Trust Policy and Procedure Document Ref. No: PP (16)282

Transcription

1 Trust Policy and Procedure Document Ref. No: PP (16)282 Slips, Trips and Falls for Staff and Others For use in: For use by: For use for: Document owner: Status: All areas of the Trust All members of staff To ensure slips, trips and falls for staff and others are appropriately managed throughout the Trust. Health, Safety and Risk Manager Approved Purpose of this Document: The purpose of this document is to enable the West Suffolk NHS Foundation Trust (WSFT) to ensure so far as is reasonably practicable that it provides a safe working environment free from slip, trip and fall hazards. Ensuring all potential slip, trip and fall hazards in the workplace are identified, and where necessary the appropriate risk assessments and risk reduction methods are in place at all times. The implementation of this policy and procedure will help the Trust and its employees to meet their obligations under the Health and Safety at Work etc. Act 1974, the Management of Health and Safety Regulations 1999 and the Workplace (Health, Safety and Welfare) Regulations Contents Page Introduction 1-2 Scope of the policy 2 Definitions 2 Relevant legislation and Standards 2-3 Roles and responsibilities 3-5 Risk Assessment 5-6 Training Expectations 6 Incident reporting 6 Monitoring Compliance 7 Appendices Appendix A: Slips and Trips Causation list 9-10 Appendix B: Action Chart for Slips and Trips 11 Appendix C: Generic Slips, Trips and Falls Risk Assessment Appendix D: Working at height Introduction Slips, trips and falls are the most common of workplace hazards and make up over a third of all specified (major) injuries. Over 13, 000 workers suffered serious injury because of a slip or trip leading to a fall last year. Last year 54% of all reported specified (major) accidents in the Health Service were caused by a slip, trip or fall, the national average is 34%. The human cost of slip, trip and fall accidents are usually easy to see. But not always so apparent is the price the NHS pays both as an organisation and as an employer. Treatment costs currently stand at 133 million per year and with 90% of specified (major) injuries resulting in a broken bone, the NHS also has the expense of long term staff absences. Source: Health, Safety and Risk Manager Status: Approved Page 1 of 19

2 Within the WSFT there were 65 incidents reported relating to slips, trips and falls of staff and others (persons not in the Trusts employment e.g. members of public, contractors and visitors) during the financial year 2015/16. Of these there were four that resulted in a serious injury or more than seven days sickness absence as a result of the incident. These resulted in notifying the Health and Safety Executive (HSE) under the requirements of Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 2013 Whilst there are significantly more patient falls reported within the WSFT these are adequately covered by the requirements of the Clinical Slips, Trips and Falls Policy PP202. This policy outlines the duties, responsibilities and procedures that are required within the WSFT in order to manage the risks associated with slips, trips and falls amongst staff and others. The Health and Safety Executive (HSE) have recognised slips, trips and falls as a significant risk and their Shattered Lives campaign provides information and resources that are industry specific in order to highlight the impacts that the consequences of slips, trips and falls can have on individuals and the organisation. These accidents can be cut dramatically through the planning and positive management during new build and refurbishment together with good housekeeping. Slips, trips and falls are not inevitable part of the healthcare industry - they can and should be prevented. Everyone in the workplace has a part to play when it comes to preventing slips, trips and falls for staff and others, from the person who designed the building to the people working inside of it. 2. Scope of policy This policy applies to all staff and others and incorporates the processes required for the management of slips, trips and falls for staff and others within the WSFT. 3. Definitions a) Slip: To slide accidentally causing the person to lose their balance. This is either corrected or causes a person to fall. b) Trip: To stumble accidentally over an obstacle, causing the person to lose their balance. This is either corrected or causes a person to fall. c) Fall: An event which results in the person coming to rest on the ground or another surface lower than the person, whether or not an injury is sustained. 4. The Relevant Legislation and Standards a) Health and Safety at Work etc. Act 1974: Employers have to ensure so far as is reasonably practicable that their employees and others are kept safe from harm and that their health is not affected. This means slip, trip and fall risks must be adequately controlled to ensure people do not slip, trip and fall. Employees must use any safety equipment provided and must not cause danger to themselves or others. Manufacturers and suppliers have a duty to ensure that their products are safe. They must also provide information about appropriate use. b) The Management of Health and Safety at Work Regulations 1999 Build on the requirements of the Health and Safety at Work etc. Act 1974 and include duties on employers to assess risks (including slip, trip and fall for staff and others) and where necessary take action to safeguard health and safety. c) The Workplace (Health, Safety and Welfare) Regulations 1992 So far as is reasonably practicable, every floor and surface of every traffic route in a workplace shall be suitable for the workplace and work activity, kept in good condition, kept free from obstructions and free from any article or substance which may cause a person to slip, trip or fall. d) Health and Social Care Act 2008 (Regulated Activities) Regulations 2014-Regulation 15: Premises and Equipment. Source: Health, Safety and Risk Manager Status: Approved Page 2 of 19

