undertaken by recognised Safety Representatives, Line Management and SERCO ASP Safety Team by arrangement Health & Safety Training Undertaken as required and supported by the SERCO ASP Safety Team in conjunction with the Corporate Affairs team Incident / Accident reporting / investigation / RIDDOR All incidents and accidents must be recorded as soon as possible using the accident book available within the CCG from the Corporate Affairs Team. Immediate investigation and remedial action (if required) is the responsibility of the immediate Line Manager and details recorded with the accident form Completed accident forms, RIDDOR forms and details to any investigation are returned and securely stored by the Corporate Affairs Team. Accident reports including RIDDOR forms and investigations will be reviewed by Serco ASP Safety Team as required and any trends highlighted. A summary of accidents will be included in the SERCO ASP Health & Safety Annual Report to the CCG Any accidents that are RIDDOR reportable are reported by the immediate Line Manager as soon as possible and the Corporate Affairs team and the SERCO ASP Safety Team informed as soon as possible. RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 201) is the law that requires employers, and other people in control of work premises, to report and keep records of: work-related accidents which cause death; work-related accidents which cause certain serious injuries (reportable injuries) diagnosed cases of certain industrial diseases; and certain dangerous occurrences (incidents with the potential to cause harm). Page 9 of 21

10 5.20 Further details and report forms relating to RIDDOR may be found at Further advice and assistance is available from SERCO ASP Safety Team Mandatory training (Health & Safety) This is undertaken as per the CCG s Training and Development Policy. Further details are available on the staff section of the CCG website Moving & Handling See Appendix 1 and specialist advice and assistance with complex risk assessment is available from SERCO ASP Safety Team. 5.2 Occupational Health This service including specialist work-health advice, support and health surveillance programmes may be accessed via a Manager referral process with further information available from the Corporate Affairs team. This service is provided by Insight Healthcare. Further details may be found at An independent counselling service is also available through Insight Wellbeing on or Risk Assessment (Health and Safety) General Health and Safety Risk Assessments for office locations may be found in Appendix 1. Further information may be found in the Risk Management Policy. Additional specialist advice and support is available from the SERCO ASP Safety Team Shared Premises Refer to your line manager for details of the local arrangements Wellbeing at work Further information is available via the Corporate Affairs team and from the NEL CSU Human Resources team, and supported with the provision of an Occupational Health service and external counselling service. See Appendix 1 re Stress risk assessment. Page 10 of 21

11 6.0 STATUTORY OR EVIDENCE BASE Health & Safety at Work etc Act 1974 Management of Health & Safety at Work Regulations 1999 The Safety Representatives and Safety Committees Regulations 1997 The Health and Safety (Consultation with Employees) Regulations 1996 Care Quality Commission The fundamental standards Managing for Health & Safety HSE HSG 65 NHS Employers Workplace health and safety standards (revised July 201) Leading Health and Safety at Work of Injuries, Disease, Dangerous Occurrences Regulations Corporate Manslaughter and Corporate Homicide Act Further information may also be found at: DISSEMINATION AND IMPLEMENTATION 7.1 This policy will be disseminated through the corporate team briefing document and will be available on the organisation s intranet. 8.0 OVERALL RESPONSIBILITY FOR THE DOCUMENT The lead contacts for this document are the Corporate Affairs team. 9.0 MONITORING AND REVIEW This document will be kept under review by the Corporate Affairs team and SERCO ASP Safety Manager. It will be reviewed following any significant changes in new national guidance or local operational arrangements and by the review date indicated on the front page (see Document Control Details). In addition to the annual review of the effectiveness of this policy, monitoring within the workplace will be carried out by: Page 11 of 21

12 Analysis of sickness absence data will be carried out by the organisation s HR team in consultation with the Optima Health Occupational Health Service Nurse Advisers. Analysis of reported incidents for health and safety issues, to include significant and high risks and emergent trends. which will be included in the SERCO ASP Annual Health & Safety Report Opportunities for audit from external inspection and assessment authorities e.g. HSE, Norfolk Fire and Rescue Service, Care Quality Commission, NHS Counter Fraud and Security Service. Evidence of benefit from health and safety training, through assessment of delegate feedback to training received and through observation of improved practice within the workplace. Page 12 of 21

13 Appendix 1 Health and Safety General Risk Assessment Risk Assessment Name General Risk assessment _ Date of Initial Assessment Assessor Name _Richard Sharman_(SERCO ASP Safety Manager) Review Date _ Annually_ Risk Rating quantified in terms of Likelihood and Consequence (L x C) (refer to detailed risk descriptors and risk matrix in the Risk Management Framework) Page 1 of 21

