2 2) TOPIC: DISCUSSION ON LEADERSHIP WALKROUNDS Issues/Risks/Outcomes Expected What progress has been made in this area? 3) Assurance Actions BS advis

Transcription

1 Health & Safety Committee 2 November 2017 Item 2 1 Assynt House Beechwood Park Inverness IV2 3BW Tel: Fax: Textphone users can contact us via Typetalk: Tel ASSURANCE REPORT of MEETING of the HEALTH and SAFETY COMMITTEE Board Room, Assynt House 10 August, am Present Ms Elspeth Caithness, Joint Chair and RCN Health & Safety Representative Ms Melanie Newdick, Joint Chair and NHS Board Non-Executive Director Mr Stephen Don, UNITE Mr David Park, Director of Operations, Inner Moray Firth Operational Unit (from 10.25am) In attendance Ms Fiona Campbell, Clinical Governance Manager, Argyll & Bute CHP (Videoconference) Ms Sarah Crawshaw, Moving and Handling Manager Mrs Morag Forbes, Employment Services Officer (from 11.25am) Ms Diane Fraser, Violence & Aggression Prevention Manager Mr Eric Green, Head of Estates (to 10.35am) Mr Paul Maber, Business Support Manager (from 11.25am) Ms Fiona Miller, Health & Safety Manager (Videoconference) Mr B Mitchell, Committee Administrator Ms Alison Moore, Health & Safety Manager Mrs Mirian Morrison, Clinical Governance Development Manager Ms Linda Rawlinson, Occupational Health Nurse Manager Mr Bob Summers, Head of Health & Safety Ms Karen-Anne Wilson, Health and Safety Manager Apologies Sally Bassett, Rosie Brunton, John Burnside, Christina West. 1) DECLARATIONS OF INTEREST There were no declarations of interest.

2 2 2) TOPIC: DISCUSSION ON LEADERSHIP WALKROUNDS Issues/Risks/Outcomes Expected What progress has been made in this area? 3) Assurance Actions BS advised a date had been set to consider all relevant current questionnaire documents with a view to combing and streamlining this activity. AG stated the aim was to extend existing Walkround activity to include aspects relating to Action: Agreed draft questionnaire to be brought to the next meeting B Summers Health & Safety. TOPIC: ASSURANCE REPORT 11 MAY 2017 Issues/Risks/Outcomes Expected Assurance Actions Any issues relating to accuracy of Assurance Noted Assurance Report had been considered Report? by NHS Board. Action Plan reviewed and future Action: Rolling Action Plan to be regularly updated Committee Administrator actions consolidated where appropriate. 4) TOPIC: MATTERS ARISING Issues/Risks/Outcomes Expected Ligature Risk Assessment - What progress has been made regarding ligature risk assessment in New Craigs and Argyll and Bute areas? Assurance Actions BS advised, following a visit to Argyll and Bute, the Lanarkshire Risk Assessment Tool had Action. been applied and a number of issues identified. M Perera to establish a SLWG to refine the A similar risk assessment workshop and on site Larnarkshire tool for NHS Highland by mid exercise was undertaken in New Craigs on 09 Sep 17 Aug 17. It was attended by most of the Ward A risk based rollout plan to be established Clinical Area Managers. Staff were engaged and implemented across the New Craig s and recognised the need to change. M Perera site by end of 2017 would establish an action plan and a formal Risk Assessment Strategy would emerge as a result. Inpatient Bed Maintenance has there been EG advised resource identified but robust movement on establishing a tracking system? solution not yet established. R&D Team were to trial a low cost Bluetooth system at CGH and 2

3 3 were hopeful this would represent a cost effective solution for the NHS Board. Noted Action: EG to present an options paper to the NHSH was leading on developing this activity. next HS committee for consideration Raigmore Hospital Service Void has access EG advised access had been restricted. An ebeen appropriately restricted? lock system would shortly be installed. Fire Safety Training What is the current EG advised Mr J Spode had taken up his position in relation to training? substantive role as Fire Safety Advisor. All Duty Holders requiring training in North and West Unit had now been identified. What movement has been made in relation to EG confirmed a revised draft Fire Safety Policy Fire Safety training? would be submitted to the next meeting, indicating this as standard for low risk staff. Adoption of Learnpro would assist in the production of associated training data. Fire Safety Compliance are there currently EG stated, following the Grenfell Tower tragedy any known issues for NHSH? an audit of NHSH buildings established no similar aluminium cladding having been installed. Regarding fire compartmentation, NHSH continued to seek to make improvements where possible however it was recognised not all buildings could be brought in to full compliance. Activity, such as in Raigmore, was undertaken in partnership with Building Warrant Officers/Fire Service etc. Work in Raigmore would be complete within two years, including installation of a fire sprinkler system. All NHSH buildings would be similarly assessed. Capital Projects Programme what progress EG advised the successful Office Redesign has been made on Capital projects? Project was nearing completion. Activity on the Ground and First floors in Raigmore was progressing well and due for completion by calendar year end, with Theatres the next area to be addressed. High Voltage electric systems would be replaced over the next two years, 3 Action: Agreed draft Fire Safety Policy to Nov 17 Committee. This should clarify the model of fire safety training required in NHS Highland Action: Agreed all Operational Units are to identify those areas requiring Duty Holder Training Directors of Operations

4 4 providing greater reliability and fully functional back-up. There would be a reduction in running costs. A design team had been appointed for the proposed service redesigns on Skye and in Badenoch and Strathspey, with contracts agreed in principle. The Committee Agreed to consider the following Items at this point in the meeting. 5.1) Issues TOPIC: ESTATES HEALTH AND SAFETY PLAN Assurance Actions What is the general position in relation to the BS stated this remained an issue and suggested Control of Contractors? a Kaizen Event may be required to work through the arrangements. There were increasing numbers of external Contractors accessing NHSH sites and EG suggested specialist assistance may be required to improve our compliance. Noted the Permit to Work system, used in both NHSH and NHS Grampian, could be adapted to fit the required purpose. Action: Agreed to approach G Hookway and discuss appropriate improvement methodology approach to adopt to improve our current compliance regarding contractors E Green/B Summers What progress has been made in relation to BS stated that the Estates Health and Safety Action: Agreed to finalise draft plan and developing the draft Estates H&S Plan? Plan, which is to be owned by the Head of submit to Estates Management Team for Estates, was nearing completion and would be discussion and approval B Summers submitted to Nov 17 Committee. The plan is likely to contain actions relating to: the review and updating of statutory maintenance job plans and associated risk assessments, review and updating of Water Safety, Fire Safety and Medical Gases Procedures, Updating of Asbestos Management Arrangements, establishment of an Estates Electrical Safety Sub Group etc. EG advised the National SCART Audit system Action: Agreed to submit plan to the Nov 17 would also and should predicate the main Committee E Green priorities in the Estates HS Plan. 4

5 5 5.2) TOPIC: NHS HIGHLAND HEALTH & SAFETY IMPROVEMENT PLAN HEALTH & SAFETY TEAM PLAN UPDATE (AUGUST 2017) Issues Assurance Actions What progress has been made in relation to the H&S Team Improvement Plan 2017/18? BS advised updates, not specifically included on the Agenda could be accessed via relevant link: Health and Safety Team Plan August 17 Updates Registered Premises Officer (RPO) Procedure BS advised the RPO role is well established in Action: Proposal to be further discussed and the Adult Social Care sites, with main duties brought back to future meeting B Summers relating to: ensuring the building is managed and operated safely, the local coordination on contractors when on site, to ensure that building fire and safety management is maintained etc. The intention is to rollout the new updated procedure in the ASC sites and support this with local awareness training. There is also an intention to roll this model out to smaller healthcare sites but this requires further scoping and consultation. An RPO/Building User Group had been suggested for Assynt House. Concern was expressed as to at the potential introduction of this role in large buildings/sites, in particular around management of contractors which was seen as the role of Estates/Facilities. BS acknowledged the wider implications of this role and suggested this be discussed at SMT. Baseline Risk Assessment Feedback BS confirmed survey had been undertaken, with mixed response levels across Operational Units against the main survey topics including; site risk assessment completion, percentage of activity based, moving & handling and lone working risk assessments completed and compliance with medical gases training. The response rate, other than South and Mid, was generally poor, however the launch of the new 5

6 6 operational health and safety plans in Aug 17 would help to focus managers on the key areas raised in the baseline audit. MP16 Quarterly Workplace Health and Safety BS advised the requirement for local managers Inspections to undertake workplace inspections has been a requirement set within the existing policy for over a decade. This procedure extends that requirement and provides clarity to local managers on when and how to conduct inspections and how to act upon the inspection findings. He confirmed the inspection activity covers a range of known hazards and any concompliances should be managed easily at a local team / departmental level. Emphasising this was not new activity; BS added he would be looking for evidence of activity being taken forward in the Operational Health and Safety Action: The Committee Agreed to Ratify the draft document B Summers Plans, possibly through use of snapshot audits. HBP 10 Draft Lone Working Procedure BS advised D Fraser was leading on this activity and that a final procedure would be submitted to the next meeting in Nov. An appropriate promulgation and communication strategy would be required when the Procedure was introduced given the results from the associated baseline questionnaire with respect to lone working risk Action: Draft procedure document to be submitted to next meeting D Fraser assessments and local procedures. The Committee adjourned at 11.15am and reconvened at 11.25am ) TOPIC: OPERATIONAL UNIT HEALTH & SAFETY MANAGEMENT PLAN STRUCTURE, TRAINING AND PLAN ROLL OUT Issues Assurance Actions What progress has been made in relation to BS spoke to the circulated report, which implementation of the Operational Health and reiterated that Plans will be held, administered Safety Management Plan? and managed within Smartsheet. These were now live and would be populated through appropriate data capture. Checkpoints had 6 Actions: Directors of Operations, Chief Officers and their deputies are to ensure these plans are routinely promoted and monitored at SMT s, Core Teams.

7 7 been built in to each of the actions contained in Plans to reflect the H&S Committee meeting schedule. Operational Unit Health, Safety and Fire Groups would monitor their plans and actions prior to Committee meetings. The circulated report outlined the Smartsheet hierarchy and structure. It was noted respective mangers had been nominated by Operational Units and shared to their own specific plan, post training. In terms of ongoing Plan management it was noted this would require administration and monitoring to ensure they remain current and realistic. BS explained that there are continuing risks in terms of engagement and action with these plans if regular monitoring and encouragement by operational units was lacking. DP welcomed both the Framework and Dashboard. How successful was the training programme for BS stated that 20 web-based interactive Operational Health and Safety Dashboard and sessions had been delivered and well received Plan owners? by the 170 odd dashboard & plan owners who attended. DP echoed this point. There would be follow up conducted in relation to those that did not respond to the training uptake request and those that Did Not Attend. This would be conducted by the Operational Health and Safety Manager. A training video, and associated training notes, would be made available as an offline resource. Action: Operational Health and Safety Managers to make contact with those plan owners who did not take up the training in Jul and offer support and orientation around the plans ) TOPIC: OPERATIONAL UNIT HEALTH & SAFETY MANAGEMENT PLAN UPDATES Issues/Risks/Outcomes Expected Assurance Actions Operational Units had been requested to provide updates, based on current Management Plans, in relation to Face Fit Testing and Sharps Safety. 7

8 8 Face Fit Testing BS spoke to the circulated report providing statistical analysis of Face Fit Testing (FFT) activity by Operational Unit. He added that the figure for Raigmore reflected the difficulty in arranging and conducting testing for front line staff. He further highlighted and reemphasied strongly the need to update and maintain the local face fit testing registers within Smartsheet. With regard to improving the position at Raigmore, BS undertook to discuss relevant Action: Agreed issues be discussed with Director of Operations (IMFOU) B Summers points with the Director of Operations. Sharps Safety Those representatives present from Operational Units confirmed that all needlestick incidents were reviewed on an annual basis by their Operational Health, Safety and Fire Groups. BS further confirmed that the Sharps Sub Group similarly considered issues around common themes and trends ) TOPIC: OPERATIONAL UNIT HEALTH, SAFETY AND FIRE GROUP MINUTES Issues Assurance Actions Are there any matters to be raised in relation to There had been circulated Minutes from the content of circulated Minutes? meetings of the North & West (01/03/07) and Raigmore Hospital (14/03/017) Operational Unit Action: All future agreed actions be allocated Health, Safety and Fire Groups. The Chair appropriate timescales Health and Safety requested timescales be allocated against all Managers recorded actions. What is the NHSH Policy on transport of patients Members briefly discussed the many complex and relatives in private vehicles? components relating to this subject, noting this also impacted upon aspects of both the NHSH Lone Working and Transport Policies. DF advised the Transport Manager was currently reviewing relevant Policies and undertook to Action: Agreed relevant issues be discussed with the Transport Manager D Fraser discuss the issues raised in this meeting. 8

9 9 How should future quarterly reports be reported? The Committee Chairs reminded those present that a reporting template had been agreed at the last meeting. This template included required elements relating to progress against Plans, issues of interest and audit outcomes requiring Committee consideration. It was agreed that the Health and Safety Managers would comply the short report on behalf of their Director/Deputy Director of Operations / Chief Officer and submit this to the Committee Secretary when called. Action: Agreed quarterly reports be submitted to the next meeting on basis of reporting by exception Operational Health and Safety Managers 6) TOPIC: HEALTH & SAFETY COMMITTEE YEAR PLANNER Issues/Risks/Outcomes Expected Assurance Actions What are the issues scheduled for consideration BS spoke to the circulated updated Committee by the Committee in 2017/18? Year Planner document detailing known items relating to Health & Safety Team, Estates and Operational Unit Health, Safety and Fire Management Plans for 2017/18. The updated Year Planner was noted. 7) TOPIC: STATUTORY AND MANDATORY TRAINING Issues/Risks/Outcomes Expected Assurance What is the position in relation to Sharps BS spoke to the circulated report which training? indicated that against a compliance target of 80%; approximately 52% of relevant staff had been trained. There was concern that the data presented was also not complete. The importance of accurate reporting was emphasised and it was noted a Training Compliance Officer had been appointed. There was agreement as to the need to maintain focus on StatMan training in staff communication. 9 Actions

10 10 What is position in relation to Moving & SC spoke to the circulated report providing Handling and Violence and Aggression training? in relation to both LearnPro and face to M&H training activity to 31 March report indicated little movement from previously reported. data face The that DF advised that in relation to V&A training, this being delivered face to face for clinical staff, overall compliance rates were not encouraging. It was suggested all relevant V&A training could be delivered via Learnpro. There was concern expressed at the lack of progress being made in relation to training compliance for these areas, despite the key issues having been previously identified and discussed. During discussion, it was suggested that given the number of identified issues relating to this subject, a whole Value Stream approach was required. It was stated managers and staff had to better recognise the designation Action: Agreed Operational Units promote the of StatMan training and ensure appropriate uptake of relevant training compliance. Reporting Process and Learnpro PM advised training compliance was being reported quarterly and confirmed this was subject to continuous review, including in relation to the relevant metrics used and background impact factors. With regard to Learnpro, PM stated that further functionality within the system has been purchased that it would provide a better overview of organisational compliance with statutory and mandatory training as managers will be able to create an online statman training plan and monitor and report progress against the plan via a dashboard. NHS Borders are using the new functionality and have linked this to eess OLM, PM is liasing with Borders to 10

11 11 share their experiences and integrated these into NHS Highlands project. Training Compliance Officer PM advised M Forbes had been appointed and would take forward a range of activity in relation to working with training providers, managers and staff. There would be further consideration of the communication processes. As an example of activity, PM advised that links with Employment Services would allow for early identification of new starts, thereby enabling training requirements to be determined, courses to be booked and compliance to be monitored. This activity would be used to help drive performance improvement in this area. M Forbes and P Maber left the meeting at 12.45pm 8) TOPIC: INTERNAL AUDIT ASSIGNMENT FOR HEALTH & SAFETY Issues/Risks/Outcomes Expected Assurance Actions What is included within the scope of the Internal There had been circulated a copy of the Internal Actions: Agreed an update of the feedback and Audit review? Audit Assignment Plan for Health and Safety, actions are to be provided to the next providing the background, scope and business Committee in Nov 17 objectives of the review along with an associated reporting timetable. BS advised that fieldwork had commenced. 9) TOPIC: REPORT BY HEALTH & SAFETY REPRESENTATIVES Issues/Risks/Outcomes Expected Assurance What is the position in relation to Health and EC advised walk-round activity had been Safety representative activity? scheduled for the remainder of 2017 in relation to South and Mid Division and New Craigs. A further H&S representative (RCM) had been identified and recruited, and would attend the 11 Actions

12 12 next Committee meeting in an observational capacity. She stated introduction of Operational Unit Work Plans had proved a positive move. 10) TOPIC: ADVISER S REPORTS Issues/Risks/Outcomes Expected Assurance Actions 10.1) RIDDOR Reporting/HSE Activity and HSE Skin Health Action Plan What is the latest position in relation to RIDDOR There had been circulated Q2 report for 2017/18 outlining RIDDOR events and an reporting in NHSH? indication of the status of possible investigation activity. What progress has been made in relation to the There had been circulated updated Plan as at 31 July The current arrangements have HSE Skin Health Action Plan? been reviewed and updated in line with HSE recommendations. It was advised that Pilot activity was to commence shortly ) CSU Electrical Isolation Adverse Event BS advised a final Adverse Event Report had Action: Agreed Action Plan be submitted to the been issued; the findings, conclusions of and next meeting E. Green / B. Summers recommendations from which are to be discussed with the Director of Strategic Commissioning, Planning and Performance as Responsible Officer and who would also jointly Chair the review process which is arranged for Sep ) Infection Control What are the current issues in relation to The Committee noted the circulated report Infection Control within NHSH? which indicated performance against relevant Local Delivery Plan Standards relating to Infection Prevention and Control. Noted that NES had, in June 2017, replaced the Cleanliness Champions programme with the Standard Infection Control Education Pathway, modules relating to which would become 12

