Corporate. Health and Safety Policy. Document Control Summary. Contents

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1 Corporate Health and Safety Policy Document Control Summary Status: Version: Author/Title: Owner/Title: Approved by: Ratified: Related Trust Strategy and/or Strategic Aims Implementation Date: Review Date: Key Words: Associated Policy or Standard Operating Procedures Replacement. Replaces: Health and Safety Policy v1.0 Date: January 2016 Nick Hulme - Health, Safety and Security Advisor Liz Lockett - Associate Director or Quality and Risk Policy and Procedures Committee Date: 21/01/2016 Trust Board Date: 28/01/2016 Risk Management Strategy February 2016 February 2019 Health; Safety; Risk; Assessment Community and/or Lone Working SOP Control of Substances Hazardous to Health (COSHH) SOP Display Screen Equipment (DSE) SOP First Aid SOP Non Clinical Risk Assessment and Management SOP Pregnancy and Parenthood SOP Safe Load Movement SOP Slips, Trips and Falls SOP, Work Equipment SOP Work Related Stress SOP, Working at Height SOP Contents 1. Introduction Purpose Scope Responsibilities The Health and Safety Committee (See Terms of Reference for Detail) Policies and Procedures Process For Monitoring Compliance And Effectiveness Further Information... 8 Page 1 of 8

2 Change Control Amendment History Version Dates Amendments 1. Introduction The Trust recognises and accepts its responsibilities for providing a safe and healthy work place and promoting safe working practices for all its staff, service users and others who may be affected by its activities. It will take all reasonable steps to meet its responsibilities. The Health and Safety at Work etc. Act 1974 and Management of Health and Safety at Work Regulations 1999 require that employers protect all people at work and others not at work including service users and the general public. Employers are required to assess risks and take positive measures to promote health and safety at work and provide employees with a safe place of work, safe equipment, safe systems of work, safe substances and competent fellow workers along with adequate information, instruction, training and supervision. This safety policy sets out the organisational arrangements to enable the Trust and staff to comply with these responsibilities and legal duties imposed by all health and safety legislation. It is supported by a number of additional health and safety policies and standard operating procedures covering a range of topics all of which are applicable to all staff as appropriate to their workplaces and work activities. If you require further information on any of the points or other issues please discuss them with your supervisor/manager or contact one of the people listed for assistance in the contacts section. 2. Purpose The purpose of this policy is to promote behaviour and practices which will minimise danger for all staff, patients, visitors, contractors and general public through the activities of the Trust. The policy has been written in general health and safety terms for all staff and is supported by directorate, departmental and local safety codes to address specific aspects relevant to those areas. You should comply with this policy and other Trust guidance at all times unless you consider that an alternative course of action is safer. If in doubt seek advice. Page 2 of 8

3 The objectives are to: Ensure as far as is reasonably practicable the health, safety and welfare of all affected by Trust activities including employees at work, service users, contractors and members of the public. 3. Scope Comply with all current health and safety legislation, regulations and codes of practice. Provide safe plant, equipment and systems and healthy work conditions. Assess and manage risks including those associated with slips, trips and falls involving staff and others in all working and patient environments to ensure that all risks are identified and minimised as far as is reasonably practicable. Raise the level of staff knowledge on health and safety through the provision of education and training programmes. Monitor and audit that working practices are in accord with relevant policies and procedures. This policy describes the procedures which the Trust has put in place to meet its legal obligations. This policy is the Trust s overarching health and safety policy which is accompanied by a number of relevant SOPs. 4. Responsibilities 4.1 The Trust Board The Trust Board has overall responsibility for the implementation of all aspects of health and safety legislation and to ensure that the organisational commitment to Health and Safety is fully implemented and monitored. The Board recognises that a successful health care organisation ensures that its expertise in service provision is translated into all aspects of its work and that effective health and safety management is an integral part of sound management practice. The Board is therefore committed to the development of comprehensive health and safety policies and management practices which fulfil both the letter and spirit of the law. The Board recognises that to ensure a safe healthy workplace and working environment also requires systems and a culture which supports the identification and control of risks at work and engages staff in promoting safe working practices. The Board believes that the allocation of resources to provide an effective system for managing health and safety will ultimately reduce accidents and ill health and enable our staff to give a better standard of patient care. To this end, the Board will ensure that health and safety objectives will stand alongside all its corporate objectives to enable progressive and sustained improvements in its attainment of the highest possible standards of health and safety. Page 3 of 8