3 The intention of this regulation is to make sure that premises where care and treatment are delivered are clean, suitable for the intended purpose, maintained and where required, appropriately located. e) Health and Social Care Act 2008 (Regulated Activities) Regulations 2014-Regulation 17: Good Governance The intention of this regulation is to make sure that providers have systems and processes in place that assess, monitor and mitigate any risks relating to health, safety and welfare of people using the services and others. 5. Roles and Responsibilities The overall accountability for the effective management of risk associated with slips, trips and falls for staff and others within the WSFT lies with the Chief Executive. At an operational level, the Executive Chief Nurse has responsibility for governance and risk management including health and safety and they will liaise with the Executive Medical Director for medical issues relating to clinical risk management. The WSFT s governance structure for managing risk and the roles and responsibilities of other managerial and clinical staff are outlined in the document Strategy and Policy for Risk Management (PP093). The responsibilities of all employees to maintain a safe working environment and exercise care for their safety and that of others are detailed in the Health, Safety and Welfare Policy (PP018). Of particular relevance to the management of risk associated with slips, trips and falls for staff and others: a) The Chief Executive is to ensure that: So far as is reasonably practicable any place of work under the WSFT s control is safe and without risks to health. Provisions for all WSFT controlled sites are in place to ensure safe access and egress. The mechanisms are in place to ensure that staff and others working for the WSFT are made aware of their responsibilities under this policy. The effectiveness of the policy is monitored via the Health and Safety Committee. b) The Executive Lead for Health and Safety: The Executive Lead for Health and Safety for the West Suffolk NHS Foundation Trust is the Executive Chief Nurse. The Executive Lead for Health and Safety will assist in ensuring high standards of health and safety are achieved and is responsible for monitoring the Trust s health and safety performance while promoting health and safety at an Executive level. Other specific duties will include ensuring that the following are carried out:- Raising issues of concern to the Chief Executive and TEG that the Health, Safety and Risk Manager and Health and Safety Committee deem to be of a serious nature and require escalation. Ensuring that the Trust has adequate resources in place to promote, monitor and manage health and safety. c) Executive and Clinical Directors are to: Ensure that General Managers, Deputy General Managers, Service Managers and Heads of Department are made aware of this policy and support in implementing and enforcing the policy throughout their areas of responsibility. d) General Managers, Deputy General Managers, lead Clinicians, Service Managers, Matrons and Heads of Department are to ensure: That all staff are made aware of the requirements of the slips, trips and falls policy for staff and others and comply with the safe systems that are contained within it. Source: Health, Safety and Risk Manager Status: Approved Page 3 of 19

4 That all staff receives appropriate information, instruction, training and supervision to enable them to utilise the appropriate safe systems for managing slips, trips and falls for staff and others within the workplace. Review and monitor all contractor work within their areas of responsibility to ensure work is not causing any hazards including those posed from slips, trips and falls. An incident form is completed on Datix for every slip, trip and fall incident relating to staff and others and any near miss incidents occurring on site. These forms must be completed according to the Trust s incident policy (PP105 and 105b). That there are at least one health and safety link person in every department within their area of responsibility that have received the appropriate training (RSPH Level 2 award in Health and Safety) in order to carry out work place inspections and risk assessments. Risk assessment and health and safety link person training is carried out by the Health, Safety and Risk Manager on ex Apply the generic slips, trips and falls for staff and others risk assessment to their areas of responsibility and ensure the control measures are fully implemented (Appendix C & Appendix D for guidance on Working at Height procedures and undertaking risk assessments) That all incidents reported on datix no matter the rating involving slips, trips and falls for staff and others are investigated and the necessary actions carried out within the agreed timescales. That appropriate action is taken when workplace inspections / audits or general observation indicates the non-adherence to this policy and procedure for controlling slips, trips and falls for staff and others in their area of responsibility. d) The Health, Safety and Risk Manager will: Review incidents relating to slips, trips and falls of staff and others and ensure that any trends are reported through the Trust s Health and Safety Committee. Health and Safety priorities and trend analysis for this category have been approved by the Health and Safety Committee and are reported on every six months. Be responsible for reporting to the Health and Safety Executive (HSE) any slip, trip and fall incidents for staff and others incidents in line with the requirements of the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) Provide slip, trip and fall training on an adhoc basis as and when requested. e) All Employees must ensure: That they undertake their duties in such a manner not to cause any potentially hazardous situations which may lead to a slip, trip or fall. That if it is safe to do so they immediately clear up any spillage they are responsible for creating or ensure that the area is made as safe as possible by restricting access to the affected area. This can be done by using appropriate warning signs and or cordons and then report the hazard to a relevant person(s) or department That all WSFT standard operating procedures (SOP s) are followed, particularly in the cleaning of floors, stairwells and high traffic flow areas to minimise the risk of slips, trips and falls. That any hazard which may lead to a slip, trip or fall (such as trailing cables and pot holes etc.) is reported to their line manager immediately. That they comply with any local area rules such as the wearing of suitable footwear to ensure the risks from slip, trip or falls is reduced to a minimum. To ensure that when working at height they have been trained to use any equipment required. If a permit to work is required for the task, this is in place prior to commencement of task They undertake any task following training and information provided i.e. standard operating procedure They are trained to use, store and wear appropriate PPE as and when required. An incident form is completed on Datix for every actual slip, trip and fall and near miss occurring on site. These forms must be completed according to the WSFT s incident policy and procedure (PP105 and 105b). Source: Health, Safety and Risk Manager Status: Approved Page 4 of 19