13 13 mandatory as part of Induction processes. 10.3) Occupational Health What are the current issues Occupational Health? relating to Committee noted and welcomed the circulated report outlining recent increased activity levels against Key Performance Indicators (KPIs). There had been no significant health concerns identified through current health surveillance programmes or referrals. It was advised that levels of self and management referrals were consistent year on year. Common themes were Action: Common themes identified within the identified and discussed within the wider HR OH Annual Report 2016/17 to be further discussed L Rawlinson/E Caithness team and included in the OH Annual Report. 10.4) Radiation Protection What is the latest position in relation to The Committee noted the circulated report Radiation Protection in NHSH? which gave updates in relation to Radon activity; Oncology; Radiology; Nuclear Medicine; Dental Services; Lasers; Phototherapy; Control of Electromagnetic Fields at Work Regulations (CEMFAW) 2016; Ionising Radiations (Medical Exposure) Regulations; new legislation; Staff dose monitoring; and the Radiation Safety Committee. BS advised there was to be a meeting to Action: B. Summers to meet with Andrew Hince discuss any relevant implications arising from a and agree the actions to satisfy the comments recently conducted inspection. raised by the IRMER Inspector regarding the 2016 Health and Safety Policy. 11) TOPIC: ELECTRICAL SAFETY GOVERNANCE ESTABLISHMENT OF ELCTRICAL SAFETY SUB GROUP Issues/Risks/Outcomes Expected Assurance Actions What is the Position in relation to establishment The Committee noted the circulated Terms of Action; Committee agreed the creation of the of an NHSH Electrical Safety Group? Reference document outlining the Role and Electrical Safety Sub Group. - Bruce Barr Remit for the proposed Group. 13

14 14 12) VALEDICTORY Noting this as the last meeting of the Committee to attended by the Director of Human Resources, prior to her retirement from post, the Chair took the opportunity to thank Mrs Gent for her long and distinguished service and commitment to the work of the Health & Safety Committee and wished her well in to the future. 13) DATE AND VENUE OF NEXT MEETING The next meeting of the Health and Safety Committee will be held on Thursday 2 November 2017 at 10.00am in the Board Room, Assynt House. The meeting closed at 1.00pm 14

15 15 Health & Safety Committee 2 November 2017 Item _NHS Highland HS Plan_HS Team Plan Item 4.1_NHSH HS Plan_HS Team Plan Nov 17 Actions Update PRINT ON A3 ID PU5 Topic for Action Annual Report Template Action Required Progress Made Create an Annual Report Template for the Op Units and distribute by Nov 17 latest NHS Highland Safety Management System and polices are based on the HSE's HSG 65 Managing for health and safety model. There are numerous SMS's but HSG65 fits well with other day to day organizational systems and it is based on the Plan, Do, Check Act principles. The Act part of the model is about us checking the validity of our policy and systems, and ensuring the systems we have in place in Highland are effective. Action Status Next Steps (List) HS Committee Reporting Date Consult with OH Agree the template format Complete the joint report for May 18 Nov 17 Ratify Finalise Document Promlugated Nov 17 RAG At present, we do not undertake a robust internal review process,whilst we report annually through the Audit Committee to the Board in terms of providing assurance that the governance arrangements for HS across NHSH are effective, working to an agreed plan and meets regularly, that is not the same as performance review. The objectives of the review would be to: 1. Make judgements about the adequacy of health and safety performance at a corporate and operational level in terms of governance and plans - operational units would be required to submitt a short summary performance review over the previous year 2. Providing assurance or not that systems for managing health and safety is working 3. Providing an overview on our compliance performance for key risks including those managed by Estates through SCART 4. Setting Standards and Improving Performance 5. Reviewing how we need to respond to change 6. Learning from experience 13 The majority of Boards health and safety and occupational health departments produce a combined performance report annually. The recommendation to the committee is that they endorse this approach from 2017 onwards and consider a joint health and safety report with Occupational Health. RA2 Procedure Revise, update and ratify MP11 General Risk Assessment Procedure by Aug 17 Update Aug 17 The current MP11 General Risk Assessment procedure is being reviewed and updated now and this will be available for ratification at Nov 17 committee. Minimal changes are anticipated 17 Update 25 Oct 17 Procedure reformatted and some minor amendments made to the previous version. VA1 Team Remit & Role Establish and communicate the role and remit for the VA team. Each NHS Scotland Board has a Violence and Agression team, howver national colaboration, cohesion, joint working and direction setting is weak, hwowever there are moves to improve thsi and standardise the discipline. Operationally, particularly in the in-patient setting, there is an elemnt of confusion about the role of the team, and it was therefore important to be clear with the Committee and Orgaisation about the roles and taks the team undertakes and doesn't undertake. The attached is for discussion Get feedback from the Committee Nov 17 Amend and finalise IPS1 Create a SLWG Write to Associate Medical Director and Nurse Director for their clinical support and leadership to establish a SLWG to assess the current systems and arrangements for managing patients from self harming on ligature points & ligatures in mental health units. This should also include general settings in particular AE, paediatrcs etc. The "next steps" for consideration are detailed in the paper from the Nov 16 HS Committee which is attached and from the outcome fo the letter. Informal discussions have been made with the Nurse Director and Associate Medical Director for MH regarding the proposed prevention work. Mental Health Argyll & Bute. A workshop was held with MH leads and Health Safety colleagues in Argyll & Bute on 20 Jun in Lochgilphead at the new IPCU/HDU facility. Staff were introduced to the new risk assessment tools, they were then practiced. AB IPCU were advised to complete the risk assessments and have them in place before the new unit opened. Mental Health New Craigs. General Manager NC, invited Head of HS and South & Mids HS Manager to attend the NC Operations Meeting (atended by service managers and the clinical lead for psychairty) to discuss the arrangements for assessing and managing suicide risk. It was explained to NC that their current arrangements require improvement and that the existing assessment tool was dated. The outcome is that an Environmental Ligature Risk Assessment Workshop has been arranged for Wed 09 Aug 17. This will be attended by Service Leads and Ward Staff. A similar apporach will be taken to that delivered in Argyll & Bute, followed up by an action plan to owned by New Craigs. This will be submitted to the Committee in Nov 17 for assurance. 1. Mon 06 Dec 17 - workshop at New Craigs to deliver final training session on how to carryout and maintain the environmental ligature risk assessment system Exported on 25 October :12:40 o'clock WEST Update 25 Oct 17 The ligature Risk Assessment Workshop took place on 09 Aug and was well attended and supported by the general manager and clincal area managers, estates, robertsons, clinical governance, VA and health and safety. It took the same format as the workshop in Argyll & Bute. It was felt that a number of adjustements would be required to the RA to ensure that it was relevant for New Craigs, and because of this, and becuase of the risks in further amending a methodology that was previsouly validated by the orginators, Manchester mental Health Trust, we have invited those involved in the creation and rollout of the original "Manchester Tool", to share their experiences with New Craigs before they undertake the risk assessment processes. Rushing and rolling out RA's without careful though and planning achieves very little in risk reduction terms other than large quantities of ineffectual paper and this strongly discouraged and is wasteful. The Head of Patient Safety & Governance, Greater Manchester Mental Health NHS Foundation Trust, will be visiting New Craigs on Mon 06 Dec, to explain and share experiences on the use and rollout of the tool. At that point the intention will be to create a risk assessment rollout plan, and then begin the assessment programme, high risk wards first. We will also be sharing this information and working alongside the regulator, as there is currently an ongoing investigation which will hopefully concluded its deliberations at the end of Nov 17. Highlighting changes made in the last Day Nov Week of 06 Dec 17 - create a risk based strategy of approach to complete the RA's 3. Complete the risk assessments. The intention is to complete them before the Xmas closedown 4. New Craigs to provide admin support Page 1 of 1

16 16

17 17 Health & Safety Committee Health and Safety Committee 2 November November 2017 Item Item Occupational Health and Safety Annual Report Report by Bob Summers Committee is asked to: Note: that NHS Highland has no regular formal review mechanism to assess the effectiveness of the current safety management system Discuss and Agree: the recommendations below 1.0 Background. NHS Highland Safety Management System (SMS s) and polices are based on the Health and Safety Executives HSG65 Managing for Health and Safety model. There are numerous SMS models but HSG65 fits well with other day to day organizational systems and it is based on the Plan, Do, Check Act principles. The Act part of the model is about the organisations role in monitoring the validity of our policy and systems, and ensuring, through a management review process that the systems we have in place in Highland are effective. At present we have no mechanism in place to achieve this. 1.1 Issue. The current Annual Report, submitted each May, provides assurance from the Committee, through the Audit Committee, to the Board that the governance arrangements established for occupational health and safety are functioning. However there is no opportunity or mechanism within the current reporting format to assure the Public, Board, or Audit and Health and Safety Committees that the current SMS remains suitable, adequate and effective. An annual Occupational Health and Safety (OHS) management review would determine whether: the current health and safety arrangements in NHS Highland still make sense, it closes the loop, it assesses opportunities for improvement and change and the outcomes set out our plan and objectives for the following year(s). 1.2 Review Standards & Criteria. HSG 65 (Appendix 1) sets out a suggested criteria for how organisations should routinely review (e.g. annually) their processes and systems, as does the forthcoming ISO (Appendix 2) and soon to be rescinded BS OHSAS 18001:2007 (Appendix 3). 1.3 Conclusion & Recommendations. The majority of Boards OHS departments produce a combined OHS performance review on an annual basis. It is recommended that the committee decides on the appropriate criteria (using Appendices 1-3) to produce a Health and Safety Annual Report. It should be noted that the Operational Units would be required to contribute to this report. It is also recommended that a combined Occupational Health and Safety Report is produced from Bob Summers Head of Occupational Health and Safety 31 Oct 17

18 18 Health and Safety Committee 02 November 2017 Item Appendix 1 HSE, HSG65, Managing for Health and Safety, 2013, Reviewing Performance Key actions in reviewing performance effectively Leaders Consider the review findings. If improvement is needed act now, rather than reacting to an incident in the future. Make sure the review is carried out according to the plans, and that a report is issued to senior leaders at least annually. Ensure the scope of the review will give assurance that risks are as low as reasonably practicable (see page 25), and that your organization is complying with health and safety law. Managers What are the objectives of the review? Making judgements about the adequacy of health and safety performance Assurance that the system for managing health and safety is working Ensuring you are complying with the law Setting standards Improving performance Responding to change Learning from experience Who will carry out the review? Someone independent, perhaps from another business area, could add value to the process. What type of information will be collected? Active monitoring (before things go wrong) Reactive monitoring (after things go wrong) Accident/incident/near-miss data Training record Inspection reports Investigation reports Risk assessments New guidance Issues raised by workers or their representatives Checks required by law, eg on lifting equipment and pressure systems How often will you need to carry out a review? This will depend on your risk profile (see pages 26 30). Think about the supply chain How could the actions or health and safety performance of suppliers or contractors affect your organisation? Consider incidents that have occurred in similar organisations Could they be repeated in your organisation? Report the review findings It is crucial that you report any findings to everyone within the organisation. Ensure remedial actions have been carried out You also need to make sure that the measures work.

19 19 Health and Safety Committee 02 November 2017 Item Appendix 2 - ISO 45001:2017 Occupational Health and Safety Management Systems (Final Standard to be published in Nov 17) Management Review Top management shall review the organization s OH&S management system, at planned intervals, to ensure its continuing suitability, adequacy and effectiveness. The management review shall include consideration of: 1.0 The status of actions from previous management reviews; 1.1 Changes in external and internal issues that are relevant to the OH&S management system including: the needs and expectations of interested parties; legal requirements and other requirements; the organization's risks and opportunities; 1.2 The extent to which the OH&S policy and the OH&S objectives have been met; 1.3 Information on the OH&S performance, including trends in: incidents, nonconformities, and corrective actions and continual improvement; monitoring and measurement results; results of evaluation of compliance with legal requirements and other requirements; audit results; consultation and participation of workers; risks and opportunities; 1.4 Adequacy of resources for maintaining an effective OH&S management system; 1.5 Relevant communication(s) with interested parties; 1.6 Opportunities for continual improvement. 1.7 The outputs of the management review shall include decisions related to: continuing suitability, adequacy and effectiveness of the OH&S management system in achieving its intended outcomes and continual improvement opportunities

20 20 Health and Safety Committee 02 November 2017 Item Appendix 3 - BS OHSAS 18001: Occupational Health and Safety Management (due to be superseded by ISO shortly) Management Review 1.0 Top management shall review the organization s OH&S management system, at planned intervals, to ensure its continuing suitability, adequacy and effectiveness. Reviews shall include assessing opportunities for improvement and the need for changes to the OH&S management system, including the OH&S policy and OH&S objectives. Records of the management reviews shall be retained. 1.1 Input to management reviews shall include: Results of internal audits and evaluations of compliance with applicable legal requirements and with other requirements to which the organization subscribes The results of participation and consultation Relevant communication(s) from external interested parties, including complaints; the OH&S performance of the organization; the extent to which objectives have been met; Status of incident investigations, corrective actions and preventive actions; follow-up actions from previous management reviews; Changing circumstances, including developments in legal and other requirements related to OH&S; and Recommendations for improvement. 1.2 The outputs from management reviews shall be consistent with the organization s commitment to continual improvement and shall include any decisions and actions related to possible changes to: OH&S performance; OH&S policy and objectives; resources; and other elements of the OH&S management system. Relevant outputs from management review shall be made available for communication and consultation

21 21 Health & Safety Committee 2 November 2017 Item 4.1.1(2) VIOLENCE AND AGGRESSION PREVENTION TEAM ROLE AND REMIT Report by Diane Fraser Violence and Aggression Prevention Manager The Committee is asked to: Discuss, Comment and Note the DRAFT Violence & Aggression Team Role & Remit Team Structure & Establishment Manager Advisors x 1.5 Trainers x 3.5 Role & Remit Our role and remit is pan Highland and is delivered locally wherever possible. This includes hospitals, care homes, day care centres, home, POS, GP practices, Dental Practices, AHP departments. This list is not exhaustive and in reality can be anywhere NHS Highland has staff working with, and coming into contact with, patients, carers and the general public. This remit ranges from generic and specialist training to protect staff, to onsite engagement, advice and support with staff and patients, to planning, monitoring and investigating STAT/MAN TRAINING: Induction/Theory & Breakaway Half Day Clinical Refreshers 3 Day Mental Health Restraint 3 Day Mental Health Refresher Tailored Training Sessions (3 Hrs - 2 Day) Lone Working Teams Place of Safety Training Dementia Training Advice & Support Given On Site/Telephone/ Completion of Mdt Risk Care Plans Completion and Review of Abc Charts Advice on application of Adults with Incapacity / Mental Health Act De-Escalation, Communication & Consistency Debriefs Therapeutic Engagement Review and Updating Of Mdt Risk Care Plans Review of Abc Charts With A View To Planning Care Person Centred Approach/Patient Quality & Safety Observations Of Practice Working with Staff To Support In Safe Care Of A Patient

22 Monitoring and Review Of Datix: Contact and Feedback to Handlers Advice Trends Analysis Visits to Ward Data around Use of Restraint/Sedation Root Cause Analysis/Investigations: Advice on undertaking investigation Advice & support during investigation Lone Working: Audits Of Procedures/Protocols In Place Support And Guidance To Develop Proc/Protocols Provide Training Snap Shot Audits Of Compliance Environmental Audits: Walkrounds with Manager/Staff Looking At Access Reception Areas/Desk Security Alarms Audit of Response Procedures/Staff Training Safe Room Layouts Safe Exits Assess Access to Weapons Ligature Points in Clinic Areas Used For MH Patients Designated Patient Scheme (Dps): Advice and Support for Completion of MDT Risk Care Plan Quarterly Monitoring Meetings Advice and Support to Staff Working With DPS Patients Protocols/MDT Risk Care Plans For Persistent A&E/Hospital Attendees: Advice and Support in Development of Protocols Communication/Information Sharing Across Disciplines: Support Staff to Share Information across Disciplines Develop/Review & Update Policy/Procedure/Guidance V&A Procedure Lone Working Procedure Restraint Procedure Training Documentation/Audit Assist & Support in Other Policy Development Data Analysis Datix (Trends, Restraint, Sedation, Severity) Stat/Man Figures Training Records

23 Capital Projects/Redesign/Refurbishments Provide advice & support to project managers Staff Bank: Work With Staff Bank To Provide Training To New Starts UHI Working In Partnership to Train & Support Students

24 24

25 25 Health & Safety Committee 2 November 2017 Item 4.1.1(3) Health and Safety Policy Hazard Based Procedure 10 HBP10 Lone Working Procedure Procedure No: HBP10 Procedure Revision No: 1.2 Prepared by: Diane Fraser, Violence & Aggression Prevention Manager Ratified by: Health and Safety Committee Effective From: 2017 Review Date: Lead Reviewers/Authors: Diane Fraser, Violence & Aggression Prevention Manager Dissemination Arrangements: Policy Area of NHS Highland Intranet NHS Highland Health and Safety Intranet Site HS Committee Membership Targeted s to Director of Operations and Operational Managers Professional Groups Staff Announcements Warning - this document is uncontrolled when printed. Please ensure you have the most recent version of this document Procedure Number: HBP10 November 2017 Page 1 of 37 Version 1.2