4 4.2 The Chief Executive The Chief Executive has overall responsibility to the board for the co-ordination of health, safety and welfare of employees. In addition the Chief Executive and the Board may designate another executive director to co-ordinate health and safety policy and ensure that decisions are implemented. (The Director of Quality and Clinical Performance has been designated as the lead director delegated by the board with responsibility to the Board for ensuring health and safety matters are corporately identified and addressed). The Chief Executive will ensure as far as it is practicable that there are adequate resources to meet health and safety requirements within the Trust and will continually review the effectiveness of the health and safety policies and those designated with specific responsibilities within the health and safety policies of the Trust. The Chief Executive has overall responsibility for policy formulation, implementation and development, of health and safety and reporting to the board. Such reporting will be on a quarterly basis, currently through the Combined Risk Management Report. 4.3 Executive Directors Board level responsibility for Health and Safety lies with the Director of Quality and Clinical Performance who will report to the board on both routine matters and other significant items of a health, safety and welfare nature. All Executive Directors are responsible for corporate health and safety along with health and safety within their respective directorates and ensuring that every manager under their control complies with this safety policy. 4.4 Directors (Clinical and Non-Clinical), Managers and Supervisors It is the responsibility of every supervisor and manager to implement and abide by this policy and take all reasonable steps to maintain, and where necessary improve health and safety. Managers/supervisors having identified shortcomings in health and safety practices must record the problem areas, and the steps taken to rectify the problems. ALL Managers and Supervisors are responsible for achieving the objectives of this Safety Policy within their own departments. They must ensure that: All new employees are given instructions in departmental safety rules and procedures. All staff are instructed in the health and safety aspects of their duties and ensure that training records for each member are maintained. All new employees (including bank staff, agency staff and temporary staff) receive a local health and safety induction and the relevant checklist is fully completed and forwarded to the HRODE training department for training record purposes. (retain copy locally also). Risk assessments are carried out for work activities in line with agreed procedures and that control measures identified are implemented. Page 4 of 8

5 Health and safety issues are a standing agenda item on all directorate, ward and departmental meetings. Equipment checks are carried out in conjunction with appropriate specialist advisers to ensure that adequate equipment is available and in good order. Accidents and dangerous occurrences are reported, investigated and relevant remedial action is taken. There is co-operation with union appointed Safety Representatives to improve health and safety standards. Managers/supervisors will be given appropriate training to effectively enable them to carry out these responsibilities. Health and safety responsibilities are included in ALL job descriptions for all staff including managers and supervisors A review of staff training is undertaken at least annually and that ALL staff undertake such mandatory training as prescribed by the Trust s mandatory training policy. 4.5 Employees All employees have a responsibility to abide by all the Trust s safety codes and procedures. In consultation with their representatives they have an equal responsibility with management for maintaining safe working practices for their own health and safety. All job descriptions will include specific health and safety responsibilities for all employees at all levels. Employees are entitled to a review of their mandatory training needs including health and safety at least annually and appropriate provision to be made for the identified training. All employees must co-operate with management to maintain safe systems of work at all times, to abide by the requirements of Trust health and safety policies and risk assessments and adhere to the specified control measures so as to prevent injury to themselves, fellow workers and others using Trust facilities and services. Employees also have a responsibility to bring to the attention of management any failings which could be detrimental to themselves, other employees, patients or visitors. 4.6 The Health and Safety Lead The Trust s Health and Safety Lead with support from the Risk Management Team and the Director of Quality and Clinical Performance will be responsible for advising on health and safety issues on behalf of the Chief Executive. 4.7 Statutory Safety Representatives Nominated by recognised trade unions and in turn recognised by the Trust in order that they may keep under review measures taken to ensure health and safety at work of employees and consult with management on the development of policy. 4.8 Corporate Manslaughter and Corporate Homicide Act 2007 This came into force in In brief it applies to any corporate body including NHS bodies and might be applied in any fatal accident prosecution. An organisation will be guilty of an offence of corporate manslaughter if the way in which its activities are managed or organised Page 5 of 8

6 causes a person s death and amounts to a gross neglect of a relevant duty of care owed by the organisation to the deceased. An organisation is guilty of the offence only if the way in which its activities are managed or organised by its senior management is a substantial element of that gross breach. Senior management means the persons who play a significant role in making decisions about how the whole or a substantial part of the activities are to be managed or organised or the actual managing or organising of the whole or a substantial part of those activities. Fines are unlimited and there may also substantial prosecution costs to pay. Charges cannot be against individuals hence no custodial sentences can be imposed. Bodies may also face remedial and/or publicity orders which potentially will incur further costs. 5. The Health and Safety Committee (See Terms of Reference for Detail) The Trust through the Joint Staff Partnership (JSP) will maintain a Health and Safety Committee comprising management and staff representatives (i.e. nominated clinical and non-clinical management members, Trade Union accredited safety reps (full-time officers have an open invitation), independent specialists e.g. Occupational Health and others as necessary to address specific issues. It will meet monthly. The Health and Safety Committee amongst other duties may examine the implications of hazard report forms arising from safety inspections and the results of investigations into accidents and dangerous occurrences together with the remedial actions required. It will provide a forum for discussion and resolution of problems that have not been initially resolved through the intervention of the Safety Representative in discussion with line managers and it has authority to review measures taken to ensure the health and safety at work of employees and to make recommendations to the Trust on the development and approval of new and revised policies and promotion of discussion on H&S issues affecting staff. Health and Safety Committee - List of Members and Distribution of Minutes A list of members of the committee will be included within the minutes of each meeting which will be widely distributed and available for ALL staff to access. Who is Your Safety Representative? (Statutory Safety Representatives) The Trust will recognise statutory safety representatives nominated by recognised trade unions and will provide all reasonable facilities and time to enable them to fulfil their role. They will keep under constant review measures taken to ensure health and safety of employees, and be responsible for consulting with management on the development of policy. Page 6 of 8