5 f) Estates and Facilities Management is to ensure: Note: Estates/Facilities have their own Working at Height policy and Code of practice both located on the O drive. That current good practice will be followed when introducing new or refurbished floor surfaces. Appropriate advice and guidance is followed with regard to flooring design, specification, procurement, construction, commissioning, cleaning and maintenance regimes. Contractors and sub-contractors are effectively monitored in order to reduce slips, trips and fall hazards, which they may create in line with the arrangements set out in the Estates and Facilities Contractors Code of Conduct. WSFT roads and pathways are suitably treated during adverse weather conditions (e.g. snow and ice) in accordance with the winter gritting plan. This forms part of the WSFT winter plan in order to reduce the risk of slips and trips leading to a fall. An effective planned preventative maintenance programme is in place for repairs to WSFT roads/potholes in order to reduce the risk of slips and trips leading to a fall. Regular inspections of WSFT car parks are carried out and appropriate action taken if there are any slip, trip leading to a fall hazards. Appropriate lighting is in place and maintained in general areas in order to reduce the risk of individuals misjudging flooring or not seeing contaminants Appropriate handrails at the recommended height are fitted where required on slopes and stairs. g) Corporate Risk Committee will: Oversee the activities of the Health and Safety Committee and monitor performance against agreed priorities and trend analysis. The Committee will provide strategic direction for the prevention and management of slips, trips and falls for staff and others. Any significant slip, trip and fall risks will be escalated according to agreed procedures to the Trust Executive Group (TEG) and/or the Board. h) The Health and Safety Committee will: Review relevant incident data with a focus to ensure any trends and learning from slips, trips and falls for staff and others are identified and appropriate action taken. Priorities and trend analysis for slips, trips and falls for staff and others are approved, monitored and reviewed every six months. 6. Risk Assessment: In order to meet its legal requirements under the Management of Health and Safety at Work Regulations 1999 the WSFT will ensure that workplace and environmental risk assessments consider the potential hazards associated with slips, trips and falls for staff and others (including falls from height), i.e. floor covering, lighting, trailing cables, wet floors and working while using step ladders etc. The slips, trips and falls for staff and others causation list (Appendix A) and the action chart for slips, trips and falls for staff and others (Appendix B) will assist Managers and health and safety link persons in identifying hazards associated with a slip, trip and fall. This information can then be used to complete a risk assessment for their area, which will then be recorded on Datix risk register. (See the Strategy and Policy for Risk Management PP093 and Risk Assessment Policy and Procedure PP132 for more information on completing a risk assessment). Following a review of any slips, trips and falls risk assessments on Datix risk register, there may be a need to add additional control measures to the risk assessment. Therefore an appropriate action plan must be put in place to reduce the risk down to an acceptable level. Any additional actions must be implemented in accordance with the requirements of the risk assessment policy and procedure PP132. (Including timescales, lead personnel and costings). Where deemed necessary there will be a multi-disciplinary approach used in order to assess the risks and implement any required additional controls. (e.g. introduction of new cleaning methods, changes in floor condition requiring the need for a slip test to be carried out, building works Source: Health, Safety and Risk Manager Status: Approved Page 5 of 19

6 impacting on footpaths and access routes). This must involve the Estates and Facilities Division if and when appropriate. A generic risk assessment recognising that there are a number of hazards that are common causes of slips, trips and falls for staff and others and the control measures that the WSFT implements can be found at Appendix C. Guidance for specifically working at height and how do undertake a risk assessment can be found at Appendix D 7. Training Expectations: All new employees will receive health and safety awareness training at a mandatory Trust induction and during the local departmental induction. All staff will complete mandatory health and safety training via e-learning every 3 years. No member of staff will carry out duties that have an obvious health and safety risk (e.g. cleaning, portering and estates maintenance) until they have received adequate training in understanding the hazards involved and the precautions to be taken in reducing the risk. 8. Incident Reporting: An incident form must be completed on Datix for every incident and near miss involving a slip, trip and fall for staff and others occurring on site. These forms must be completed according to the Trust s incident policy and procedure (PP105 and 105b). The Health and Safety Committee will review incident data with a focus to ensure any trends and learning from slips, trips and falls for staff and others are identified and appropriate action taken. Source: Health, Safety and Risk Manager Status: Approved Page 6 of 19