26 26 CONTENTS 1 DEFINITIONS OF LONE WORKING INTRODUCTION PRINCIPLES AND VALUES PRIORITIES AND ACTIONS SCOPE AIMS LONE WORKERS LEGISLATION RESPONSIBILITIES POINTS OF CONTACT ASSESSMENT AND MANAGMENT OF LONE WORKING RISK ESCORTING/TRANSPORTING PATIENTS/SERVICE USERS DEALING WITH ANIMALS ESCALATION PROCESS REPORTING OF INCIDENTS TRAINING MOBILE PHONES POOR PHONE NETWORK SIGNAL/BLACKSPOTS SAFEGUARDS & CONTROL MEASURES MONITORING AUDIT AND REVIEW OTHER RELEVANT POLICIES COMPLIANCE AUDIT...12 APPENDIX 1 - LONE WORKING IN COMMUNITY SETTINGS...13 APPENDIX 2 - LONE WORKING IN BUILDINGS...15 APPENDIX 3 - LONE WORKERS TRAVELLING...17 APPENDIX 4 ASSESSMENT OF RISK...19 APPENDIX 5 EXAMPLE RISK ASSESSMENT...21 APPENDIX 6 LOCAL LONE WORKING PROCEDURE GUIDANCE...28 APPENDIX 7 USE OF HUB OUT OF HOURS...32 APPENDIX 8 HUB REGISTRATION FORM...33 APPENDIX 9 STAFF PROTOCOL EXAMPLE FOR LONE WORKING MANAGEMENT.34 APPENDIX 10 - COMPLIANCE AUDIT TOOL...35 Procedure Number: HBP10 November 2017 Page 2 of 37 Version 1.2

27 27 1 DEFINITIONS OF LONE WORKING 1.1 NHS Protect s definition of lone working is: any situation or location in which someone works without a colleague nearby; or when someone is working out of sight or earshot of another colleague 1.2 NHS Highland defines lone working as: Activities undertaken by employees that involves them working without any kind of close or direct contact with colleagues. 1.3 The HSE defines lone workers as those who work by themselves without close or direct supervision and there is a requirement to assess all risk to these staff and put measures in place to control these risks 2 INTRODUCTION 2.1 NHS Highland fully recognises and accepts its responsibility to ensure, so far as is reasonably practicable, the health, safety and welfare of all its employees with regards to all situations where they are involved in working in isolation from colleagues in connection with their duties. 2.2 Where lone working can be avoided it should be. However, NHS Highland recognises that a number of employees will be required to work in isolated situations or be on their own for long periods of time. NHS Highland will ensure therefore that all risks associated with lone working will be assessed. This should ensure that the health and safety of employees and the wellbeing of patients is not compromised. 2.3 Employees must only work within their own recognised area of competence and capability. 2.4 Local procedures will be developed in partnership with the relevant teams to ensure good communication links are maintained with those who are required to work alone. The effectiveness of these procedures will be audited at least annually by the Health and Safety Team 3 PRINCIPLES AND VALUES 3.1 NHS Highland will promote a culture whereby the increased risks associated with working alone, are seen as unacceptable. This will be in accordance with NHS Highland s vision of valuing and protecting the personal safety of our employees and others. 3.2 All employees should expect that safe systems of work will be in operation to reduce the risks associated with lone working to a minimum. 3.3 There may be situations where working alone will not be acceptable. In such situations, NHS Highland s managers will ensure that local procedures and protocols are devised, in place and adhered to. These procedures and protocols will include contingency measures for foreseeable and unforeseeable problems and issues that may arise. 3.4 NHS Highland will review this policy to ensure its effectiveness on an identified and agreed basis. Procedure Number: HBP10 November 2017 Page 3 of 37 Version 1.2

28 28 4 PRIORITIES AND ACTIONS There are a number of priorities and actions that underpin the development of this procedure. They are: Staff working within NHS Highland have the potential to be required to lone work as part of their job role. This can be Fixed (within a building), Mobile (working in the community or Travelling (between NHS premises). As a result it is necessary to undertake risk assessments (See Appendix 5) which identify any hazards staff could be exposed to, the current control measures and any enhanced measures that may be required to either remove the risk or minimise it to its lowest possible form. Appropriate measures must be put in place to ensure staff safety. Employees and their representatives will be fully involved in the development and implementation of local procedures to reduce the risks associated with lone working. 5 SCOPE 5.1 This procedure applies to all situations where employees are involved in working alone arising out of or in connection with their duties and activities as employees of NHS Highland. 5.2 The policy includes and applies to temporary staff, agency staff, independent contractors, students, and volunteers. 5.3 Those working for another employer will be reminded of their responsibilities and will be given information in order for them to carry out their duties within a safe system of work by those managers who employ them. 6 AIMS 6.1 To provide guidance to managers on how to implement safe systems of work with respect to lone working in order to reduce the risks to lone workers. 6.2 To clarify the roles, responsibilities of those who manage lone workers and of those who work alone 6.3 To ensure there are effective risk assessment processes in place 6.4. To ensure that clear and robust local procedures are in place, identifying any known and potential risk along with all control measures to address these risks with the purpose of reducing said risk and wherever possible removing risk 6.5 To increase staff awareness to risks of working alone 6.6 To encourage full reporting and recording of incidents related to lone working and that these incidents are dealt with as they occur. 6.7 To share information with staff/colleagues both within own work area and those who work in other disciplines/agencies where there has been known and potential risks identified. 6.8 To ensure that staff training and support are provided to those who are required to work alone. 6.9 To reduce the number of incidents related to lone working. Procedure Number: HBP10 November 2017 Page 4 of 37 Version 1.2

29 29 7 LONE WORKERS 7.1 This term is used to describe a broad spectrum of staff groups who may regularly work alone or may occasionally be asked by their manager to work alone, as an exception to their normal duties and are without immediate access to support and assistance from colleagues and/or managers. The very nature of lone working may increase the risks for these staff. 7.2 The following identifies examples of staff groups who are likely to be identified as lone workers. This list is not exhaustive: Staff working in isolation within a building: Reception staff Staff undertaking clinics in rooms alone Estates staff Domestic Staff Staff working outwith normal working hours: Domestic staff Drivers Nursing and Medical staff Estates staff Laboratory staff Care at Home staff Social Work Staff who work within the Community: Nursing & Midwifery/AHPs/GPs/Social Work Care at Home Staff Estates NHS staff who are travelling between premises 8 LEGISLATION The main pieces of legislation that apply are: 8.1 Health & Safety at Work Act 1974 NHS organisations have responsibilities under the above Act, particularly in relation to employers ensuring, as far as reasonably practicable, the health, safety and welfare of employees at work. This involves the implementation of safe systems of work, health and safety policies, guidance, training and safe working environments. 8.2 The Management of Health & Safety at Work Regulations These regulations require organizations to assess risks to staff having adequate and sufficient risk assessments in place along with effective control measures and monitoring and audit processes in place 9 RESPONSIBILITIES The following outlines the responsibilities within NHS Highland: 9.1 The Chief Executive/Lead Executive for Health & Safety - The general accountabilities and responsibilities for the Chief Executive, Directors, and Lead Executive for Health and Safety, with respect to Health and Safety Management are detailed in the Boards Health and Safety Policy These will apply equally to this procedure. 9.2 Area / Local Area / District & Locality Managers are responsible for providing reassurance to their Director of Operations / Chief Officer that this procedure is implemented throughout their areas of responsibility and that there are suitable and sufficient arrangements in place to safeguard staff whilst lone working whilst carrying out their duties. Procedure Number: HBP10 November 2017 Page 5 of 37 Version 1.2

30 30 Ensure that regular auditing is carried out to ensure this procedure is implemented and working effectively. take place of lone working procedures currently in place within their areas of responsibility 9.3 Local Managers, Team Leaders and Supervisors are responsible for: a) Making sure that their staff are aware of the procedure b) Identify all staff who are lone workers c) Ensure that suitable and sufficient risk assessment has been undertaken around the hazards and risks associated with lone working, putting appropriate control measures in place to minimise, control or remove the risks d) Developing and implementing local procedures taking into account the required controls for the risks associated with lone working e) Ensure that the risk assessments and lone working procedures are implemented, managed, reviewed and updated on a regular basis f) Ensuring that staff are provided with access to, and are up to date with, all Statutory/Mandatory training as identified for their job role in the Staff Training Prospectus (NHS Highland 2017). g) Ensuring that their staff are given adequate and sufficient information to be able to carry out their role safely h) Ensuring that risk information is readily available to staff at all times i) Ensuring that staff feel supported and adequately protected whilst undertaking lone working duties j) Managing the effectiveness of preventative measures through an effective system of reporting, investigation and recording of incidents as laid out in the NHS Highland Adverse Event Management Policy and Procedures (NHS Highland, 2017) k) Follow and adhere to Adverse Event Management Policy and Procedure l) Arrange a debrief for staff involved in an adverse event. m) Regularly review and update Lone Working Procedures, ensuring control measures in place are adequate and that lessons learnt are taken into account Following any adverse event, staff involved should have access to appropriate support e.g. access to Occupational Health. Should the adverse event be identified as RIDDOR reportable then the adverse event must be reported to the Health and Safety team immediately thereby ensuring timely reporting to the Health and Safety Executive. 9.4 Employees are responsible for: a) Taking all reasonable care of themselves and any other people who may be affected by their acts or omissions b) Assisting in the development of and complying with lone working guidelines and procedures c) Employees should check that there are up to date risk assessments in place and that these are still adequate d) Ensuring that all incidents and near misses, however minor, are reported to their line manager and also through Datix e) Taking part in Statutory/Mandatory Violence & Aggression training with a focus of lone working f) Employees should plan appropriately and risk assess prior to any visit and undertake continuous dynamic risk assessment of the situation they find themselves in, taking account of changing circumstances and taking necessary action to minimise the possibility of an incident occurring. Any dangers or concerns identified as a result of lone working must be reported to their line manager and also through Datix g) At no time should an individual feel pressured into undertaking a task where they consider themselves to be at risk this will be fully supported at all levels of management in NHS Highland Procedure Number: HBP10 November 2017 Page 6 of 37 Version 1.2

31 31 10 POINTS OF CONTACT 10.1 During normal Hours In all instances a written local procedure or suite of rules, which sets out how lone working practice will be managed locally, must be in place which supports the principles of this procedure The numbers of points of contact will vary dependent on assessed risk. As an absolute minimum the local procedure will ensure a three-point contact during normal working hours. There should be a start of day contact and an end of day contact with at least one contact during the working day. Local procedures and arrangements must be effectively communicated to all staff within teams Local procedures must be adhered to between the hours of 0900 and Out-with normal Hours In all instances between the hours of 1700 and 0900 Monday to Friday; 24 hours Saturday and Sunday and public holidays the NHS HUB must be used as a point of contact A checklist of the details required for the HUB is available in Appendix 8. ASSESSMENT AND MANAGMENT OF LONE WORKING RISK 11.1 Assessment The general principles of risk assessment, which are detailed in Management Procedure 11 General Workplace Risk Assessment, must be followed. Lone workers should not be exposed to avoidable risks. A risk assessment may show that a safe system of work cannot be established for a lone worker, therefore other arrangements, such as additional staffing, must be put in place. Any risk assessment should take account of all factors as well as normal work. (See Appendix 5 for examples) 11.2 Managing the Risks The risks to lone workers should be reduced to as low a level as is reasonably practicable. Safe systems of work (procedures) must be adopted locally to reflect the specific circumstances of the job, geography and availability of help. Specific guidance must be in place and communicated to employees and employees must adhere to these local procedures It is of vital importance that all appropriate staff are fully aware of all control measures which are in place. It is of equal importance that employees alert managers to other issues of which they may not be aware. (See Appendix 5 for examples) 11.3 Dynamic Risk Assessment The importance of dynamic assessment is that it enables lone workers to anticipate and recognise the early warning signs of suspected risks and enables safe early interventions to minimise or negate the risk to themselves and others. It recognises that situations change rapidly as do associated risks and that dynamic risk assessment should be an ongoing process. (See Appendix 5) 11.4 Sharing Risk Information Information concerning risks from individuals and addresses should be communicated internally to all relevant staff who may work with the same patient/service user including Staff Bank, agency, temporary or part time staff. The NHS as an organisation should also share information on known risks of addresses and associated individuals with other colleagues externally, within health and social care and other relevant public sectors. This should include the ambulance service and Procedure Number: HBP10 November 2017 Page 7 of 37 Version 1.2

32 32 patient transport services and any other disciplines/agencies that might be faced with the identified risks Serious & Imminent Danger Employees who believe themselves to be in serious and imminent danger should, where possible, cease or postpone the work activity and remove themselves to a place of safety. The member of staff is to inform their manager of any such situation and the reasons for their actions, at the earliest opportunity. It is impossible to give precise advice for every situation, however a decision taken at the time in the interest of their own or another person s safety, will be supported by NHS Highland Employees in these circumstances should ask themselves the following: Should I be here; is it safe to remain; should I seek assistance? - If in doubt, the employee should leave and inform their manager as soon as possible Lone visits MUST NOT be made to clients or locations where there is a history of violent or aggressive incidents. Staff should only visit these places in very exceptional circumstances, where there are no practicable alternatives, as sending staff in pairs cannot be relied upon to reduce the risks. IF VIOLENCE IS THREATENED - LEAVE IMMEDIATELY 12 ESCORTING/TRANSPORTING PATIENTS/SERVICE USERS Those services that have occasion to escort/transport service users are to ensure that they risk assess each service user and individual occurrence. They should consider: a) The physical and mental state of the patient and whether they are capable of being transported. b) The level of staff experience, their qualifications and the number of staff needed to manage the patient. c) The type of transport to be used (e.g. ambulance, patient transport service, contracted taxi service or lone worker s vehicle). d) Physical safety measures during the escorting process should be outlined. Lone workers should not escort a patient if there are any doubts about their own safety. e) What is the process if conflict arises? This should follow local procedures, which may involve calling the police, their manager, a colleague or buddy. f) Appropriate planning and provision should be made for the safe return of a lone worker to a familiar place, once the patient has been dropped off. 13 DEALING WITH ANIMALS 13.1 Staff must consider the potential risks posed by household pets when conducting home visits. Considerations will of course involve safety, allergies and infection control Where animals are present and the staff member is concerned for any of the above reasons, a polite request should be made for the animal to be placed in a different room. If the resident/owner is not content with this request and has had the clinical and personal safety issues explained in a calm manner and if appropriate the visit should be abandoned and reported in accordance with the Adverse Event Management Policy and Procedure. Procedure Number: HBP10 November 2017 Page 8 of 37 Version 1.2

33 Once staff are aware of any risk posed by animals, it is perfectly acceptable for a letter to be sent to the patient/household asking them to ensure that the animals are kept separate from the patient 14 ESCALATION PROCESS All services must operate an escalation procedure, outlining who should be notified if a lone worker cannot be contacted or if they fail to contact the relevant individual within agreed or reasonable timescales. The escalation process should include risk assessment and identification of contact points at appropriate stages, including a line manager, senior manager and, ultimately, the police. Any individual nominated as an escalation point should be fully aware of their role and its responsibilities. 15 REPORTING OF INCIDENTS All incidents and near misses should be reported by telephone to the staff member s line manager as soon as possible following an incident and then through Datix at the earliest opportunity. Incidents should be investigated by managers and feedback provided to staff. Ongoing monitoring of systems should take place, and managers should regularly review local incident reports. 16 TRAINING Following initial induction, employees will receive ongoing training on the lone working procedure to ensure their safety. Additional training will be needs based and will take place through a needs assessment identified through risk assessment. The recommended training for any lone worker is: Risk assessment Violence and Aggression Prevention Violence and Aggression Prevention Training with a focus on Lone Working Moving and Handling Driving in Adverse Weather Conditions 17 MOBILE PHONES 17.1 Lone workers should be provided with mobile phones, however as much as a mobile phone is an essential control measure when lone working, it should not be relied upon as the sole means of communication. Lone working staff should follow their team s local lone working procedure and they should ensure their line manager knows of any potential lone working situations, and if not their line manager then there should be an identified point of contact who is fully aware of lone working staffs schedules, including location and nature of visit/appointment 17.2 Staff are responsible for checking phone network signal strength before entering a lone working situation If there is a delay in the agreed time frame for a visit/appointment then the lone working procedure should instruct the manager/point of contact to attempt to contact the lone worker and check that they are safe Lone workers should ensure that they are fully familiar with the mobile phone and that they can use it properly and that it is always fully charged Procedure Number: HBP10 November 2017 Page 9 of 37 Version 1.2