7 Overview of arrangements: Board Trust Management Team The Board, in particular the Chief Executive has ultimate responsibility for Trust Health and Safety issues. The Trust Management Team (TMT) will advise the Chief Executive of any actions necessary and of decisions taken to meet Health and Safety and will bring these to the attention of the Board for ratification. Members of the TMT will advise the Chief Executive of specific trust, directorate and departmental health and safety issues. The Joint Staff Partnership (JSP) and the Health and Safety Committee may also provide advice and raise concerns with the Chief Executive and/or FMT members. Quality Governance Committee Reporting & stage 2 policy / SOP approval route* Joint Staff Partnership Information and reporting route* The H&S committee is a sub-committee of the JSP to which it reports. It will consider issues from the TMT or the JSP and will be a forum for discussion between staff and management representatives. The H&S committee reports to / feeds-back to staff / management through the JSP and also reports to Quality Governance Committee through which policies and standard operating procedures are directed for approval prior to Board ratification. Health & Safety Committee* (a sub group of JSP) Consultation & stage 1 policy/sop approval (* see terms of reference for detail) The H&S Committee, as a committee of the JSP is an advisory group which considers Health and Safety issues raised by staff, managers, trades union representatives or staff representatives and occupational health. All staff have responsibility for their own and others health and safety and can and should therefore raise any health and safety concerns they have with their line manager a staff representative or relevant contact or through the Occupational Health Service provider. Management reps Accredited trade union reps Occ. health & other specialists Where appropriate, issues which require further management attention will be referred to the H&S Committee who will advise management of the action needed to overcome the concerns. 6. Policies and Procedures Standard Operating Procedures (SOP) This policy permits the use of Standard Operating Procedures to address the multitude of Health and Safety topics which arise in the Trust where it is considered that this is a preferred format. Policies may continue to be used where the subject matter merits. Relationship to Other Policies The Trust has a range of policies and procedures covering a wide range of subjects. There are also strong links between documents, for example nursing procedures, Human Resources and Health and Safety; therefore they must be implemented jointly. Directorate and Departmental Safety Codes and Procedures In addition each Directorate, Department and significant activity may have its own safety code giving detailed safety procedures to be observed by staff normally working within the Page 7 of 8

8 respective areas and others e.g. maintenance staff and contractors not normally present but who visit on occasions. Such other safety codes and procedures will be read and implemented along with this Trust health and safety policy. Applying the Safety Policies All safety policies, procedures, information, codes etc. will apply to all staff at all times irrespective of status, including student nurses, other trainees, temporary workers, bank staff, locum staff etc. irrespective of hours worked and on-call staff. It will also apply to contractors and volunteers. Resolving Health and Safety Problems In the first instance it is preferred that health and safety problems are discussed directly with managers as health and safety is always an essential and integral function of management. If the matter is unresolved you may wish to raise the issue with the Health and Safety Lead or your union safety representative. Alternatively, on raising the issue with your manager you may concurrently involve either your union safety representative or Health and Safety Lead or both. Please note that it is courtesy to involve your manager as it will usually be necessary to include and involve them in order to resolve issues. The Trust will endeavour to minimise effects upon health and safety of employees etc. and will aim to identify solutions and prioritise resources to address identified issues. Access to Information All health and safety policies are available on the Trust website and are the preferred source as these are the most up to date. Care should be exercised as to ensure any copy from another source or hard copy is the most up to date version. 7. Process for Monitoring Compliance and Effectiveness Compliance to this policy and associated SOPs will be monitored through annual audits, incident reporting, mandatory training, offered advice, published documents and committees and meetings. 8. Further Information A full list of health and safety policies is available on the Trust website section at: Examples include but are not limited to Non Clinical Risk Assessment and Management, Safe Load Movement, Display Screen Equipment, Fire, First Aid, Pregnancy and Parenthood. Please note that many other policies both clinical and non-clinical also include health and safety aspects e.g. clinical waste. The Health and Safety Executive website is a useful source of information. Page 8 of 8

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