7 9.0 Monitoring Compliance In order to ensure compliance with the slips, trips and falls for staff and others policy and procedure the following will be used. Element to be monitored Duties are performed as per procedure Lead responsible for monitoring Health, Safety and Risk Manager Monitoring tools/method of monitoring Internal workplace inspections Frequency of monitoring 3 monthly, six monthly or annually Lead responsible for developing action plan & acting on recommendations Health, Safety and Risk Manager and Health and Safety Link Persons Reporting arrangements WSFT Health and Safety Committee Requirement to undertake appropriate risk assessments for the management of slips, trips and falls for staff and others (including falls from height) Staff training Health, Safety and Risk Manager Human Resources / OLM Co- Coordinator / Department Managers Workplace Inspections Risk Register Reports Internal Audits External Audits 3 monthly, six monthly or annually Monthly Department Managers, Health and Safety Link Persons and Health, safety and risk manager WSFT Health and Safety Committee Divisional Governance Meetings Monthly Department Managers Mandatory Training Committee Source: Health, Safety and Risk Manager Status: Approved Page 7 of 19

8 Author(s): Other contributors: Approvals and endorsements: Consultation: Issue no: 3 File name: PP (16) 282 Supercedes: PP(14) 282 Equality Assessed Yes Implementation Monitoring: (give brief details how this will be done) Other relevant policies/documents & references: Additional Information: M Dixon, Health, Safety and Risk Manager None Health and Safety Committee. This document will be widely circulated within the WSFT including all Heads of Department and Ward Managers and will be made availability on the WSFT s Intranet and Internet sites. Relevant changes will be brought to the attention of staff during circulation. Comprehensive training programmes exist including mandatory training and relevant modules as detailed in the WSFT s training prospectus. Specialist training will also be targeted at those with responsibility for managing hazards with a high risk rating. See section 9 Risk Management Strategy and policy (PP093) Incident reporting policy (PP105 and PP105b) Health, Safety and Welfare Policy (PP018) Risk Assessment policy and procedure (PP132) Clinical slips, trips and falls policy (PP202) None Source: Health, Safety and Risk Manager Status: Approved Page 8 of 19

9 Appendix A What causes slip, trips and falls Slips Slip and trip accidents can happen for a number of reasons, but all too frequently we jump to conclusions about why they happen rather than really looking for the true cause or, we decide that it is just one of those things and do nothing. The diagram below is the slip potential model. The bubbles highlight the main factors that can play a part in contributing to a slip accident. One or more may play a part in any situation or accident. (HSE, 2011) Slip potential model Trips The majority of trips are caused by obstructions in walkways. The rest are caused by uneven surfaces. Preventing these accidents is often simple and cost effective. All three of the below need to be right (walkways, housekeeping and design and maintenance), to prevent tripping accidents. Preventing trips Trip potential triangle Walkways Check for a suitable walkway- are they in the right place, are they being used, are they available for use? What tasks are taking place on the walkway? is the task preventing the employee from seeing where they are going for example. Source: Health, Safety and Risk Manager Status: Approved Page 9 of 19

10 Housekeeping It is not just good enough to have a walkway; it must be kept clear, no trailing cables and no obstructions. Employees and cleaners need to have a see it, sort it attitude to ensure these and other work areas are kept clear. Is the cleaning regime effective? Are there enough bins, storage facilities etc.? Design and maintenance Is the floor suitable for the environment, fitted correctly and properly maintained. Are the walkways wide enough and level. Are stairs suitable, are risers consistent, are nosing s highlighted where necessary, are handrails available. Environmental factors also fall into this category, is the lighting good enough for employees to see hazards, what about distractions that might prevent them from seeing where they are going e.g. mobile phones. Also listed below are some of the common causes of slips, trips and falls in the workplace. A Slip Hazards Spills and splashes caused by water and other fluids e.g. coffee and tea Wet floors (following cleaning) Unsuitable footwear Rain, sleet, snow and ice Change from a wet to dry surface (footwear still wet) Unsuitable floor surface/covering Dusty floors caused by talcum powder Uneven sloping surfaces B Trip Hazards Loose floorboards/tiles Uneven outdoor surfaces Holes/cracks Changes in surface level-ramps, steps and stairs Cable across walking areas Obstructions Bumps, ridges and protruding nails etc. Low wall and floor fixtures-door catches, door steps Electrical and telephone socket outlets Poor or unsuitable lighting C Fall Hazards Over reaching Climbing on furniture Rushing down steps/stairs Ladders Faulty or unsuitable equipment D Factors which Increase Risk Poor health and safety culture Untrained staff Risk assessments not reviewed regularly or not completed Wrong cleaning regime/materials Moving goods/carrying/pushing or pulling a load Rushing around Distractions/fatigue Effects of alcohol Drugs and Medication Source: Health, Safety and Risk Manager Status: Approved Page 10 of 19