34 Emergency contact numbers should be kept on speed dial 17.6 The mobile telephone should always be kept on the person and easily accessible Mobile phones should not be left unattended Lone workers need to be fully aware that using a mobile phone in certain situations could escalate an aggressive situation 17.9 As part of the local lone working procedure, an agreed code word/phrase could be use to alert their manager/point of contact that the lone worker is feeling threatened or uncomfortable with a situation. This would allow the manager/point of contact the opportunity to raise an alert e.g. contact the Police. The decision to use code words/phrase should take into consideration the ability of any staff member to recall and use them effectively in a highly stressful situation Staff are reminded that it is against the law to use a mobile phone whilst driving. 18 POOR PHONE NETWORK SIGNAL/BLACKSPOTS 18.1 A record of all known phone network blackspots should be kept as part of the lone working procedure/documentation. Staff should be aware that they are going into a blackspot and should notify their manager/point of contact prior to going in. They should agree a timeframe e.g. 30 minutes and if after 35/40 mins there has been not contact from the staff member, the manager/point of contact should be trying to contact the staff member Where there is a poor network signal, agreement should be made with the client/patient to be able to use the landline to contact their base to notify arrival at destination. 19 SAFEGUARDS & CONTROL MEASURES 19.1 If potential risks are identified in respect of patients, relatives or location, suitable safeguards must be put in place before contact is made with the service user. The precise nature of the safeguards will depend on the situation, but any of the following may be appropriate: Arrange for meetings to be held on NHS site or other suitable premises, rather than at the service user s home. Allocate two members of staff to make the visit. Arrange for a reliable relative to be present, if, for example, an employee might be vulnerable to sexual harassment or allegations of it. If the presence of relatives is problematic, ask the patient to arrange for them not to be present. For persistent, low-level problems, agree a contract with the service user or relative which, if broken, would result in the withdrawal of home care. In the case of severe problems, home care should be withdrawn and the individual concerned be identified as unsuitable for home visits It is essential for employee s safety that when they are working in the community they can be located by their colleagues. Managers must have a reporting system to ensure that the individual s whereabouts are known, this could be as simple as keeping copies of the lone workers diary pages. There must be a procedure for checking in and out, which should include an agreed return and/or ring-in times. If employees expect to finish outside normal office hours, arrangements for checking in should be negotiated with an agreed contact. Procedure Number: HBP10 November 2017 Page 10 of 37 Version 1.2

35 If there is any change in arrangements the employee must inform their manager, or a person nominated within the team. If the employee does not report back as agreed the manager or the nominated person must attempt to make contact If contact cannot be established with the employee, the service user should be contacted to confirm the visit and last known whereabouts. If the employee can still not be contacted, the line manager must take further action agreed within the procedure of the assessment dependent on the level of risk When established via risk assessment a mobile phone or lone working device should be available to each team, pre-programmed with a contact telephone number so that in emergencies only one or two buttons need to be pressed and in the case of a lone working device staff must be trained in its use. As previously discussed, Code words/phrases might be agreed where open communication is difficult. 20 MONITORING AUDIT AND REVIEW 20.1 Managers are to monitor the effectiveness of the control measures implemented as a result of the risk assessment process to find out how successful they have been. This will allow managers to identify those control measures and strategies that are not working, or which have unforeseen consequences, and modify or replace them where appropriate There are two types of monitoring, which managers should carry out: a) Active Monitoring: Managers should ensure that local systems and procedures are working, without waiting until something goes wrong. It will confirm whether agreed procedures are actually being complied with by employees and whether they are workable in the individual circumstances and have the desired effect of preventing accidents or incidents. b) Reactive Monitoring: Managers should investigate all adverse events and near misses so that everyone involved can learn from the experience. Managers must ensure that employees understand how to report and record incidents through DATIX or to their manager. Information gained from this process will also assist in the effective review, and modification if necessary, of risk assessments and control measure The Boards Health & Safety Committee will review this procedure at regular intervals and ensure its implementation. Operational Health, Safety and Fire Groups have a similar but operational obligation to ensure the implementation of this procedure. Monitoring will take place on an ongoing basis and will include: a) Collation of all reported adverse events by the appropriate departments. b) Quarterly reporting to the Operational Unit H&S Groups on incident statistics and safety improvement measures which have been introduced and any barriers as identified. c) Annual reporting and recommendations for the forthcoming year to the Health & Safety Committee and Staff Governance Committee. Procedure Number: HBP10 November 2017 Page 11 of 37 Version 1.2

36 36 21 OTHER RELEVANT POLICIES 21.1 This procedure relates specifically to lone working. It is not stand alone and relies on access to and reading of the following policies which relate to, interlink with and support this procedure for example: 22 MP00 Health and Safety Policy and Management Procedures Adverse Event Management Policy and Procedures HBP08 Management of Violence and Aggression Procedure HPB09 Management of Occupational Road Risk Procedure COMPLIANCE AUDIT Use of and compliance with this procedure will be internally audited on an identified and agreed basis. REFERENCES Health and Safety Executive (2013) Working alone Health and safety guidance on the risks of lone working available at: Health and Safety Executive (2013) Reporting of Accidents and Incidents at Work: A brief guide to The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 Available at: NHS Highland (2017) Adverse Event Management Policy and Procedures available at: NHS Highland (2017) Statutory and Mandatory Training Prospectus Version 10.0 Available at: nd%20mandatory%20training%20prospectus%20v10.0.pdf NHS Protect (2017) A guide for the better protection of lone workers in the NHS Version 3 pg 5 Available at Procedure Number: HBP10 November 2017 Page 12 of 37 Version 1.2

37 37 Appendix 1 - Lone Working in Community Settings Hazard Risk Level Low Level of Protection/Control Visiting familiar low risk clients, during normal working hours, but in socially rough areas, carrying valuables and drugs; and travelling in isolated and remote locations Medium Requirement to establish a checking and monitoring system. Monitoring between each appointment. Use of daily itinerary and mobile phones Have a personal attack alarm, to startle and elude an aggressor and summon assistance from others within vicinity where possible. Training in Violence and aggression prevention, de-escalation and break away. High Avoid the need to visit alone where possible, Assess new clients in health clinics, or have accompanied visits. Risk information sharing with other professionals. Accompanied visits where there are concerns for safety. Controls as detailed for medium risk are all appropriate where the need for lone working cannot be avoided. Visiting familiar low risk clients, during normal working hours; not particularly remote or rough areas. Visiting unfamiliar clients and relatives. Visiting high risk or unstable clients Requirement to establish a checking and monitoring system. Use of daily itinerary and mobile phones At least two times of contact established, start and leaving. Factors for consideration when drawing up local procedures include: Procedure Number: HBP10 November 2017 Page 13 of 37 Version 1.2

38 38 WORKING ALONE IN COMMUNITY SETTINGS 1. During the Working Day Ensure that prior to undertaking lone working a risk assessment has been completed. 2. Employees must ensure that detail of their movement is communicated to colleagues locally. This may take the form of an itinerary for the day. As a minimum, employees should report to the nominated reporting base at the start and end of the working day. This may be by phone or in person. Depending on the assessed level of risk it may be necessary to use a staff double up system for initial and subsequent patient visits. Employees should never put themselves in a situation where they are in danger. Therefore there will be situations where Lone Working is not advisable or permissible. Outwith Normal Working Hours Ensure that prior to undertaking lone working a risk assessment has been completed. Employees who work outwith normal hours must ensure that they have a method of letting appropriate persons know of their whereabouts. All employees working outwith normal hours should contact the NHS HUB and provide details of whereabouts and contact details. The above will operate with employees who are, for example, on call overnight or working over a weekend period. A checklist for details required by the HUB can be found in Appendix 8. Procedure Number: HBP10 November 2017 Page 14 of 37 Version 1.2

39 39 Appendix 2 - Lone Working in Buildings Hazard Working alone within an area of a building, otherwise occupied by other staff Undertaking low risk tasks e.g. office duties Working within normal working hours and with a telephone available Risk Level Low Working alone, as for low risk situation, but out with normal working hours Medium Meeting clients or patients in isolated locations within an otherwise occupied building, within normal working hours Dealing with unfamiliar clients or patients Dealing with clients with a history of mental illness/drug dependency and unpredictable behaviours Alone within a building which is not occupied by others Working alone within an area of building, otherwise occupied by staff, undertaking tasks that could result in severe injury with rapid onset, inability to administer first aid Medium to High High Level of Protection/Control No requirement to establish a checking and monitoring system except at the request of the individual concerned. Consider security systems e.g. key pads, swipe cards Consider reporting check-in systems Consider security lighting around access points and parking areas Requirement to establish a checking and monitoring system. At least two times of contact established; start of day and end of day Establish if the contact person and number is within the building or if it is necessary to go outwith, eg. The HUB Ensure the procedure is known by staff concerned Consider security system, check-in and security lighting as for low risk controls Mobile phones Try to avoid isolated locations Ensure that the room design and layout are such that the member of staff can readily leave the room, absence of items which can be used as weapons Ensure there are panic buttons, pin point etc, installed and that they are linked to staff that will attend and know the procedure to follow Emergency response procedures in place Requirement to establish a checking and monitoring system Regular and frequent contact Ensure there is a panic alarm system, such as pin point and that this is linked to staff that will attend or know to follow an agreed protocol Emergency response procedure in place and all staff familiar with this Factors for consideration when drawing up local procedures include: WORKING IN BUILDINGS ALONE Procedure Number: HBP10 November 2017 Page 15 of 37 Version 1.2

40 40 1. Buildings General Buildings and their access and exit routes should be adequately lit at all times. Car parks should also have adequate lighting Dark corners and blind alleyways should be eliminated wherever possible In appropriate instances CCTV can and should be used Vehicles should be parked in an exiting direction as near to buildings as possible Alarm systems such as the Pinpoint system should be seriously considered for buildings where employees may find themselves isolated in any vulnerable situation Layout of rooms should always allow employees a safe route of escape Adequate means of restricting unauthorised access to and within premises should be considered Swipe card system, keypads etc Ensure all external doors are locked out-with opening hours Ensure local procedures are in place for securing and opening of premises Ensure all visiting persons are made aware of local procedures. 2. In Buildings with Others There Employees should inform colleagues of their whereabouts and how long they expect to be away from fellow colleagues There must be an adequate and tested method of contacting colleagues if the need arises If a person does not return to their colleagues at the specified time, then they should be sought out after an appropriate interval has passed. This will depend on the local procedures. 3. In Buildings Alone Employees should ensure that access doors are locked. There should be an adequate means of escape should it be needed If anybody tries to gain access employees should have the ability to establish the identity of that person Employees must ensure that they have method of letting appropriate persons know of their whereabouts. Procedure Number: HBP10 November 2017 Page 16 of 37 Version 1.2

41 41 Appendix 3 - Lone Workers Travelling Hazard Travelling from NHS sites to other NHS sites, where somebody is expecting your arrival, within normal working hours. Risk Level Extremely Low Level of Protection/Control Availability of mobile phone to summon assistance for a breakdown and a travel kit within the vehicle ( torch, fluorescent tabard, triangle, first aid kit) No requirement to establish a checking and monitoring system. Diaries and contact details available Travelling on NHS business out with normal working hours. Very Low Availability of mobile phone to summon assistance for a breakdown and a travel kit within the vehicle ( torch, fluorescent tabard, triangle, first aid kit) Establishment of a checking and monitoring system which can be used on a voluntary basis, at the end of a day (eg nobody at home to raise the alarm) Travelling on NHS business out with normal working hours and in remote and isolated locations, with unpredictable poor weather conditions Low Availability of mobile phone to summon assistance for a breakdown and a travel kit within the vehicle ( torch, fluorescent tabard, triangle, first aid kit) Establishment of a checking and monitoring system, report safe arrival with base on each occasion that merits this, (see situation above) Establishment of a checking and monitoring system which can be used on a voluntary basis, at the end of a day (eg nobody at home to raise the alarm) Factors for consideration when drawing up local procedures include: LONE WORKERS TRAVELLING ON NHS HIGHLAND BUSINESS 1. Diaries Diaries, preferably electronic diaries should be as up to date as possible Line Manager/Administration staff should have access to employee s diaries. If employees will be away from the base for some time they must identify their whereabouts on each day until they return to the base. Procedure Number: HBP10 November 2017 Page 17 of 37 Version 1.2

42 42 2. Keeping in Contact If an employee is away from base they will contact base on at least one occasion every day. If an NHS telephone is available this should be used. A mobile phone should be used if there is no access to a landline. If an employee uses their own phone for business purposes then they are entitled to reclaim the costs incurred. If employees are not coming into their base before travelling then they should contact base at the start of the normal working day 3. Travelling within Highland and Other Destinations On arrival at the destination a call will be made to base to notify the employee s safe arrival. This call may be made on behalf of more than one person. For example, one employee may report that they and their colleague(s) have arrived at their destination safely. On occasion more than one destination may be arrived at each day. On occasions such as this a list of destinations should be given to one of the administration staff at base with approximate times at each. A call to base should be made at the start of the first visit and at the end of the last visit. 4. Returning home or to temporary accommodation On returning to home or to temporary accommodation (if away for more than one night) a call will be made to base. This call will notify the safe return of each employee individually, as in the case of home or a collective call in the case of overnight accommodation. Procedure Number: HBP10 November 2017 Page 18 of 37 Version 1.2

43 43 Appendix 4 Assessment of Risk ASSESSMENT OF RISK There are many factors to be considered when carrying out a risk assessment on lone working and these should include: a) b) c) d) e) f) g) h) i) j) k) l) m) n) o) p) Does the work present a specific risk to the lone worker? Is a home visit essential? Are there procedures in place around first time appointments? Can any risk be adequately controlled to ensure the safety of a person working alone? What training has the lone worker had to ensure competency in safety issues? Is the person able to work alone? What supervision measures are in place? Is there a threat of violence to employees? Are employees experienced enough to work alone? Is there a specific threat for example due to race, age, gender, ethnic origin or religious beliefs? Are expectant mothers or young workers especially at risk? Are there systems in place to take account of emergency situations which may arise (fire, illness etc.)? Are there systems in place for contacting and tracing those who work alone? Are there systems in place for those who work alone to contact a base or other persons? Are there issues around network connectivity? Is consideration given to weather conditions, time of day, available light (natural or otherwise)? Lone travelling on work related business Working with substances hazardous to health Estates work Home Visits Working out-with normal office hours. q) r) s) t) u) v) WORKING WITHIN AREAS SUCH AS LABORATORIES MANAGEMENT These systems should include the following: a) b) c) d) e) f) Joint working for higher risk activities The use of checking in and monitoring systems Improvements to building security arrangements CCTV monitoring external areas to buildings Adequate lighting in appropriate areas e.g. parking areas Communication systems for sharing risk information with colleagues and staff of other disciplines and agencies g) Whilst maintaining client confidentiality there is a legal duty to pass on information to others who may be involved in that client s care where this is seen to pose a significant risk h) The use of personal protective equipment, mobile telephones, and any other staff protection systems available, e.g. CM2000, man down systems, high visibility jackets i) Appropriate training as identified. Procedure Number: HBP10 November 2017 Page 19 of 37 Version 1.2

44 44 DYNAMIC RISK ASSESSMENT Dynamic risk assessments should be conducted as necessary in the circumstances in place at the time. The process involves: a) The assessment of risk in dynamic situations is undertaken before, during and after a home visit, potentially hazardous appointment or working period. b) The benefits of proceeding with a task must be weighed carefully against the adverse risk posed to the lone worker c) What sets Dynamic Risk Assessment apart from systematic risk assessment is that it is applied in situations that are: unpredictable/unforeseen risks the risk environment rapidly changes allows individual to make a risk judgement provides personnel with a consistent approach to assessing risk Procedure Number: HBP10 November 2017 Page 20 of 37 Version 1.2

45 45 Appendix 5 Example Risk Assessment EXAMPLE: NHS Highland Risk Assessment Form Operational Unit/Site Note 1 Ward/Department Assessment No Assessment Date Activity/Process: Staff working alone in the community in isolated conditions inside or outside a building, patients homes, non-commuter driving etc. Please indicate if a specific risk assessment is required Manual Handling Noise Hazardous Substances (inc biological agents Use of Display Screens Confined Spaces Ionizing Radiation Lead Asbestos Vibrating equipment Fire PPE Violence & Aggression Note 2 What are the Hazards? Visiting familiar low-risk patients/clients during normal working hours (not remote, socially deprived areas) Who is at Risk? Staff Control Measures (Specific existing Control measures) Diary schedule with name, address, contact details of visits along with times of visits, available at base (or held by a point of contact if single-person team ). Risk of V&A Process in place to monitor start and finish of working day and agreed times of contact with base during working day Use of work mobile phone. For remote areas, notify base if visiting in mobile blackspot and agree a time to contact base after visit. Risk Rating Note 3 L S R Additional Controls (Each Control Measure is to be specific and managed) Residual Risk Rating Note 4 L S R Buddy system in place (start and leaving visit) Use of Electronic Diary Identify consistent point of contact Ensure that mobile phone has speed dial numbers to emergency contact numbers e.g. Police, base. Ensure that phone is ready to hand at all times All staff up-to-date with V&A training Procedure Number: HBP10 November 2017 Page 21 of 37 Version 1.2 Management Action Plan Owner Target Date Completion Date

46 46 Visiting familiar low-risk patients/clients during normal working hours (in socially deprived areas, carrying drugs or travelling in isolated and remote areas Staff All of the above plus: Notify base if visiting a client in an area with poor mobile connectivity Blackspot Risk of V&A Working in the community with a client on a one-one basis e.g. supporting client to go shopping, going to the pictures, any outside activities All of the above plus: Ensure all necessary contact numbers are in mobile phone directory with emergency ones on speed dial Risk of V&A Visiting unfamiliar clients and relatives. Visiting high risk or unstable clients Staff Ensure that mobile phone is immediately to hand e.g. in pocket with quick access to speed dial. Do not have mobile phone in a handbag or briefcase. All of the above plus: Ensure risk information is included in referral Risk of V&A Complete Risk Assessment and Management Plan for each client, can incorporate relatives, visitors, address Work in pairs (avoid lone working) Contact base before visit starts and again at end of visit. Base should know expected length of appointment. Use of specific words during phone call to base to raise alarm e.g. Can you check if Yvonne is around later or Can you look out the red folder for me please Initial visit to assess new clients/patients made in clinic setting Working alone in an area of a building occupied by other NHSH staff and carrying out low risk activities within normal working hours ie: office work (risk of accident, Staff Procedure Number: HBP10 November 2017 Share any risk information with other professionals Door has a security system (keypad/swipecard etc) CCTV Landline and mobile phone available to request assistance Page 22 of 37 Version 1.2