14 Ref no Description of Hazard & Risk Hazard = Anything with the potential to do harm Risk = The likelihood of that harm occurring 1 Desk based activities including use of IT equipment Staff risk posture problems and pain, discomfort or injuries, e.g. to their hands/arms, from overuse or improper use or from poorly designed workstations or work environments. Headaches or sore eyes can also occur, e.g. if the lighting is poor. 2 Slips, trips and falls within the workplace. Persons at risk may be injured if they trip over objects or on spillages. Who might be harmed? Any individual who using this type of equipment including staff, visitors and Any individual who using the premises including staff, visitors and Existing controls - DSE Assessments at are carried out for all users of DSE and reviewed as required. - Work planned to include change of activity or regular breaks. - Employer pays for eye tests for display screen equipment users. - Employees receive mandatory Back Care Training as part of Induction training or as a separate course, which covers setting up of DSE Workstations and correct posture and procedures whilst working at display screens. - Workstations are equipped with correct desks, adjustable height screens, fully adjustable chairs with suitable foot and wrist rests. - Additional information and advice is available from SERCO ASP Safety Team and Optima Health Occupational Health Service. - Staff encouraged to maintain good housekeeping. - No items to be stored within corridors and walkways. - All spillages are cleaned up as they occur. - All areas are well lit. - All rubbish / waste products are removed from the workplace on a regular basis by cleaning contractor. - All physical defects reported as they occur and repaired appropriately. Risk Rating (L x C) L = 2 C = of 6 = L = 2 C = of 6 = Mitigation Action plan All managers to ensure and remind staff that all control measures are being followed. Any incidents to be reported using incident reporting procedure and All managers to ensure and remind staff that all control measures are being followed. Any incidents to be reported using incident reporting procedure and Timescale Page 14 of 21

15 Ref no Description of Hazard & Risk Hazard = Anything with the potential to do harm Risk = The likelihood of that harm occurring Manual Handling. Employees risk injuries or back pain from handling heavy/bulky objects, e.g. deliveries of paper. Who might be harmed? Any individual who using the premises including staff, visitors and Existing controls - Qualified First Aider and suitably stocked First Aid Box located within building. -Trolley used to transport boxes of paper and other heavy items when collecting deliveries, etc. - Loads broken down into small / lighter components as appropriate - Heavy items are located on appropriate height shelves. - Employees undertake Manual Handling / Back Care Training as part of Induction training to the organization. - Further training is carried out as required to ensure staff are carrying out the appropriate procedures when undertaking Manual Handling activities. - Additional support available from SERCO ASP Safety Team 4 Working from height Staff -It is not anticipated that working at height will take place within the working environment by staff. - Any requirement to work at height i.e. light bulb changes is carried out by the local Estates provider, further details available from the local Building Manager. Risk Rating (L x C) L = 2 C = of 6 = L = 1 C = 5 of 5 = Mitigation Action plan All managers to ensure and remind staff that all control measures are being followed. Any incidents to be reported using incident reporting procedure and If this was to occur, further risk assessment would be required dependant on the activity to be undertaken. Further advice is available from the SERCO ASP Safety Team. Timescale Page 15 of 21

16 Ref no Description of Hazard & Risk Hazard = Anything with the potential to do harm Risk = The likelihood of that harm occurring 5 Young persons, Disabled workers or New & Expectant Mums. 6 Fire Staff could suffer serious or fatal injuries from smoke inhalation/burns. 7 Work Equipment inc electrical safety Staff could get electrical shocks or burns from using faulty electrical equipment. Staff may also suffer injury from moving parts of equipment or unbalanced equipment. Who might be harmed? Any individual who using the premises including staff, visitors and Any individual who using the premises including staff, visitors and Any individual who using the premises including staff, visitors and Existing controls Managers to undertake specific Risk Assessment in relation to issues as they arise. No initial score is available for this risk as the specifics around the person and role will be varied and individual each time this risk is assessed. - Each building has a comprehensive Fire Risk Assessment (FRA) which will detail relevant information relating to fire safety for the building. - Further information is available from the Building Manager. - Fire safety training is included in the Corporate Induction training, and refresher fire safety training is coordinated by the Corporate Affairs team. -All new equipment checked before first use to ensure there are no obvious accessible dangerous moving parts. - Siting of the equipment does not cause additional hazards. - All electrical equipment is PAT tested on receipt and on a regular schedule. - Staff trained in use of equipment where necessary. - Staff are encouraged to spot and report any defective plugs, discoloured sockets or damaged cable/equipment to Risk Rating (L x C) L = 1 C = 5 of 5 = L = 2 C = of 6 = Mitigation Action plan Dependent on the individual and the situation All managers to ensure and remind staff that all control measures are being followed. Any incidents to be reported using incident reporting procedure and All managers to ensure and remind staff that all control measures are being followed. Any incidents to be reported using incident reporting procedure and Timescale Page 16 of 21