11 Appendix B action to manage slips, trips and falls at work There are many simple measures that can be taken to reduce or eliminate slip, trip or fall risks. The following table gives some suggestions. Hazard Spillage of wet and dry substances including: water, tea, coffee, cleaning chemicals, talcum powder and bodily fluids Unsuitably trained staff No appropriate risk assessments Miscellaneous items stored or discarded in access routes (broken equipment, trollies etc.) Slippery surfaces Poor lighting Changes of level Slopes Unsuitable footwear Trailing cables Rugs/mats Suggested action Clean up any spills immediately using an appropriate spill kit if available. If no spill kit available ensure suitable cleaning agents are used and the floor is left dry. Whenever there is a wet floor after cleaning, use appropriate signs to tell people the floor is still wet and arrange alternative routes. Contact housekeeping department for further advice Ensure appropriate training is undertaken and recorded to enable staff to carry out the required duty, i.e. knowledge of cleaning processes and chemicals. Risk assessments should be completed and reviewed at regular intervals depending on the risk rating. All significant risks must be captured on Datix risk register and approved by the appropriate person. Only staff who have been trained in the risk assessment process can undertake risk assessments and put them on Datix. Keep access and egress routes clear at all times, remove rubbish and do not allow area to build up with equipment and trollies etc. Assess the cause and measure how slippy the floor is using the WSFT s slip alert device (available through Housekeeping) and treat accordingly, with appropriate measures that could include mats, cleaning and signage. Improve lighting levels and placement or light fittings to ensure more even lighting of all floor areas. Improve lighting, consider high visibility tread nosing and high visibility paint on raised curbs Improve visibility, provide handrails, and use floor markings. Ensure employees wear suitable footwear, particularly with the correct type of sole for the work undertaken. Employer to provide safety footware if there is an assessed need for it. Position equipment to avoid cables crossing pedestrian routes, use cable covers or cable ties to securely fix to surfaces or restrict access to prevent contact. Consider using cordless tools. Contractors will also need to be managed. Ensure mats are kept clean, securely fixed and regularly checked for wear and tear. Source: Health, Safety and Risk Manager Status: Approved Page 11 of 19

12 Appendix C Risk Assessment Form Local Activity ref: Directorate/Service: Trust-Wide Dept/Ward/Other: Site: West Suffolk Hospital Trust Risk Register Number: (To be added by the Assessor when allocated by Risk Office) Original Assessment Date: Dates on which reviews have taken place: Date of next review: Name of Assessor: Address: Hardwick Lane, BSE Signature of Assessor: Please ensure all sections of form are complete before sending to the Risk Office. Description of the task/activity/issue: Any activity where staff and others are at risk from slips, trips and falls around and within the trust site Frequency of task/activity: Daily Please identify category of people affected: Staff / Visitors / Contractors Estimate of number of people affected by hazard: Hazards identified: 1) Slip Hazards: Significant consequences: 1) Due to slip: Potential for musculoskeletal injury or Spills and splashes of liquids and solids sprain due to slip. Possible over 7 day injury Wet floors ( after cleaning) (reportable to HSE under RIDDOR 2013). Potential for Unsuitable footwear Minor injury (bruise, laceration) to Specified Injury Loose mats on polished floors (fracture or dislocation). Specified injury (reportable to Poor weather conditions- rain, sleet, snow HSE under RIDDOR 2013). Staff absence due to Change from a wet to dry surface (footwear still injury. Poor morale, due to staff absence and increased wet) work load. Litigation and associated costs. Local media Unsuitable floor surface/covering publicity and potential visit from HSE Dusty Floors Sloping surfaces 2) Trip Hazards: Loose floor tiles Loose and worn mats/carpets Uneven out door surfaces e.g. pathways, car park. Holes and cracks Changes in surface level- ramps, steps and stairs Cables across walking areas / any trailing cables Obstructions Bumps, ridges and protruding nails etc. Low wall and floor fixtures-door catches, door stops Hand bags handles- untidy work stations Miscellaneous rubbish i.e. plastic bags on the floor. Electrical and telephone socket outlets Poor lighting 2) Die to a trip: Potential for musculoskeletal injury or sprain due to trip. Possible over 7 day injury (reportable to HSE under RIDDOR 2013). Potential for Minor injury (bruise, laceration) to Specified Injury (fracture or dislocation). Specified Injury (reportable to HSE under RIDDOR 2013). Staff absence due to injury. Poor morale, due to staff absence and increased work load. Litigation and associated costs. Local media publicity and potential visit from HSE. Source: Health, Safety and Risk Manager Status: Approved Page 12 of 19