47 47 medical emergency etc) Working alone in a building not occupied by others e.g. out of normal working hours Car park well lit (security lighting etc) Staff Reporting check-in (buddy) system in place (on entering and leaving) Security system on door and security lighting CCTV Report check-in (buddy) system in place (minimum on entering and leaving) Identify a point of contact for during hours being worked. If OOH contact could be the HUB Ensure all staff are aware of the procedure Mobile phone or landline available Consider car parking (as close to building as possible) Meeting clients or patients in isolated locations within an otherwise occupied building not client home (risk escalates if person unfamiliar or mental health issues/drug, unstable or unpredictable). This could be a clinic room Staff Isolated locations are avoided where possible and check-in and out system in place. Ensure room layout is such that member of staff can readily leave the room Ensure that there are no turn locks in situ on the inside of clinic room doors Risk of V&A Not seeing client/patients who turn up without an appointment Ensure that clinic rooms are locked when not in use Ensure waiting areas are clearly visible Consider CCTV to monitor waiting areas and corridors Hard-wired attack alarm is in place e.g PIN Point System, Panic alarm and staff are trained in its use. There is a protocol in place for responding to any alarm system with staff trained and Procedure Number: HBP10 November 2017 Page 23 of 37 Version 1.2

48 48 available to respond. Ensure staff are familiar with the sound of the alarm Working alone within an area of building, otherwise occupied by staff, undertaking tasks which could result in severe injury, rapid onset with inability to administer first aid Travelling from NHSH sites to other NHSH sites where someone is expecting arrival (normal working hours) Staff Two persons work together where patient/client is a known risk or person is NOT seen in these circumstances Check-in and monitoring system Buddy system First Aider availability Ensure staff have access to an alarm system that will raise alarm when necessary. Staff Ensure protocols in place regarding use of and response to alarm Mobile phone to summon assistance in event of RTA, breakdown etc Travel kit within vehicle (torch, triangle, first aid kit, fluorescent tabard etc) Road Risk Assessment completed Access Driving in adverse weather conditions training Dairies and contact details available within the team (or held by a point of contact if single-person team ) Travelling from NHSH sites to other NHSH sites (out with normal working hours or travelling on NHSH business out with normal working hours in remote and isolated locations, with unpredicatable or poor weather conditions ) Travelling to visits and between visits within normal working hours Travelling to visits and between visits outwith normal Staff Travel is not undertaken if weather conditions too severe All of the above Staff All of the above Staff All of the above plus: Ensure that contact is made Procedure Number: HBP10 November 2017 Page 24 of 37 All of the above Register with the HUB Version 1.2

49 49 working hours General risks (relatives, pets, passive smoking, electrical shock risk, slips trips & falls) Staff Risk of V&A with identified person at start and finish of journey Staff with allergy or fear of domestic animals to be ascertained and allocated work elsewhere Mobile phones available Send letter to client outlining expectations e.g. Pets to be locked out of area visit taking place, no birds to be loose in room, room to be well ventilated prior to staff arriving. All staff current with V&A training Consistent and agreed approach by staff in dealing with issues Patients/clients requested not to smoke for a period of 60mins prior to visit request windows opened where appropriate Visual inspection of electrical sockets prior to use (not to be used if evidence of damage, burn etc) Park as close as possible to clients home in a well-lit area, facing the direction you wish to leave in Assessor s Name: Designation: Signature: Line Manager s Name: Designation: Signature: Line Manager s Assessment Review (See Notes 5 and 6) Review Date Review Date Review Date Review Date Name Name Name Name Designation Designation Designation Designation Signature Signature Signature Likelihood, Severity & Risk Rating is abbreviated in the RA1 form to: L / S / R Procedure Number: HBP10 November 2017 Page 25 of 37 Signature Version 1.2

50 50 Notes: 1. If using a Generic risk assessment, Assessors and Line Managers are to satisfy themselves that the assessment is valid for the task and that all significant hazards have been identified and assessed. If additional hazards are identified they are to be recorded and attached to the Generic assessment. 2. Certain hazards require specific risk assessments under various sets of Regulations. Managers should indicate which of these are applicable, and ensure that the assessments are undertaken. 3. Risk Matrix SEVERITY / IMPACT LIKELIHOOD AC = Almost Certain L = Likely P = Possible U = Unlikely R = Rare Procedure Number: HBP10 November 2017 Page 26 of 37 Insignificant (Ins) Minor (Min) Moderate (Mod) Major (Maj) Extreme (Ext) MEDIUM HIGH HIGH VERY HIGH VERY HIGH MEDIUM MEDIUM HIGH HIGH VERY HIGH LOW MEDIUM MEDIUM HIGH HIGH LOW LOW MEDIUM MEDIUM HIGH LOW LOW LOW MEDIUM MEDIUM Version 1.2

51 51 Risk Rating LOW MEDIUM HIGH VERY HIGH 4. Action Required to Reduce Risk Score Acceptable Risk Manage by monitoring and review of existing control measures, any further actions to reduce risk should take place within 2-3 months Manageable Risk Decide on any new control measures and develop action plan aim to implement these actions within 4 weeks Unacceptable risk Task must be stopped immediately. Decide on any new control measures and develop action plan, new controls must be implemented prior to resuming/starting the task Unacceptable risk Task must be stopped immediately. Decide on any new control measures and develop action plan, new controls must be implemented prior to resuming/starting the task Record the residual Risk Rating to demonstrate that the risk has been reduced to an acceptable level; record Likelihood and Consequence scores. 5. Line Managers are to note that they are responsible for production of the risk assessment and that they are signing to indicate that the risk assessment is suitable and sufficient and they consider the risks to be acceptable. 6. Risk Assessments are to be reviewed: In the following timescales: Level of Residual Risk High Medium Low Risk Assessment Review Period Every 1 Year Every 2 Years Every 3 Years If there is reason to doubt the effectiveness of the assessment. Following an accident or near miss. Following significant changes to the task, process, procedure or Line Management. Following the introduction of more vulnerable personnel. If Generic prior to use. Procedure Number: HBP10 November 2017 Page 27 of 37 Version 1.2

52 52 Appendix 6 Local Lone Working Procedure Guidance Example/Template Local Lone Working Procedure/Protocol Operational Unit: District/Speciality: Team/Ward: Manager s Name: Base Address: Team Geographical Area: Author: Date completed: Review date: Introduction This local Lone Working procedure is intended to manage and facilitate lone working undertaken by staff from... (Name of team). It is also a requirement of PIN Policy Managing Health at Work 5 Protecting the Health, Safety & Welfare of People Working Alone Policy which must be read in conjunction with this local procedure. Staff should not enter into lone working situations where they feel that their safety or the safety of their colleagues could be compromised. Where there are perceived or real risks, alternative provision should be made, such as arranging treatment in secure premises or organising accompanied visits. Identification of Lone workers List of staff job titles, where they are based. Low risk activities examples Consider: Staff undertaking office work during normal daytime hours. High risk activities examples. Consider: Do you carry prescription cards, drugs, poor lighting, staff delivering bad news, clients with alcohol/drug misuse, carrying equipment to make them a target of theft, staff members capacity to undertake lone working e.g. pregnancy, disability What hours do they work? When is lone working carried out? Consider: Are staff seeing patients/clients on a one to one at base. How would emergency assistance be summoned. Recording of Lone Worker movements How and where are the movements of lone workers recorded including details of who they are visiting, telephone numbers and arrival/departure times? Diary of visits etc How is the start and finish of staff s working day captured? How many times do they check back in at base and at what times? What do they do if a visit is cancelled or refused? What happens out of hours? Where is staff s personal emergency information held and if applicable how is accessed out of hours? Is there a Buddy system? Who is the point of contact between 9-5 and what happens in their absence? Prior to Lone Working Do staff access risk information prior to visit? Procedure Number: HBP10 November 2017 Page 28 of 37 Version 1.2

53 53 Where is risk information recorded? Is it detailed on the referral? How is this information shared? What is the process for a first visit? Emergency equipment What is in place i.e. work mobile phones, staff attack alarm? Do all staff have access to such equipment? Where are the known blackspots? List areas what precautions should be taken when visits are carried out in a mobile blackspot? Do staff carry torches, map of the local area or first aid kit? CCTV External lighting During a lone working situation Staff carry out dynamic risk assessment 10 seconds risk assessment. Leave immediately if felt at risk of harm Placing themselves in a position to make a good escape, i.e. where possible, being the closest to an exit, being aware of all entrances and exits Being aware of the positioning of items, including those belonging to the lone worker (scissors, scalpels, etc), that could be used as a weapon Making a judgement as to the best possible course of action for example, whether to continue working or withdraw Check there is sufficient charge and the signal strength on mobile phone before entering a lone working situation. Having easy access to their mobile phone, using speed dials In some circumstances, agreed code words or phrases should be used to help lone workers convey the nature of the threat to their managers or colleagues so that they can provide the appropriate response, such as involving the police. Ensuring that when they enter an area or room, they can operate the door lock in case they need to make an emergency exit Do staff carry money/drugs? How is this managed? Staff should ask that animals are removed or secured. If a lone worker is confronted by an aggressive animal on a visit to a patient/service user s address, they should not put themselves at risk. If necessary, they should abandon the visit and report the incident How to contact and Escalation Process Diagram: e.g. Procedure Number: HBP10 November 2017 Page 29 of 37 Version 1.2

54 54 Lone Working in cars Park close to location near to street lights Keep keys easily accessible to avoid being distracted when searching for them outside Adequate fuel Items stored out of sight Visual check of the area and around the car Lock car doors Reverse into spaces so car door can be used as a barrier. What to do in case of breakdown including out of hours If it is inclement weather is the journey essential? Escorting patients/clients in vehicles Is a patient/client risk assessment in place? Are they capable of being transported? Is the patient/client in the back seat behind the passenger seat, is the seat belt fastened? What should the lone worker do if conflict arises? Working alone in departments Are staff aware of how to call for help in an emergency? Who would assist them? Do they position themselves closest to the door. Training What training have your staff received? Responsibilities Procedure Number: HBP10 November 2017 Page 30 of 37 Version 1.2

55 55 Team Manager s responsibilities The Team Leader will ensure that: all staff have read and follow this Lone Working Procedure. This includes ensuring that staff are appropriately trained, and compliance is monitored. risk assessments are carried out for all identified hazards and are reviewed annually. Occupational Driving Risk Assessments are to be completed by all staff who drive to other locations as part of their employment. Reassessment must be completed for any significant change e.g. permanent change of vehicle or medical condition. This includes ensuring that staff who use their own cars for business purposes are aware that they must submit a copy of their insurance policy to the Team Leader when they renew the policy or change vehicles. All incidents are investigated and reported using NHS Highland s procedures and DATIX System. This includes undertaking post-incident investigations and ensuring support is available to staff when required. The Team Leader should review resulting incident reports and carry out any resulting actions and recommendations. Employee s responsibilities To take all due care to maintain the personal equipment in good working order and ensure it is fully charges and ready to use. To complete the emergency contact details. To alert the Team Leader to any issues which could affect their ability to undertake lone working? To adhere to this procedure for all instances of Lone Working. To update records with risk information. To pass on information to appropriate colleagues if a patient, or their carers, are considered to pose a significant risk whilst recognising the importance of maintaining patient confidentiality. To report all incidents and near misses are reported on the DATIX system at the earliest opportunity. The employee should carry out any resulting actions and recommendations made by the Team Leader. To keep up to date with training in: Risk Assessment, Protection against Violence and Aggression, Moving and Handling, Fire and Resuscitation. To provide the responsible person with details of daily calendar, planned visits and addresses. Compliance How is the system monitored for compliance and who by? Procedure Number: HBP10 November 2017 Page 31 of 37 Version 1.2

56 56 Appendix 7 Use of HUB Out of Hours NHS Highland employees working out of hours and in accordance with the Lone Working Policy will be able to utilise the services of Highland HUB as their point of contact. Contact received by the HUB from a Lone Worker, under this policy, includes GPs working Out of Hours. Prior to the HUB taking details from an employee they must ensure that they have access to the most recent contact information (Name and contact numbers) for the senior manager on call. Employees required to work alone out-with the hours of will be asked to complete a checklist providing information that is to be submitted to the HUB (Appendix 8). On receipt of this information the HUB Controller should note the expected length of visit and time of return on the Lone Worker Tracker Sheet. New sheets to be used daily and new columns for each planned event. The employee who submitted the information should re-contact the HUB to advise of any delays encountered and update the expected time of return. At the expected time of return the HUB Controller should wait for the employee to make contact. Should the HUB not receive contact from the employee within 20 minutes of the expected time of return, the employee s contact/mobile number should be tried for up to a maximum of 10 minutes. Should there be no response from the employee during these 10 minutes, the HUB must contact the Senior Manager on call. The senior manager will attempt to contact the lone worker and personal contact for that employee for a maximum of 10 minutes. If there is no response the Senior Manager will make the decision on what further action must be taken. Should all attempts of contact fail police should be contacted by the senior manager and asked to follow up on the employee s whereabouts. Procedure Number: HBP10 November 2017 Page 32 of 37 Version 1.2

57 57 Appendix 8 HUB Registration Form Team Details: Team/Department Name: Address: Manager/Team Leader's Name: Manager/Team Leader's Manager/Team Leader's Contact Number: Lone Worker Details: Surname First Name Designation Base Office Number Work Mobile Number Make & Model of Mobile Address Description of all vehicles accessed (make/model/colour) All Vehicle Registration Personal Mobile No Home Tel No Home Address Name of Contact in case of emergency Address of contact Contact details Relationship Allergies/significant medical issues ie: diabetes Distinguishing Marks: birthmarks, scars, tattoos etc Hair colour Eye colour Height Procedure Number: HBP10 November 2017 Page 33 of 37 Version 1.2

58 58 Appendix 9 Staff Protocol Example for Lone Working Management Procedure Number: HBP10 November 2017 Page 34 of 37 Version 1.2

59 59 Appendix 10 - Compliance Audit Tool Please note this is an audit of the procedure and the supporting local procedures, it is not an audit of the individuals applying these. Information: Auditor Job Title Date of Audit Signature of Auditor Location being audited Address Department Interviewee Signature of Interviewee Job Title Telephone no. Manager Signature of Manager Telephone no. No. 1 Question Are you aware of the NHS Highland Lone Working procedure? 2 Have you implemented this procedure in your team? 3 Have you completed Lone Working Risk Assessments e.g. Working in the Community/Working within a Building/Travelling Yes No If the answer to questions 1 or 2 or 3 is No, do not proceed with this compliance audit. Please contact the Health and Safety Team: No. 3 Question Have you found the procedure straightforward to use? 4 Do you have any suggestions for improvement to the procedure? 5 Yes No If yes please put them into the comments/suggestion box at the end of this audit. Do you understand your responsibilities as set out in the procedure? Procedure Number: HBP10 November 2017 Page 35 of 37 Version 1.2

60 60 6 Do you have a local lone working procedure in place? Please provide a copy or explain the procedure. 7 Do you know who to report to during normal working hours? 8 Do you carry out start and end of day contacts? Please provide copy of phone log or similar documentation. 9 Have you ever worked alone out-with normal working hours? If no go to question Did you complete a risk assessment prior to lone working? Please provide copies. 11 Did you use the HUB as required by the procedure? Please provide copies of information sheets or similar documentation. 12 Have you ever taken the decision not to work alone? 13 Did your manager support that decision? 14 Have you been provided with first aid facilities for lone working? 15 Do you know what your first aid arrangements are whilst lone working? 16 Has there ever been an incident or near miss whilst lone working? Remember to include incidents relating to threatening or abusive behaviour. 17 Was the incident reported? If yes, provide Datix Number(s) 18 Have you been provided with any of the following training? Risk Assessment Violence and Aggression Violence and Aggression with focus on Lone Working Moving and Handling Driving in Adverse Weather Conditions 19 Do you know how to access NHS Highlands Health and Safety Policy and associated procedures? Procedure Number: HBP10 November 2017 Page 36 of 37 Version 1.2

61 61 Comment/suggestions for improvement: Please return the completed audit to: Health & Safety Team Assynt House Beechwood Business Park Inverness IV2 3BW Procedure Number: HBP10 November 2017 Page 37 of 37 Version 1.2

62 62

63 Health & Safety Committee 2 November 2017 Item 4.1.1(4) 63 Health and Safety Policy Hazard Based Procedure HBP HBP Control of Substances Hazardous to Health (COSHH) Managing Skin at Work Procedure Procedure No: HBP Procedure Revision No: 1.5 Prepared by (Group and Date): Workplace Hazards Sub Group Ratified by (Group and Date): Health and Safety Committee Effective From: 02 November 2017 Review Date: 02 November 2020 Lead Reviewer: Director of Occupational Health Head of Occupational Health and Safety North & West Health and Safety Manager OH Nurse Manager (Strategy & Development) Dissemination Arrangements: Policy Area of Intranet Targeted NHS Highland Health and Safety Intranet Site Warning - this document is uncontrolled when printed. Please ensure you have the most recent version of this document Procedure Number: HBP November 2017 Page 1 of 34 Version Number: 1.5