17 Ref no Description of Hazard & Risk Hazard = Anything with the potential to do harm Risk = The likelihood of that harm occurring 8 Scalds and/or burns preparing hot drinks and food. 9 Security Potential for intruders leading to theft of personal belongings / company equipment or personal injury. Who might be harmed? Any individual who using the premises including staff, visitors and Any individual who using the premises including staff, visitors and Existing controls the Building Manager. - Defective equipment taken out of use safely and promptly replaced. - All employees complete DSE Risk Assessment - Qualified First Aider and suitably stocked First Aid Box located within building. - Estates provider to undertake fixed wiring electrical test every five years - Kitchen area provided for the preparation of hot drinks. - Use of kitchen covered within local induction process. - Qualified First Aider and suitably stocked First Aid Box located within building. - Access to building through main door only. - Main door secured outside of working hours. - Visitors escorted as required within the building. - Log of all visitors maintained by reception. - Employees have access to lockable cabinets to secure small personal items and all appropriate items are locked away at the end of the working day. - All staff to wear ID badges at all times. Risk Rating (L x C) L = 2 C = of 6 = L = 2 C = of 6 = Mitigation Action plan Any incidents to be reported using incident reporting procedure and Any incidents to be reported using incident reporting procedure and Timescale Page 17 of 21

18 Ref no Description of Hazard & Risk Hazard = Anything with the potential to do harm Risk = The likelihood of that harm occurring Who might be harmed? 10 Lone working Staff and 11 Driving for work Staff and Existing controls -Electronic calendars in Outlook kept up to date, with appropriate details of visit. - Work mobile phones provided - Call back / buddy system utilized as appropriate. - Visits risk assessed as required and taken e.g. two staff if considered necessary. - Corporate Affairs team maintain list of car details and emergency contact details of staff. - HR procedure for annual checking of driving licence and car compliance i.e. insurance, MOT and registration. - Importance of posture covered as part of Back awareness training and in Induction training Risk Rating (L x C) L = 2 C = of 6 = L = 2 C = of 6 = Mitigation Action plan All managers to ensure and remind staff that all control measures are being followed. Any incidents to be reported using incident reporting procedure and All managers to ensure and remind staff that all control measures are being followed. Any incidents to be reported using incident reporting procedure and Timescale Page 18 of 21

19 Ref no Description of Hazard & Risk Hazard = Anything with the potential to do harm Risk = The likelihood of that harm occurring Who might be harmed? 12 Stress Staff and 14 Control of substances hazardous to health (COSHH) Any individual who using the premises including staff, visitors and Existing controls -Wellbeing initiatives facilitated by Corporate Affairs team, - All employees to receive regular 1 to 1 s with their line manager - Regular communication of relevant information to employees as appropriate -Occupational Health Services available from Insight Healthcare -Insight counselling service available to employees tel Stress Awareness for Managers training available on request from the SERCO ASP Safety Team. HR Policies relating to No bullying and Flexible working. -It is anticipated in an office environment that substances that require assessment as required by the COSHH regulations is limited. If any substances are identified by employees, then a Material Data Safety sheet (MSDS) must be obtained from the supplier and further advice obtained from the SERCO ASP Safety Team. Risk Rating (L x C) L = 2 C = of 6 = L = 1 C = of = low Mitigation Action plan All managers to ensure and remind staff that all control measures are being followed. Any concerns with individuals or teams to be raised by Line management with HR Team and All managers to ensure and remind staff that all control measures are being followed. Any incidents to be reported using incident reporting procedure and Timescale Page 19 of 21

20 Ref no Description of Hazard & Risk Hazard = Anything with the potential to do harm Risk = The likelihood of that harm occurring 15 Building related issues including asbestos, legionella and fixed electrical testing. Who might be harmed? Any individual who using the premises including staff, visitors and Existing controls Appropriate surveys and assessments should be undertaken dependent on the landlord / tenant agreement. Further information should be sought initially from the Building manager or Estates provider. Further technical advice is available from the SERCO ASP Safety Team Risk Rating (L x C) L = 2 C = of 6 = Mitigation Action plan Site audits to be arranged late with assistance of SERCO ASP Safety Team to determine status of compliance of these issues Timescale Page 20 of 21

21 Appendix 2 - Equality Analysis Initial Assessment Title of the change proposal or policy: Health and Safety Policy Brief description of the proposal: This Health and Safety policy applies to all employees, Interim and Consultancy staff, Governing Body members whilst conducting CCG business, volunteers and, and all other people working at the CCG s premises regardless of role or occupational responsibility. Name(s) and role(s) of staff completing this assessment: Heidi Davey Corporate Affairs and Complaints Manager. Date of assessment: Please answer the following questions in relation to the proposed change: Will it affect employees, customers, and/or the public? Please state which. This policy will be applied to all employees, Interim and Consultancy Staff, Governing Body members whilst conducting CCG business, volunteers and, and all other people working at the CCG s premises regardless of role or occupational responsibility. Is it a major change affecting how a service or policy is delivered or accessed? NO Will it have an effect on how other organisations operate in terms of equality? NO If you conclude that there will not be a detrimental impact on any equality group, caused by the proposed change, please state how you have reached that conclusion: N/A Page 21 of 21