13 3) Fall Hazards: Over reaching Climbing on furniture Using step ladders/kick stools Rushing down steps/stairs Using ladders without any training Working on the roof Calculate the Risk Rating without controls in place (please see scoring matrix on following page): L (Likelihood) X C (Consequence) = Weekly X Moderate =Amber 3) Due to fall: Potential for musculoskeletal injury or sprain due to fall. Possible over 7 day injury (reportable to HSE under RIDDOR 2013). Potential for Minor injury (bruise, laceration) to Specified Injury (fracture or dislocation). Specified Injury (reportable to HSE under RIDDOR 2013) Possible death if fall from substantial height i.e. the roof (reportable to HSE under RIDDOR 2013). Staff absence due to injury. Poor morale due to staff absence and increased work load. Litigation and associated costs. Local media publicity and potential visit from HSE What controls are in place and used to reduce the risk: Policy: Policy for the management of slips, trips and falls for inpatients over the age of 16 (PP202) Incident reporting policy (PP105) Health, safety and welfare policy (PP018) Strategy and policy for risk management (PP093) Risk assessment policy and procedure (PP132) Winter gritting plan provided by Estates & Facilities which forms part of the Trusts winter plan. Contractors Code of Conduct and Construction Health and Safety plans Standard operating procedures (SOP s) in place and followed by Housekeeping and Estates / Facilities staff Environment High housekeeping standards maintained at all times. Cabinet drawers and doors kept closed when not in use. Trailing cable from electrical machinery/equipment managed by re-routing, cable protectors or using clips All bags with handles put away, not left on the floor Equipment stored tidily in all areas, away from traffic routes Floors, staircases and doors cleaned on a regular basis by the housekeeping staff Visible warning signs, are put in place when cleaning occurs on site Housekeepers trained in correct floor cleaning techniques The use of micro fibre floor mops for floor cleaning Repairs and maintenance to flooring carried out when necessary Stairs are in good condition with good noses, well lit and handrail provided All areas well lit. Over flow car park is not used between the hours of 20:00 and 08:00 due to lack of lighting during winter months Instructions given to staff that spillages should be cleaned and dried up immediately. Rubbish collected on a regular basis throughout the day Slip resistant flooring is placed in high-risk areas, such as bathrooms, kitchens, workshops etc. Entrances to the building have carpet / absorbent mats which are cleaned and checked regularly for signs of wear and tear. Grounds maintenance team regularly remove tree/plant foliage/spoils throughout the year Grounds maintenance team regularly salt and clear pathway/roadways in snowy and icy conditions Pathways and roads regularly maintained Ladders, step ladders and kick stools checked daily by the staff who use them to ensure they are in good repair Clear defined walkways and edge protection for staff/contactors working on the roof. Contractors are controlled by a working at height permit system. Suitable footwear worn at all times by staff All staff to report any hazards, incidents and near misses relating to slip, trips and falls for staff and others to their line manager immediately. Monitoring, training and support Generic risk assessments in place and used by all departments Departmental workplace Inspections carried out by the health and safety link person Source: Health, Safety and Risk Manager Status: Approved Page 13 of 19

14 Quarterly and monthly monitoring of incidents to Directorates Monthly monitoring of incident reports by Ward Manager, Service Manager and General Manager Monitoring of patient falls by Falls Group Monitoring of non-patient falls by the Health and Safety Committee and Corporate Risk Committee Mandatory staff training for health and safety inform of induction and e-learning. Advice, support and counselling for staff from Occupational Health Department Housekeeping and facilities staff regularly trained on using step ladders and kick stools through toolbox talks Health, Safety and Risk Manager available to offer advice and ad hoc training when required Recalculate the Risk Rating with existing controls in place: L X C = Quarterly X Moderate= Amber Are the existing controls listed above satisfactory? Yes If No, complete the following: Describe the key risk(s) to be addressed: Description of additional controls required (actions being taken) to reduce the risk Cost Lead Completion date Recalculate the Risk Rating with the additional control measures in place: L X C =. X. =.. Please send an amended risk assessment to the Risk Office when additional controls have been implemented so the Trust s Risk Register can be updated. Signature of responsible Manager as determined by Risk Rating score (please use guide on next page): Green: Amber: Red: Risk Assessment Form Version 7 (August 2011) Location: Intranet/Trust Info/Forms/General Forms/Risk Assessment Form Impact on the safety of patients, staff or public (physical/ psychological harm) Risk Assessment guidance sheet Likelihood Scoring Matrix: Likelihood Description 20-Yearly Expected to occur once every 20 years 5-Yearly Expected to occur once every 5 years Annually Expected to occur once a year Quarterly Expected to occur quarterly Weekly Expected to occur weekly Consequence Matrix: Negligible Minor Moderate Major Catastrophic Minimal injury Minor injury or illness requiring requiring minor no/minimal intervention. Requiring intervention or time off work for <3 treatment. No time days. Increase in off work required length of hospital stay by 1-3 days Moderate injury requiring professional intervention. Requiring time off work for 4-14 days. RIDDOR / agency reportable incident. An event which impacts on a small number of patients Major injury leading to long-term incapacity/disability. Requiring time off work for >14 days. Increase length of hospital stay by >15 days. Mismanagement of patient care with long-term effects Incident leading to death. Multiple permanent injuries or irreversible health effects. An event which impacts on a large number of patients. Source: Health, Safety and Risk Manager Status: Approved Page 14 of 19