64 CONTENTS Procedure Status Purpose Scope Prevalence and Organisational Impact Legal Framework The law The Health and Safety at Work etc Act 1974 (HSWA) Standard Infection Control Precautions Skin Management Folder Glove (Including Latex) and Skin Product Use And Choice Latex General Glove Choice Product Choice Managing Skin at Work Folder. : Roles and Responsibilities Implementation Procedure and Next Steps Monitoring and Review Appendix 1 Wet Work Risk Assessment Appendix 2 - Gloves Risk Assessment Appendix 3 - Glove use and Selection Chart Appendix 4 Approved Gloves List Appendix 5 Hand Hygiene Products Appendix 6 - Faculty of Occupational Medicine Appendix 7 - Responsible Persons Documentation Appendix 8 Health Record/Baseline Skin Assessment & Annual Skin Assessment Form Appendix 9 - Managers referral checklist to Occupational Health Appendix 10 - Further information on skin for Managers Procedure Number: HBP November 2017 Page 2 of 34 Version Number: 1.5

65 65 Document Information (does not change) Board Library Reference Document Type Document Subject Original Document Author HBP03.02 Procedure Health & Safety Head of Health & Safety Policy Assured By Review Cycle Health and Safety Committee 3 years Version Tracking (updated for all subsequent versions) Version Date Revision Description /11/2012 New document in support of NHS Highland BS PN08 COSHH Procedure Approved /12/2012 On Appendix 1, Page 7, Column 2 Remove KC Ultra Kind, Liquid Soap Insert KC Frequent Use BS Approved /12/2013 Remove Softcare Med H5 Johnsons BS Diversity insert Softcare Med H5 Johnson Diversey Remove Johnson Diversity/Derma Soft insert Johnsons Diversey Derma Soft Approved /03/2015 Para 1.0 reference now made to HBP 03 COSHH Procedure Para 1.1 reference now made to the National IPC manual A number of hyperlinks have been updated throughout Appendix 2 Hand Hygiene Products list has been overhauled and updated Appendix 4 Glove Poster has been removed and replaced by the Approved Gloves Appendix Approved by WHAG 29 Jan /07/2016 Procedure has been updated with various amendments. 1.5 July 2017 Substantial change as a result of HSE NOC letter dated Feb 17. New baseline questionnaire and revised health record included in this version. Procedure Number: HBP November 2017 Editor Page 3 of 34 BS Ratification Status Approved & Ratified by Health and Safety Committee Aug 17 Version Number: 1.5

66 1.0 Procedure Status Status. This procedure has been reviewed in support of the Health and Safety Policy. It forms part of NHS Highlands Health and Safety and COSHH Management System and it supports HBP03 Control of Substances Hazardous to Health (COSHH) Procedure1 and it should be read in conjunction with HBP 02 Health Assessment and Surveillance Procedure. It also includes information on Gloves (including those made from Latex) and replaces in its entirety PIN 10 Glove Section Policy. 1.2 Purpose. The purpose of this guidance is to provide both managers and staff with the information they need to know about managing skin care at work within NHS Highland. It sets out recommendations for health surveillance in accordance with HSE Guidance Note MS242 as well as recommendations for hand care and protection in accordance with the National Infection Prevention and Control (IPC) manual3, the Control of Substances Hazardous to Health Regulations 2002 (COSHH) and NHS Highland s recommendations for glove protection. It also covers the use of Latex gloves at work. 1.3 Scope This procedure covers all areas of NHS Highland. The approved gloves and approved hand-care products lists must be used across NHS Highland whether staff are wet workers or not. For staff who are wet workers - i.e. for staff involved in wet work (20-40 hand washes per shift), the entire procedure applies. A risk assessment for wet work is appended as Appendix 1. For staff who do some wet work i.e. for staff washing their hands occasionally for work purposes, but who may not be classified as wet workers. Managers should contact their Health and Safety Manager for advice on which elements of the procedure may be helpful for their department and staff. The approved lists will still apply. For staff who do not wash their hands for work purposes i.e. for office staff who do not wash hands for work purposes, the requirement to have hands checked regularly will not apply. The folder should be kept for reference and staff should be informed of its location. The approved lists will still apply. The arrangements for self-referral or management referral to Occupational Health are standard arrangements for NHS Highland. For other products which may involve the skin, the NHS Highland Procedure HBP02 Health Assessment and Surveillance, and assistance from both Occupational Health and Health and Safety should be sought HBP03 Control of Substances Hazardous to Health (COSHH) Procedure HSE, Medical Aspects of Occupational Skin Disease Procedure Number: HBP November 2017 Page 4 of 34 Version Number: 1.5

67 Prevalence and Organisational Impact. Contact dermatitis4 is the most common form of work-related skin disease suffered by health and social care professionals. The most affected groups are: nurses, midwives, medical radiographers, nursing auxiliaries, medical practitioners and physiotherapists. Other people affected in this sector include: catering, domestic services and laundry staff who are at risk from work related contact dermatitis where there is a need to wash their hands regularly (known as wet work 5 or, where the skin is frequently exposed to chemicals or rubber materials (e.g. gloves) used in personal protective equipment. In terms of impact it is suggested that in the UK, occupational dermatitis comprises up to 20% of all occupational diseases each year, with nurses nearly seven times higher than the average for all professions As well as the debilitating effects of dermatitis on the staff member, there is now evidence emerging that suggests that those suffering from severe or acute dermatitis may be more likely to be colonised with micro-organisms than normal skin. There may also be an increased risk of transmission to patients, although this evidence at present is weak. The consequences to staff if left unmanaged can be severe resulting in sickness absence, staff replacement costs, incident investigation and prolonged enforcement activity. 2.0 Legal Framework 2.1 The law The Health and Safety at Work etc Act 1974 (HSWA) requires that NHS Highland ensures the Health, Safety and Welfare of their employees. It also places duties on employees to co-operate with NHS Highland so that employees are kept safe at work Any substances used by employees at work are covered by the Control of Substances Hazardous to Health Regulations 2002 (COSHH) including the use of latex, which has known health effects. The Personal Protective Equipment at Work (PPE) Regulations (1992) requires NHS Highland to identify the risks around work and provide PPE which will protect employees and reduce the risk of harm. 2.2 Standard Infection Control Precautions. The NHS HPS National Infection Prevention and Control Manual is the mandatory practice guide for NHS Scotland and is referred to throughout this procedure. NHS Highlands s Infection Prevention Control Team can provide additional advice and guidance on its implementation. 2.3 Skin Management Folder. NHS Highland has developed the Skin Management Folder to help managers to proactively check employees skin where it may be affected by wet work, PPE or substances used at work. The folder covers the roles and responsibilities for managers and employees and it should be read in tandem with HBP 02 Health Assessment and Surveillance, and HBP03 COSHH. 4 Dermatitis Definition: An inflammatory condition of the skin caused by contact with outside agents which can result in irritation, redness, cracking and blistering 5 Wet Work Definition: HSG262 Skin at Work Wet work is a term used to describe prolonged or frequent contact with water (particularly with soaps, cleaners and other chemicals). Wet work can cause the skin to over-hydrate. It is the leading cause of Irritant Contact Dermatitis but often goes unrecognised. prolonged contact of more than 2 hours, or more than hand washes a day, are likely to lead to dermatitis Procedure Number: HBP November 2017 Page 5 of 34 Version Number: 1.5

68 Glove (Including Latex) and Skin Product Use And Choice 3.1 Latex NHS Highland is latex free however there are areas, principally in theatres, where some staff choose to use disposable gloves containing latex where tactile sensitivity is an issue. Latex is well known for being a skin and respiratory sensitiser and in some people it can cause serious allergy. Latex is only permitted in such areas where clinical procedures are carried out which require superior tactile sensitivity A risk assessment must be carried out for all staff who use Latex gloves. It must identify Natural Rubber Latex as necessary for the procedure being carried out i.e. that it is the safest choice of material, and assess the respiratory and dermatological risk to the wearer, to other staff in theatre at that time and to the patients involved in the procedure. These must be assessed against the increase in tactile sensitivity and other issues. In any case these gloves must be low-protein (reduces the risk of contact dermatitis leading to urticaria) and powder free (reduces the risk of respiratory and dermatological reaction to the product) latex Staff using Latex gloves must attend Occupational Health for Health Surveillance and regular Surveillance will be required to assess the continued use of this product. Managers should inform Occupational Health that their area uses Latex gloves. The Occupational Health Service can provide assistance with completion of the assessment and associated surveillance. 3.2 General Glove Choice The choice of glove used in NHS Highland includes the statutory requirements (HSWA, COSHH & PPE Regs), NHS Scotland/Health Protection Scotland (HPS) mandatory Practice Guidance, and the National Infection Prevention and Control Manual. It also takes into account the particular chemicals and processes that NHS Highland use. However for departments whose PPE requirements exceed those standards offered by the approved gloves list, they should contact their Health and Safety Manager and Occupational Health Service for guidance on providing gloves which suit the particular needs of their department There are alternative gloves for those who require them after consultation with Occupational Health. The Risk Assessment for Glove use is appended as Appendix Vinyl Gloves are only used in kitchens for food preparation. They can be used for other tasks but those tasks should not include patient care, cleaning with chemicals or any task where abrasion is likely. Therefore they are normally restricted to kitchen duties. Vinyl gloves comply with British Standard (BS) EN Reusable nitrile gloves (often referred to as Marigold type) can be used, for example, for pot washing or other tasks in the kitchen where hands are in water for long periods. These should be on personal issue (not shared) and kept clean and dry. These comply with EN 374 (chemicals) and EN 388 (abrasion). Reusable nitrile gloves can also be used for cleaning tasks (sometimes used for deep cleans). These should be treated in the same way as nitrile disposable gloves and removed and disposed of after 30 minutes or when required by the task being carried out. Due to the increased cost, this option is normally only for staff who have been to Occupational Health and been advised to use reusable gloves in this way, or where a risk assessment shows the gloves to be a requirement. In these circumstances, cost is not an issue. Procedure Number: HBP November 2017 Page 6 of 34 Version Number: 1.5

69 Disposable Nitrile gloves have been chosen for both patient care and cleaning tasks and sterile and non-sterile types are available. All the listed nitrile gloves comply with EN 374 (can be used with chemicals including Actichlor) and EN 388 (are not abraded easily) as well as EN455 (biological hazards) and EN 420 (for comfort and fit). All nitrile gloves should be replaced after 30 minutes use no matter the task Longer cuff nitrile gloves are available on the Approved Gloves list for routine use and can be used for cleaning (EN 374) but not for work where puncture or abrasion is likely or for patient care. These gloves do not carry EN 388 (abrasion) standards or the medical glove standard EN For tasks that may involve contamination of the forearms, forearm protectors are available and can be used with disposable nitrile gloves. These must be changed at the same time that the disposable gloves they are worn with, are changed The Approved gloves list (Appendix 3) contains alternative gloves for those who have attended Occupational Health and been advised to use Accelerator Free gloves for example. Further alternatives are available and again, will be ordered in conjunction with Occupational Health. Accelerator free gloves can be used in the following circumstances (sterile or non-sterile) for patient care (EN 455) and for chemical use (EN374). However they should not be used where abrasion is an issue as they do not carry the EN 388 standard A glove use and selection flowchart is included as Appendix 4. This chart is taken from the IPC Manual and changed to reflect the NHS Highland Approved List. The approved gloves list is also included as Appendix 3 and included in the skin folder (Section 6). 3.3 Product Choice The choice of products for skin (soap, gels, moisturiser and scrubbing products) reflects the NHS Scotland contract choice with alternative products chosen for those who are not able to use the routine use products after Occupational Health referral. Additional alternatives can be sourced by Procurement if required and this is always done only after Occupational Health advice. This information is included as Appendix The folder contains a list of approved soaps, gels, moisturisers, and scrubbing products for use on the hands. Some of these are for every day routine use and should be found in wall dispensers throughout the organisation. Smaller packs should be ordered for community or visiting staff who would carry these for personal use. The details are on the Approved Products List The products are ordered through PECOS (or through Pharmacy) and the alternative products are only authorised for those who have attended Occupational Health and received instructions to use alternative products such as Dermol Managing Skin at Work Folder. The skin management folder was developed as a coherent process to comply with the law in a way that could be used across NHS Highland and gave employees and managers enough information to reduce the risk to NHS Highland staff from wet working. The sections of the folder are: Section 1 Implementation Procedure Actions required at ward/department/area level including instructions on how to sign in on Learnpro from another (non-nhs) computer Procedure Number: HBP November 2017 Page 7 of 34 Version Number: 1.5

70 70 Section 2 - Signature sheet for all staff to sign - This sheet must be filled in with the name of the Manager and Responsible person(s) for the area to ensure that all staff can be seen by a responsible person every 3 months (e.g. holiday cover, seeing staff permanently on nights, or weekend work etc). Staff are required to sign this sheet to demonstrate they are aware of the content and location of the folder. Section 3 - Wet Work Risk Assessment, and SOP - This assessment covers glove use and product use for wet work in NHS Highland. If your department is doing something differently please contact your Health and Safety Manager who will discuss further steps with you. Section 4 Gloves Risk Assessment - If this Risk Assessment does not reflect conditions in your department please contact the Health and Safety Team Section 5 Skin Management Procedure (this policy) - This policy will be updated as required. Section 6 - Approved list of Skin products and Gloves - This section will be updated as required. The order numbers for all products and gloves are contained in the sheets. Procurement department can help with orders for 2nd or 3rd choice products only after an Occupational Health requirement to order these. Section 7 - Soaps COSHH control sheets, Sypol and Manufacturers Safety Data Sheets (MSDS) - This section should contain three poly pockets, one for each product. The polypockets should contain - the COSHH Control sheet, (should be on top) Sypol sheet, and Manufacturers Safety Data Sheet for the product. The COSHH Control Sheet contains information summarised from the other two sources of information. Section 8 - Gels - COSHH control sheets, Sypol and MSDS - As Section 7 above. Section 9 - Emollients COSHH control Sheets and MSDS (no Sypol assessment) - (As above). This section does not contain a Sypol Assessment as these products are safe to use and there is no legal requirement to do an assessment. However this information is enclosed to complete the folder. Section 10 - Scrubbing products - COSHH control sheets, Sypol and MSDS) - As Section 7 above. Section 11 Contact details and further information - This section contains information on the Health and Safety Team, Occupational Health, Infection control and Procurement contacts. Section 12 - Responsible person s documentation. - This section contains the Individual Health Record/Baseline/Annual assessment form and the Quarterly staff check sheet. It can be accessed from the Health and Safety site on the intranet (see below) and saved as an Excel Spreadsheet or photocopied from this folder. Procedure Number: HBP November 2017 Page 8 of 34 Version Number: 1.5

71 71 All of the documents in this section can be accessed via the Health and Safety Page on the Intranet at Health and Safety Skin Management6. The site will show any updates and the sections can be printed in one go (from a pdf file) or individually. 4.1 Roles and Responsibilities Managers. Managers are required to ensure the policy and skin checking regimen is implemented. Staff should be referred timeously to Occupational Health if referral is indicated. Enough responsible persons should be appointed to cover all of the staff in your area over a three month period taking into account shifts, weekend and night work. The Learnpro Module Highland Skin at Work - Managers should be completed by the Manager Responsible Persons. The role of the Responsible Person is detailed below. Before assuming the appointment the responsible person must undergo training, in the form of a module through Learn Pro titled Highland Skin at Work Responsible Persons. The role covers: Assessing the condition of a new staff member s skin before, or immediately after, they start work by completing the Individual Health Record and Baseline questionnaire (part 1 and 2) Periodically checking the hands and forearms of staff for the early signs of skin disease. Skin checks should be carried out at least every 3 months or more frequently if need be and recording on the Skin Register The Annual questionnaire form (Part of the Health Record/Baseline form) should be updated and signed annually by the Responsible person and the employee concerned (part 3) Advise local managers on the outcomes of skin checks or questionnaires and any referrals to be made to Occupational Health Keep the individual health records secure and Advise line managers when to seek expert help, from Occupational Health, on any skin disease outbreak, and for restoring the control of exposure. 5.0 Implementation Procedure and Next Steps. Managers must ensure the following steps are undertaken: 6 Step 1. Managers must decide if staff who work in their area are wet workers or not. If staff wash their hands regularly (20-40 times) throughout the day then they are wet workers and the entire skin management folder applies. For those departments office based or who do not wash their hands regularly for work purposes then the sections on Learnpro for Managers and Responsible persons do not apply, nor will the requirement to carry out three monthly skin checks however the rest of the folder (approved product ordering) will still apply. Some departments will have staff who are, and who are not, wet workers. Health and Safety Intranet Page-Skin Management Pages/Default.aspx Procedure Number: HBP Page 9 of 34 Version Number: November 2017

72 72 Step 2. Ensure staff use appropriate hand washing procedures as detailed in the HPS National Infection Prevention and Control Manual7 and the supporting Appendices8, and use the approved hand hygiene products listed (Appendix 5). The alternative products on the sheets (2nd and 3rd choices) are only to be used on an individual basis following authorisation by occupational health. A leaflet on Hand Hygiene is appended as Appendix 6. Step 3. Ensure staff are informed and have appropriate gloves available for the procedures that they undertake. Appendix 3, the Gloves use and selection chart should be shared with all staff. Appendix 4 provides a list of approved gloves along with the appropriate order numbers; this should be widely distributed and communicated. Step 4. A managers legal duty is to make sure that the information on Skin Management is accessible to staff, and that they are aware of the hazards, risks and controls associated in preventing and managing dermatitis. Staff can demonstrate this by signing the skin management folder signing sheet. Step 5. If health surveillance is required (for wet workers) the line manager must complete a Skin Health for Managers Learn pro Module. All managers whose staff are exposed to wet work or products that can damage skin are to complete this training. This can also be accessed via the LearnPro link above. Step 6. The manager must then nominate a responsible person within wards and departments to manage skin care on behalf of that manager. The Responsible person needs to be identified, along with a deputy and with sufficient numbers to be able to physically inspect employee hands every three months at least. Before assuming the appointment responsible persons must undergo training, this will be provided in the form of an e-learning module through LearnPro. The LearnPro link is here: (requires Internet Access) Please register with LearnPro first if you haven t before and then navigate to the module. NOTE: If you are a Manager who is taking up the role of responsible person then complete the Line Manager Course and NOT the RP Course. Responsible persons must understand the requirement for them to physically inspect / check skin at least 3 monthly (recorded on Appendix 7) and to fill in the Individual Health Record/Baseline/Annual Questionnaire (Appendix 8) on appointment of a staff member and annually thereafter. 7 Step 7. The LearnPro Hand Hygiene Module is now available for all staff who are wet workers. This should be revalidated every 2 years. The module contains a sub-module on good skin care practice. Managers are to ensure that staff will be aware of good skin care practice and are given the appropriate time at work to complete this module (which is short approx 30min to complete). Hand Hygiene training should be incorporated within e-ksf. Step 8. If you are informed that a staff member has a work related skin problem then you must refer the affected person to Occupational Health using the online management referral system. HPS National Infection Prevention and Control Manual dated Jan 15; 8 HPS, Appendices to National Manual Jan 15; Procedure Number: HBP Page 10 of 34 Version Number: November 2017

73 73 Step 9. The advice given by the Occupational Health department to managers, about the management of staff, is deemed as a risk control measure under the Health and Safety at Work Act and COSHH, and cannot / must not be ignored. If the measures advised by OH appear impractical then you must liaise further with OH. The Individual Health Record/Baseline/Annual Questionnaire should then be filed in the employee s personal file (or wherever this is kept confidentially in your area). 5.1 A flowchart version of the steps to be taken if a member of staff has a skin problem is attached as Appendix 9 and further information for managers can be found in Appendix Monitoring and Review. 6.1 This policy will be reviewed three yearly and on any NHS Scotland contract change for gloves or soaps to ensure the policy remains up to date with current products. 6.2 Incidents involving gloves and soaps should be reported through DATIX. DATIX reports are taken to the appropriate local and divisional health and safety group four times a year. Reports are tabled at NHS Highland Health and Safety Committee. 6.3 As part of the Workplace Improvement Plan, the Health and Safety Team will audit the Skin Management Process regularly to ensure departments and managers are complying with the policy. The Infection Control team regularly audit compliance with hand hygiene policies. Procedure Number: HBP November 2017 Page 11 of 34 Version Number: 1.5

74 74 Appendix 1 Wet Work Risk Assessment NHS Highland Risk Assessment Form Operational Unit/Site Ward/Department NHS Highland All clinical & non clinical areas Assessment No Assessment Date Activity/Process: Repetitive hand washing/cleansing Defined as wet work: Hands being wet for significant periods during the working day. As a guide this means more than two hours/day or hand washes/day. What are the Hazards? Who is at Risk? Control Measures (Specific existing Control measures) Risk Rating L S R Physical: Frequent exposure to chemicals, soap and water. Risk of irritant contact dermatitis on hand, wrists and forearms from frequent hand washing with soap and water and associated abrasive hand rubbing. All staff defined as wet workers (washing hands around times a day) All staff to comply with Wet Working Procedure All staff to have access to COSHH policy & assessments contained within this folder, for washing hands All clinical staff to be trained in hand hygiene/washing techniques Alcohol gel must be used in rotation with soap and water for routine hand cleansing Alcohol Gel: Soap & Water ratio 5:1 Moisturising cream to be used at breaks, end of shift etc. Staff to ensure they dry their hands fully. Only products form the Approved list (Section 6) to be used Additional Controls (Each Control Measure is to be specific and managed) Residu al Risk Rating L S R Management Action Plan Audits to be scheduled to ensure compliance with the procedure at intervals Line manager* Review numbers of responsible persons appointed to ensure number is still adequate for area/shift work/holiday cover etc to ensure availability to all staff. New staff to be added to register and hand checks are completed when starting in an area. Line Managers and Responsible person to be appointed, for each area. Manager and responsible person to complete Learnpro Courses. A sufficient number of responsible persons to be appointed for Procedure Number: HBP November 2017 Page 12 of 34 Version Number: 1.5 Owner Target Date Comp Date

75 75 each area of NHSH. Regular skin checks and baseline and annual audits carried out by a responsible person Management referral to Occupational Health if skin issues are suspected. * Where audits stated as a requirement please contact your H&S Manager to arrange. Relevant Documentation: Health & Safety policy, Health Surveillance Procedure, Managing skin at work procedure, Glove selection Procedure., COSHH Assessments, COSHH control Sheets, Dermatitis leaflets & Posters, Infection Control policy, Hand Hygiene Policy, Wet working Procedure. Assessor: Name: R Brunton/K Wilson Designation: H & S Managers Signature: R Brunton/K Wilson Line Manager: Name: Bob Summers Designation: Head of H&S Signature: B Summers Line Manager s Assessment Review Review Date 27/6/17 Review Date Review Date Review Date Name K Wilson Name Name Name Designation H&S Manager Designation Designation Designation Signature K Wilson Signature Signature Signature Likelihood, Severity & Risk Rating is abbreviated in the RA1 form to: L / S / R Procedure Number: HBP November 2017 Page 13 of 34 Version Number: 1.5

76 76 Notes: 1. If using a Generic risk assessment, Assessors and Line Managers are to satisfy themselves that the assessment is valid for the task and that all significant hazards have been identified and assessed. If additional hazards are identified they are to be recorded and attached to the Generic assessment. 2. Line Managers are to note that they are responsible for production of the risk assessment and that they are signing to indicate that the risk assessment is suitable and sufficient and they consider the risks to be acceptable. 3. Risk Matrix SEVERITY / IMPACT LIKELIHOOD Procedure Number: HBP November 2017 Insignificant Score 1 Minor Score2 Moderate Score 3 Major Score 4 Extreme Score5 Almost Certain Score 5 MEDIUM 5 HIGH 10 HIGH 15 VERY HIGH 20 VERY HIGH 25 Likely Score 4 MEDIUM 4 MEDIUM 8 HIGH 12 HIGH 16 VERY HIGH 20 Possible Score 3 LOW 3 MEDIUM 6 MEDIUM 9 HIGH 12 HIGH 15 Unlikely Score 2 LOW 2 MEDIUM 4 MEDIUM 6 MEDIUM 8 HIGH 10 Rare Score 1 LOW 1 LOW 2 LOW 3 MEDIUM 4 MEDIUM 5 Page 14 of 34 Version Number: 1.5

77 77 Risk Rating LOW Score 1-3 MEDIUM Score 4-9 HIGH Score VERY HIGH Score Action Required to Reduce Risk Score Acceptable Risk Manage by monitoring and review of existing control measures, any further actions to reduce risk should take place within 2-3 months Manageable Risk Decide on any new control measures and develop action plan aim to implement these actions within 4 weeks Unacceptable risk Task must be stopped immediately. Decide on any new control measures and develop action plan, new controls must be implemented prior to resuming/starting the task Unacceptable risk Task must be stopped immediately. Decide on any new control measures and develop action plan, new controls must be implemented prior to resuming/starting the task 4. Record the residual Risk Rating to demonstrate that the risk has been reduced to an acceptable level; record Likelihood and Consequence scores. 5. Risk Assessments are to be reviewed: In the following timescales: Level of Residual Risk High Medium Low Risk Assessment Review Period Every 1 Year Every 2 Years Every 3 Years If there is reason to doubt the effectiveness of the assessment. Following an accident or near miss. Following significant changes to the task, process, procedure or Line Management. Following the introduction of more vulnerable personnel. If Generic prior to use. Procedure Number: HBP November 2017 Page 15 of 34 Version Number: 1.5

78 78 Appendix 2 - Gloves Risk Assessment NHS Highland Risk Assessment Form Operational Unit/Site NHS Highland Ward/Department All Clinical areas, Care at Home and Care Homes in NHS Highland Assessment No 1 Assessment Date 8/7/2016 Activity/Process: PPE for staff carrying out personal care or clinical cleaning activities, specifically for the protection of hands and arms in Clinical Areas. Legislation - Health and Safety at Work etc Act 1974, Control Of Substances Hazardous to Health Regulations 2002, Management of Health and Safety at Work Regulations 1999 and Personal Protective Equipment at Work Regulations Please indicate if a specific risk assessment is required What are the Hazards? Who is at Risk? Manual Handling Noise Hazardous Substances (inc biological agents Lead Asbestos Vibrating equipment Control Measures (Specific existing Control measures) X Use of Display Screens Confined Spaces Ionizing Radiation Fire PPE Violence Aggression Risk Rating L S R General information common to all hazards on this assessment for Glove use and wet work in NHS Highland. The documents and policies that refer to glove use are - Health and Safety Policy, Hazard Based Procedure (HBP) HBP 03 COSHH, HBP03.02 Managing Skin at Work Procedure and HBP 02 - Health Assessment and Surveillance. Legislation as above. Managing Skin at Work Procedure includes the Skin Management folder which contains a Wet Work Risk Assessment, a Standard Operating Procedure for wet work and this Gloves Risk Assessment. Staff have regular hand checks and baseline and annual questionairres to ensure early signs of skin irritation are recognised and staff affected attend the Occupational Health Service. Alternative gloves are available (e.g. accelerator free) only after Occupational Health referral. The National Infection Prevention and Control Manual requirements are incorporated into this assessment and the requirements of Infection Control policies. Any use of gloves outwith this Manual in clinical areas must be risk assessed. The Skin Management procedure contains Approved Gloves list and Procedure Number: HBP November 2017 Page 16 of 34 Version Number: 1.5 Additional Controls (Each Control Measure is to be specific and managed) Residual Risk Rating L S R & Management Action Plan Owner Target Date Comp letion Date

79 79 Approved Hand Hygiene Products for use throughout NHS Highland. These lists contain alternative products for tasks that need them including longer cuff nitrile non-sterile gloves and forearm protectors for tasks where splashing during cleaning tasks may occur. Forearm protectors must be used in combination with disposable gloves. All disposable gloves should be removed after 30 minutes and disposed of. The information in the National Infection Prevention and Control Manual, and hand hygiene training should be followed with regard to hand washing. All gloves are listed on Approved Gloves sheet and have been approved with H&S, IC, OH, and Procurement input. Infection Control carries out Hand hygiene audits to check compliance with hand washing and donning and doffing gloves. They also carry out training with clinical staff on hand washing, other staff are trained by Line managers. Health and Safety carry out skin audits to ensure compliance with the skin management procedure. Chemicals used in NHS Highland are assessed before use. Paper or electronic copies of the Manufacturers Safety Data Sheet, Sypol print out and COSHH control or summary sheet must be available for each chemical used. All staff across NHS Highland carrying out cleaning tasks. Risk that exposure to and cleaning Kitchens staff should use vinyl disposable gloves for food preparation where gloves are required. Food Safety Assurance Manual advises Any deviation from this assessment must be notified to your health and safety Manager. LOW Risk that exposure to water and food items lead to dermatitis from wet work or contact with allergens All staff groups preparing food and washing pots in kitchens LOW Kitchen staff involved in food preparation and pot washing in kitchen areas. Any deviation from this assessment must be notified to your health and safety Manager. Kitchen staff may use nitrile reusable gloves for specific tasks where hands are in water for long periods e.g. pot washing. These are described as Marigold type but are nitrile and therefore do not contain latex. Nitrile re-useable and vinyl disposable gloves are from Approved list. Vinyl gloves are to BS EN 455 standard and not to be used for personal care or where there is a risk of puncture or for use with cleaning chemicals. Nitrile reusable gloves are to BS EN 374 and EN 388 and cannot be used for personal care. All staff groups who carry out cleaning tasks Employees using cleaning products use the Approved gloves list for routine use. These gloves are non sterile nitrile and meet EN374 standard for chemical breakthrough (30 mins max), EN388 standard for abrasion, EN 455 for personal care and EN 420 for comfort. All Approved Nitrile Gloves have been checked and the manufacturer s assurance that they can be used with Actichlor have been received provided the gloves are changed after 30 minutes as IC procedures Procedure Number: HBP November 2017 Page 17 of 34 Version Number: 1.5

80 80 chemicals, or prolonged glove use lead to dermatitis from wet work All staff who carry out invasion procedur es Infection risk from cross contamination Risk of chemical exposure to staff, infection, cross contamination Any deviation from this assessment must be notified to your health and safety Manager. An accelerator free version which may be used by staff who have been referred to Occupational Health. Accelerator free gloves are EN455 for personal care and EN 374 (chemical use). They cannot be used for tasks which involve abrasive use. All managers must check that any chemicals that their staff are using do not require a higher level of protection (e.g. for some cytotoxic use which are ordered by the department concerned). Employees carrying out personal care or procedures use the Approved gloves list for routine use. These gloves are Sterile nitrile and meet EN 374 standard for chemical breakthrough (30 mins max), EN388 standard for abrasion, EN 455 for personal care and EN 420 for comfort. An accelerator free version which may be used by staff who have been referred to Occupational Health. Accelerator free gloves are EN 455 for personal care and EN 374 for chemical use. They cannot be used for tasks which involve abrasive use. NHS Highland does not routinely use latex except for some procedures which require exceptional tactile sensitivity. Staff who use latex glove MUST attend Occupational Health for Health Surveillance and a Risk Assessment for the procedure concerned and the glove must be carried out before latex gloves are used. Reusable Nitrile gloves (Marigold/Gauntlet type) are used for some outbreak situations but disposed of after 30 minutes as per the instructions for disposable gloves in the IPC manual. 2 2 If a risk assessment for a task requires the use of reusable gloves Infection Control should be consulted if the task is in a clinical area and the gloves treated as disposable. For other work e.g. Estates gardening work, the risk assessment should ensure the gloves are suitable for the task to be carried out. Reusable gloves conform to EN374 for chemical breakthrough and EN 388 Procedure Number: HBP November 2017 Page 18 of 34 Any deviation from this assessment must be notified to your health and safety Manager. Departments using latex must carry out their own risk assessment for the glove and its use before wearing. LOW Cleaning in an outbreak situation, Use of re-useable gloves. All staff who carry out surgical procedur es 2 LOW Clinical tasks carried out on NHS Highland premises surgical procedures or invasive procedures e.g. insertion of CVC s. All managers must check that any chemicals that their staff are using do not require a higher level of protection (e.g. for some cytotoxic use which are ordered by the department concerned). Employees carrying out personal care or procedures use the Approved gloves list for routine use. These gloves are nitrile and meet EN 374 standard for chemical breakthrough (30 mins max), EN 388 standard for abrasion, EN 455 for personal care and EN 420 for comfort. LOW Staff who carry out non-sterile procedures with a risk of blood or body fluid contamination, personal care require. Longer cuff nitrile gloves can be used which are EN 374 and EN 420. These cannot be used for tasks which require EN 388 (abrasion standard) or for personal care EN 455). Version Number: 1.5 Any deviation from this assessment must be notified to your health and safety Manager.