15 Experience / complaints Human resources / organisational development/ staffing/competence Unsatisfactory service or experience not directly related to care. No impact or risk to provision of care Short-term low staffing level that temporarily reduces services quality (<1 day) Unsatisfactory service or experience related to care, usually a single resolvable issue. Minimal impact and relative minimal risk to the provision of care or the service. No real risk of litigation. Basic administration error Attitude of staff but with low impact on patient experience Delays in outpatient clinic Lack of communication/ Information (administrative / nursing-with low level impact on patient experience) Delays in TTO s ( to take out, medicines to be taken away by a patient being discharged) Problems with facilities /premises (e.g. car parking) Unsatisfactory patient experience, readily resolved or easily resolvable Low staffing levels that reduce the quality of service Low staffing level that reduces service quality Service or experience below reasonable expectations in several ways, but not causing lasting problems. Has potential to impact on service provision. Some potential for litigation. Attitude of staff has greatly affected patient experience (normally medical/ Nursing staff) Serious lack of communication/ information (medical/ nursing- which has had significant effect on patient experience/ outcome) Unacceptable delays in treatment whilst an inpatient (e.g. awaiting emergency surgery/ investigations) Cancelled Operations Insufficient pain management Serious problems with facilities/premisesserious risk to patient safety Major changes need to be implemented to systems/procedures Local media interest likely to go public MP concerns Late delivery of service due to low staffing levels Late delivery of key objectives/service due to lack of staff. Unsafe staffing level or competence (>1 day). Low staff morale. Poor staff attendance for mandatory /key training Significant issues regarding standards, quality of care and safeguarding of, or the denial of rights. Complaints with clear quality assurance or risk management issues that may cause lasting problems for the organisation. Possibility of litigation and adverse local publicity. Uncertain delivery of key objective/service due to lack of staff. Unsafe staffing level or competence (>5 days). Loss of key staff. Very low staff morale. No staff attendance for mandatory/key training Serious issues that may cause long-term damage, such as grossly substandard care, professional misconduct or death. Will require immediate and in-depth investigation. May involve serious safety issues. A high probability of litigation and strong possibility of adverse national publicity. Serious untoward incident Serious drug errors Delays in treatment which could cause death Clinical negligence /equivalent Litigation Potential damage to reputation. Adverse media coverage lasting more than three days Serious & totally unacceptable suboptimal care An event which impacts on a large number of patients DOH concern Non-compliance with national standards with significant risk to patient if unresolved Non-delivery of key service due to lack of staff Non-delivery of key objectives/service due to lack of staff. Ongoing unsafe staffing levels or competence. Loss of several key staff. No staff attending mandatory training/ key training on an ongoing basis Statutory duty/inspections Adverse publicity/ reputation No or minimal impact or breach of guidance/statutory duty Rumours. Potential for public concern Breach of statutory legislation. Reduced performance rating if unresolved Local media coverage - short-term reduction in public confidence Elements of public expectations not being met Single breach in statutory duty. Challenging external recommendations/ improvement notice Local media coverage - long-term reduction in public confidence Enforcement action. Multiple breaches in statutory duty. Improvement notices. Low performance rating. Clinical report National media coverage with >3 days service well below reasonable public expectation Multiple breaches in statutory duty. Prosecution. Complete system change required. Zero performance rating. Severely critical report National media coverage with >3 days service well below reasonable public expectations. MP concerned (questions in the house) Business objectives/projects Finance including claims Insignificant cost increase/schedule slippage Small loss. Risk of claim remote <5 percent over project budget. Schedule slippage Loss of percent of budget percent over project budget. Schedule slippage Loss of percent of budget. Claim Non-compliance with national percent over project budget. Schedule slippage. Key objectives not met Uncertain delivery of key objectives/loss of Source: Health, Safety and Risk Manager Status: Approved Page 15 of 19 Total loss of public confidence Incident leading >25 percent over project budget. Schedule slippage. Key objectives not met. Non-delivery of key objectives/loss of >1

16 Service/business interruption Environmental impact Loss/interruption of >1 hour. Minimal or no impact on the environment Claim less than 10,000 Loss/interruption of >8 hours. Minor impact on environment between 10,000 and 100,000 Loss/interruption of >1 day. Moderate impact on environment percent of budget. Claim between 100,000 and 1 million. Purchasers failing to pay on time Loss/interruption of >1 week. Major impact on environment The Risk Rating is the likelihood multiplied by the consequence, as seen in the matrix below: percent of budget. Failure to meet specification/slippage. Loss of contract/payment by results. Claim > 1 million Permanent loss of service or facility. Catastrophic impact on environment Likelihood of harm Consequence of harm Negligible Minor Moderate Major Catastrophic 20-Yearly Green Green Green Green Green 5-Yearly Green Green Green Amber Amber Annually Green Green Amber Amber Red Quarterly Green Green Amber Red Red Weekly Green Green Amber Red Red Action required once the Risk Rating has been determined: Risk Rating Green Amber Red Action Required Escalate to Ward/Department Manager or equivalent to: Implement additional controls whenever possible to reduce/eliminate (through routine procedures). Funded by Division or escalated if required. Review progress of active risk assessment as appropriate, including the implementation of additional controls (minimum every 12 months) Accept risk if mitigated as far as reasonably practicable. Accepted risk assessment to be reviewed as appropriate (minimum every 12 months) Escalate to Service Manager, Head of Department or equivalent to: Implement additional controls whenever possible to reduce/eliminate risk (as soon as reasonably practicable). Funded by Division or escalated if required Review progress of active risk assessment as appropriate, including the implementation of additional controls (minimum every six months) Accept risk if mitigated as far as reasonably practicable. Accepted risk assessments to be reviewed as appropriate (minimum every 12 months) Escalate to Director, General Manager or equivalent to: Implement additional controls whenever possible to reduce/eliminate risk (as soon as reasonably practicable). Funded by Division or escalated if required. Review progress of active risk assessments as appropriate, including the implementation of additional controls (minimum every three months). Escalate to Board to Accept risk if mitigated as far as is reasonably practicable. Accepted risk assessment to be reviewed as appropriate (minimum every 12 months Source: Health, Safety and Risk Manager Status: Approved Page 16 of 19

17 Appendix D Guidance to the Working at Height procedures and carrying out risk assessments. PART 1.0: QUICK REFERENCE GUIDE What is work at height? Work at height means work in any place where, if precautions were not taken, a person could fall a distance liable to cause personal injury. You are working at height if you: Work above ground/floor level Could fall from an edge, through an opening or fragile surface Could fall from ground level into an opening in a floor or hole in the ground Work at height does not include a slip or a trip on the level, as a fall from height has to involve a fall from one level to a lower level, nor does it include walking up and down a permanent staircase in a building. Is it illegal to work at heights? It is not illegal to work at height as there will be occasions when working at height has to take place and the law does not prevent it from happening. However the law requires so far as is reasonably practicable that any work at height be planned, managed and safe. What legislation covers working at heights? The Working at Height Regulations 2005 covers all working at height activities and excavations came into force in April 2005.The Regulations repeal all earlier legislation, which used to cover working at heights e.g. parts of the Construction (Health, Safety and Welfare) Regulations 1996 are repealed. Does the 2.0 metre rule regarding falling from heights still apply? No. The Working at Height Regulations 2005 applies to all work at heights, no matter how far the distance of the potential fall. Injuries occur from low distance falls as well as high distance falls. What do the Regulations require employers to do? The Regulations apply to all work at height, where there is a risk of a fall liable to cause personal injury. The Regulations place specific duties on employers, and those who control any work at height activity (such as facilities managers or building owners who may contract others to work at height). As part of the Regulations, you must ensure: All work at height is properly planned, managed and safe Those involved in work at height are competent (have sufficient skills, knowledge and experience to perform the task) The risks from work at height are assessed, and appropriate work equipment is selected and used The risks of working on or near fragile surfaces are properly managed The equipment used to work at height is properly inspected and maintained When is a Risk Assessment required for working at height? Employers and those in control of work at height must first assess the risks. Before working at height the below steps should be followed: Avoid working at height where it is reasonably practicable to do so Where work at height cannot be easily avoided, prevent falls using either an existing place of work that is already safe or the right type of equipment Minimise the distance and consequences of a fall, by using the right type of equipment where the risk cannot be eliminated Source: Health, Safety and Risk Manager Status: Approved Page 17 of 19

18 Every time someone is to undertake a task where there is a risk that they could fall and injure themselves a risk assessment must be completed. The risk assessment approach required is no different than for all other risk assessments completed by the employer. The risk assessment approach is to: 1) Identify the hazard 2) Decide who might be harmed and how 3) Evaluate the risks and decide whether the existing precautions are adequate or whether more needs to be done i.e. identify the control measures necessary to reduce the risks of injuries. 4) Record your findings and implement them and ensure the relevant staff is made aware. 5) Review the assessment- periodically or when something has happened or changed or the assessment is no longer valid Note: If the working at height task is to be carried out using a kick stool or similar the generic slips, trips and fall risk assessment can be used. However in most cases where working at height is to be undertaken a specific risk assessment will be required and captured on datix risk register. What is the most important aspect of working at height that must be considered? The most important aspect of working at height that an employer should consider is whether the work at height needs to be done at all. The first principle of safe working at height is not to work at height at all. Consider whether there are alternative ways to do things e.g. if the light fittings are high up over say, a stairwell, and access to them is unsafe due to height and risk of falls, consider whether the light fittings could be put on to a winch downable mechanisms so that maintenance and cleaning can be carried out at ground level. Working at height should only be carried out if there is really no alternative. What type of issues should be addressed in the risk assessment? Some examples of what to consider are: The work activity The equipment to be used The duration of the work Those involved with working at height are competent The location where the work activity is due to take place i.e. presence of hazards such as overhead power lines, open excavations, underground services, vehicle access, people still at work, public access etc. The working environment.g. weather conditions, lighting, type of ground, slopes etc. Condition and stability of existing work surfaces Physical capabilities of the workers e.g. vertigo sufferers and pregnancy. People carrying out work at height have to be competent. What does this mean? Competency is the experience, knowledge and appropriate qualifications that enable a worker to identify the risks from a situation and the measures needed to be taken to eliminate or reduce them. Anyone working at height needs to be trained in the hazards and risks and in what control measures are being put in place to eliminate or reduce the risks of injury. Those undertaking work at height activity must be trained in the selected system of work and on the use of any particular equipment chosen e.g. how to use mobile elevating platforms, tower scaffolds etc. Managers and supervisors must check that anyone carrying out work at height are trained and competent to do so. Source: Health, Safety and Risk Manager Status: Approved Page 18 of 19