81 for abrasion. They cannot be used for personal care. 81 Assessor s Name: K-A Wilson Designation: Health and Safety Manager Signature: K Wilson Line Manager s Name: B Summers Designation: Head of Health and Safety Signature: B Summers Line Manager s Assessment Review Review Date Review Date Review Date Review Date Name Name Name Name Designation Designation Designation Designation Signature Signature Signature Signature Likelihood, Severity & Risk Rating is abbreviated in the RA1 form to: L / S / R Procedure Number: HBP November 2017 Page 19 of 34 Version Number: 1.5

82 82 Notes: 1. If using a Generic risk assessment, Assessors and Line Managers are to satisfy themselves that the assessment is valid for the task and that all significant hazards have been identified and assessed. If additional hazards are identified they are to be recorded and attached to the Generic assessment. 2. Certain hazards require specific risk assessments under various sets of Regulations. Managers should indicate which of these are applicable, and ensure that the assessments are undertaken. 3. Risk Matrix SEVERITY / IMPACT LIKELIHOOD AC = Almost Certain L = Likely P = Possible U = Unlikely R = Rare Procedure Number: HBP November 2017 Insignificant (Ins) Minor (Min) Moderate (Mod) Major (Maj) Extreme (Ext) MEDIUM HIGH HIGH VERY HIGH VERY HIGH MEDIUM MEDIUM HIGH HIGH VERY HIGH LOW MEDIUM MEDIUM HIGH HIGH LOW LOW MEDIUM MEDIUM HIGH LOW LOW LOW MEDIUM MEDIUM Page 20 of 34 Version Number: 1.5

83 83 Risk Rating Action Required to Reduce Risk Score LOW Acceptable Risk Manage by monitoring and review of existing control measures, any further actions to reduce risk should take place within 2-3 months Manageable Risk Decide on any new control measures and develop action plan aim to implement these actions within 4 weeks Unacceptable risk Task must be stopped immediately. Decide on any new control measures and develop action plan, new controls must be implemented prior to resuming/starting the task Unacceptable risk Task must be stopped immediately. Decide on any new control measures and develop action plan, new controls must be implemented prior to resuming/starting the task MEDIUM HIGH VERY HIGH 4. Record the residual Risk Rating to demonstrate that the risk has been reduced to an acceptable level; record Likelihood and Consequence scores. 5. Line Managers are to note that they are responsible for production of the risk assessment and that they are signing to indicate that the risk assessment is suitable and sufficient and they consider the risks to be acceptable. 6. Risk Assessments are to be reviewed: In the following timescales: Level of Residual Risk High Medium Low Risk Assessment Review Period Every 1 Year Every 2 Years Every 3 Years If there is reason to doubt the effectiveness of the assessment. Following an accident or near miss. Following significant changes to the task, process, procedure or Line Management. Following the introduction of more vulnerable personnel. If Generic prior to use. Procedure Number: HBP November 2017 Page 21 of 34 Version Number: 1.5

84 Appendix 3 - Glove use and Selection Chart (from HPS IPC Manual9) 84 9 IPC Scotland Manual (HPS 2015) Procedure Number: HBP November 2017 Page 22 of 34 Version Number: 1.5

85 85 Appendix 4 Approved Gloves List NHS Highland Approved Gloves Order Information 21 July 2016 Routine Use Vinyl Gloves Nitrile Non-sterile Nitrile Sterile Food preparation and kitchens Personal Care, Cleaning For clinical use where required Healthgard Vinyl Examination Glove Dermagrip Ultra LT Dermagrip Ultra These gloves can be ordered off catalogue for tasks which require them. Small PSCR0105 (sku ) (non cat) Med PSCR0106 (sku ) Large PSCR0107 (sku ) Nitrile Disposable longer cuff Fore arm protectors (Longer cuff than normal, approx halfway (Boxes of 100) from wrist to elbow) Bodyguard (non-catalogue) FOR USE ONLY AFTER OCCUPATIONAL HEALTH AUTHORISATION Polar Stretch soft white stretch vinyl Procedure Number: HBP November 2017 Ex Small (sku ) Small - D (sku ) Med D (sku ) Large D (sku ) Ex Large (sku ) Small - (Sku ) Med - (sku ) Large - (sku ) Ex Lge (sku ) Small D Order non catalogue Med D Order non catalogue Large D Order non catalogue Page 23 of 34 Nitrile Reusable Household Gauntlet Type)(Kitchens only) Oversleeves (Sku Glove Domestic plastic disposable ) Nitrile 2944 One (non-cat) size Premier Accelerator Free Nitrile Nonsterile Small P2760AF6 (sku ) Med P2761AF6 (sku ) Large P2762AF6 (sku ) Version Number: 1.4 Small D (sku ) Med D (sku ) Large D (sku ) Premier Accelerator Free Sterile Nitrile Glove (Marigold Med (sku ) Lge (sku ) Small P2760AF/S (sku ) Med P2761AF/S (sku ) Large P2762AF/S (sku )

86 86 Appendix 5 Hand Hygiene Products - April 2016 Hand Hygiene Products Protocol NP573/13 SOAP Product Routine Use GELS Order Details Order Details Product Order Details Product Softcare Med H5 Gel (Diversey) For dispenser (800ml) Pump Bottle 500ml ( ) PECOS Diversey Derma Soft ( ) 800ml For dispenser PECOS Hydrex Surgical Ordered via Scrub (replacing PHARMACY Hibiscrub) PECOS VIA SUPPLIES 118ml bottle Softcare Med H5 Gel ( ) 100ml bottle PECOS Diversey Dermasoft PECOS ( ) ml bottle Dermol 500 Purell 70% (mild) Alcohol Foam Dispenser 1.2L ml personal ml pump bottle PECOS GOJO Hand Medic PECOS Videne Surgical Ordered via (8242) VIA SUPPLIES Scrub PHARMACY 150ml tube (Povidone Iodide) Kimberly PECOS Clark Frequent Use Liquid Soap For dispenser (1L) 6333 Ordered via PHARMACY (2nd Choice) FOR USE ONLY AFTER OCCUPATIONAL HEALTH AUTHORISATION (3rd choice) SCRUBBING Product Community or Visiting GOJO Mild (2903) Staff use FOR USE ONLY AFTER OCCUPATIONAL HEALTH AUTHORISATION or IN AREAS WHERE INGESTION IS A POSSIBILITY (NEW CRAIGS) EMOLLIENT GOJO Mild PECOS VIA 5767 SUPPLIES 535ml pump Procedure Number: HBP November 2017 Softalind Visco Rub (B- PECOS VIA Braun) SUPPLIES ml Pump bottle Page 24 of 34 B Braun Trixolind 100ml tube ml pump bottle Version Number: 1.4 PECOS VIA SUPPLIES perfumed Unperfumed Order Details Kimberly Clark Dispensers (soap), and Diversey dispensers (gel or moisturiser) should be ordered through procurement HIGHUHB.Contracting@nhs.net Dispenser code Dermol 500 Ordered via +liberal app of PHARMACY alcohol gel after hand washing etc (OH auth)

87 87 Appendix 6 - Faculty of Occupational Medicine - Protecting Your Hands Guidance for Employees Procedure Number: HBP November 2017 Page 25 of 34 Version Number: 1.4

88 88 Procedure Number: HBP November 2017 Page 26 of 34 Version Number: 1.4

89 89 Appendix 7 - Responsible Persons Documentation Advice on Completion of the Skin Surveillance This quarterly skin surveillance register is to be completed regularly as hands are checked. It may be helpful for a local ward template, based on this document, to be produced with staff names populated, to make checks and recording easier. Take advantage of your safety briefs, ask staff if they have problems, check their hands, and if they are showing the signs and symptoms of dermatitis then take immediate early action by ensuring your manager refers that member of staff to Occupational Health. This is a statutory requirement under Health and Safety law. If staff are referred the manager should ensure the Health Record/Baseline/Annual Questionnaire has outcome letters from Occupational Health attached (this is NOT a confidential medical record, and is required under the CSOHH regulations). The Health Record should be inserted into the Staff Members Personnel File, or in another secure place and requires to be kept for 40 years. NOTE: Status of Health Record The Health Record is not the same as the medical record held by occupational health or a GP practice. The Health Record is required under the remit of the COSHH and an individual record is to be maintained by line management for staff that require statutory health surveillance. The Health Record will NOT contain confidential clinical data. Individual Health Record / Baseline / Annual Questionnaire This should be completed before starting work or immediately after starting work. The details for the Individual health record (Part 1) should be completed by the employee and the Responsible Person or line Manager and then the responsible person should complete the rest of Part 1, the baseline skin questionnaire. Thereafter Part 2, the annual skin questionnaires should be completed either on an annual date with the rest of the department or annually after the anniversary of employment. The exact timing is dependent on the department and internal procedures. Procedure Number: HBP November 2017 Page 27 of 34 Version Number: 1.5

90 90 NHSH Skin Surveillance Register (please print/copy additional sheets as required) Name First Quarter Date Procedure Number: HBP November 2017 Skin Checked Y/ N Second Quarter Refer to OH Y/N DATE Page 28 of 34 Skin Checked Y/N Third Quarter Refer to OH Y/N DATE Skin Checked Y/ N Version Number: 1.5 Fourth Quarter Refer to OH Y/N DATE Skin Checked Y/N Refer to OH Y/N

91 91 Appendix 8 Health Record/Baseline Skin Assessment & Annual Skin Assessment Form HEALTH RECORD/ BASELINE SKIN ASSESSMENT AND ANNUAL SKIN ASSESSMENT FORM This document must be kept with Employees Personnel Files and retained for a period of 40 years. Part 1 to be completed on employment. Part 2 annually as part of ongoing screening programme. Part 1 Health Record PERSONAL DETAILS: Surname: Forename: Home Address National Insurance No: Date of Birth: Gender: Date commencing employment: Job Title: Line Manager: Location: Department: Please list previous jobs where you have been exposed to wet work:... Date:... Date Part 2 Baseline Skin Assessment To be completed by employee: Do you have a persistent/recurrent skin problem Yes No Have you been seen or treated by your GP for a skin problem Yes No Employee signature: To be completed by responsible person: Are there any signs of cracking of skin, itching, blisters, redness or swelling of hands Yes No If yes to any of the above, the responsible person should notify the line manager for referral to Occupational Health. Comments (if applicable): Action: refer to OH remain on spot and annual skin checks Responsible person signature: Date: Procedure Number: HBP November 2017 Page 29 of 34 Version Number: 1.5

92 92 Part 3 Annual skin assessment. All yes responses should be referred to Occupational Health. Individuals referred to OH will receive an OH health surveillance outcome form which should be attached to this form. Employee name: Date Employee to complete Do you have a persistent/recurrent skin problem Yes No Responsible Person to complete Are there any signs of cracking of skin, itching, blisters, redness or swelling of hands Yes No Have you been seen or treated by your GP for a skin problem Yes No Refer to OH Yes No Employee signature Responsible person signature Do you have a persistent/recurrent skin problem Yes No Are there any signs of cracking of skin, itching, blisters, redness or swelling of hands Yes No Have you been seen or treated by your GP for a skin problem Yes No Refer to OH Yes No Employee signature Responsible person signature Do you have a persistent/recurrent skin problem Yes No Are there any signs of cracking of skin, itching, blisters, redness or swelling of hands Yes No Have you been seen or treated by your GP for a skin problem Yes No Refer to OH Yes No Employee signature Responsible person signature Do you have a persistent/recurrent skin problem Yes No Are there any signs of cracking of skin, itching, blisters, redness or swelling of hands Yes No Have you been seen or treated by your GP for a skin problem Yes No Procedure Number: HBP November 2017 Page 30 of 34 Refer to OH Yes No Version Number: 1.5

93 93 Employee signature Responsible person signature Do you have a persistent/recurrent skin problem Yes No Are there any signs of cracking of skin, itching, blisters, redness or swelling of hands Yes No Have you been seen or treated by your GP for a skin problem Yes No Refer to OH Yes No Employee signature Responsible person signature Do you have a persistent/recurrent skin problem Yes No Are there any signs of cracking of skin, itching, blisters, redness or swelling of hands Yes No Have you been seen or treated by your GP for a skin problem Yes No Refer to OH Yes No Employee signature Responsible person signature Do you have a persistent/recurrent skin problem Yes No Are there any signs of cracking of skin, itching, blisters, redness or swelling of hands Yes No Have you been seen or treated by your GP for a skin problem Yes No Refer to OH Yes No Employee signature Responsible person signature Do you have a persistent/recurrent skin problem Yes No Are there any signs of cracking of skin, itching, blisters, redness or swelling of hands Yes No Have you been seen or treated by your GP for a skin problem Yes No Refer to OH Yes No Employee signature Responsible person signature Procedure Number: HBP November 2017 Page 31 of 34 Version Number: 1.5

94 94 Do you have a persistent/recurrent skin problem Yes No Are there any signs of cracking of skin, itching, blisters, redness or swelling of hands Yes No Have you been seen or treated by your GP for a skin problem Yes No Refer to OH Yes No Employee signature Responsible person signature Do you have a persistent/recurrent skin problem Yes No Are there any signs of cracking of skin, itching, blisters, redness or swelling of hands Yes No Have you been seen or treated by your GP for a skin problem Yes No Refer to OH Yes No Employee signature Responsible person signature Do you have a persistent/recurrent skin problem Yes No Are there any signs of cracking of skin, itching, blisters, redness or swelling of hands Yes No Have you been seen or treated by your GP for a skin problem Yes No Refer to OH Yes No Employee signature Responsible person signature Procedure Number: HBP November 2017 Page 32 of 34 Version Number: 1.5

95 95 Appendix 9 - Managers referral checklist to Occupational Health Procedure Number: HBP November 2017 Page 33 of 34 Version Number: 1.5

96 96 Appendix 10 - Further information on skin for Managers. HSE s Skin at Work web pages ( HSE s Work-related contact dermatitis in the health services ( Substances with a skin notation (symbol SK ) in EH40/2005 Workplace exposure limits ( HSE, Dermatitis in health and social care The product label look for the risk and safety phrases e.g. S24 Avoid contact with skin Health Protection Scotland Standard Infection Control Precautions Literature Review: PPE Aug 2016 Health Protection Scotland Standard Infection Control Precautions Literature Review: Hand Hygiene Use of Alcohol Based Hand Rub Sithamparanadarajah Rajadurai, Controlling skin exposure to chemicals and wet-work, BOSH and RMS publishing 2008, Stourbridge Procedure Number: HBP November 2017 Page 34 of 34 Version Number: 1.5

97 Health & Safety Committee 2 November 2017 Item 4.1.1(5) 97 Health and Safety Policy Management Procedure 11 MP11 General Workplace Risk Assessment Procedure Procedure No: MP11 Procedure Revision No: 1.2 Prepared by (Group and Date): Health and Safety Team Ratified by (Group and Date): Health and Safety Committee 02 November 2011 Effective From: 02 November 2017 Review Date: 02 November 2020 Lead Reviewer: Head of Occupational Health and Safety Dissemination Arrangements: Intranet Policy Area & Intranet Health and Safety Staff Announcement Warning - this document is uncontrolled when printed. Please ensure you have the most recent version of this document. Procedure Number: MP11 Page 1 of 24 Revision Number 1.2

98 98 Document Information (does not change) Board Library Reference PN08 Document Type Procedure Document Subject Original Document Author Assured By Review Cycle Health & Safety Policy Head of Health & Safety Health and Safety Committee 3 years Version Tracking (updated for all subsequent versions) Version Date Revision Description Editor Ratification Status /04/2012 New Policy BS Approved /04/2013 BS Approved Oct 2017 Procedure Number: MP11 Number scoring removed from Risk Matrix Appendix 1 - Risk Assessment Form updated Appendix 2 Guidance on completion updated JG Typos & grammatical errors Para Amendments to likelihood table in line with NPSA Pub - A risk matrix for risk TBC managers. Para Amendments to Risk Page 2 of 24 Revision Number 1.2

99 99 Contents 1.0 Purpose Scope Accountability, Responsibility and Compliance Definitions The following definitions are used in the risk assessment process: Specific Regulations and Requirements Individual v General Risk Assessment General Principles The NHS Highland Procedure for Risk Assessment Step 1. Examination of Work Activities Step 2. - What are the hazards? Step 3 - Deciding who is likely to be harmed Step 4 Part 1 - Examining What Existing Control Measures Are In Place Step 4 Part 2 - Evaluating the level of risk Step 5 Decide on What Else Needs To Be Done and What Level of Risk Remains Step 6 - Who Is Responsible For Getting These New Controls Done? (Action Plans) Step 7 Record and Review the Assessment Competence / Training Requirements Measuring Performance Review of Procedure References and Additional Guidance Appendix 1 - NHS Highland Hazard Survey Template - RA1 (Revised Apr 2013) Appendix 2 - Guidance on Completion - NHS Highland Hazard Survey Form Procedure Number: MP11 Page 3 of 24 Revision Number 1.2

100 100 General Workplace Risk Assessment Procedure 1.0 Purpose We face and deal with risks everyday, most of the time we assess and manage risks without making a formal written assessment. However, there are some risks which are beyond our ability to fully understand or control. These risks need formal risk assessment, after which some can be controlled and managed by the individual or local team, however others may need to be referred to more senior staff in the organization who will decide how to manage the risk. A risk assessment is an important tool in protecting employees and others, by analyzing hazards, deciding on the level of risk and identifying risk reduction measures. The law requires that the risk reduction measures which are put into place ensure that everything reasonably practicable is done to protect people from harm. The risk assessment helps us to focus on the risks that really matter in the workplace the ones with the potential to cause real harm. In many instances, straightforward measures can be effective in controlling risks. 2.0 Scope The purpose of this Procedure is to allocate responsibility and to detail the arrangements for the implementation of risk assessments across NHS Highland in line with the Boards Health and Safety Policy and general duty of care. The responsibility for compliance with this Procedure lies with managers. This document should be read in conjunction with the following NHS Highland documents: Risk Management Policy Health & Safety Policy Fire Safety Policy Incident Management Policy & Procedures 3.0 Accountability, Responsibility and Compliance 3.1 Chief Executive The Chief Executive has ultimate responsibility for Governance including Risk Management but delegates this responsibility through the Boards Directors and General Managers 3.2 Directors and Senior Management Directors and senior operational managers have joint responsibility for ensuring that appropriate risk management, quality improvement and patient safety processes are in place. In respect of this procedure they are to ensure that eeffective systems are established to identify, assess, manage, monitor and review significant hazards and risks within their areas of responsibility where relevant and that those tasked with its implementation are afforded the appropriate level of resource to do so (personnel, competence, time). 3.3 Head of Health and Safety The Head of Health and Safety is the competent person, accountable to the Director of Human Resources and Chief Executive, who advises the Board in respect of health and safety policy formulation and development Procedure Number: MP11 Page 4 of 24 Revision Number 1.2

101 Board Specialist Advisors1 Have responsibility for ensuring that: Managers are assisted when identifying risks: both proactively and actively Managers are assisted when undertaking specialist risk assessments They impart knowledge and use their expertise to help the assessment teams develop their skills and awareness They contribute to training programmes on risk assessment and awareness 3.5 Responsible Leads Are responsible for ensuring that the actions or controls to reduce the risks are implemented 3.6 Risk Assessors Have responsibility for ensuring that: They have undertaken appropriate training and are familiar with, and use, the correct methods of risk identification and assessment as set out in this procedure Any identified risk issues are communicated through the line management system 3.7 All Managers Managers are responsible for ensuring that there are operational systems in place within their teams to fulfill the requirements of this procedure. Within that context, managers must ensure that their staff are released for training and are fully assisted when undertaking any aspect of the risk assessment process 3.8 All staff Staff have responsibility for ensuring that: They support Managers in achieving their responsibilities, as outlined above Any identified risk issues are communicated through the line management system They contribute to minimising risk wherever possible They attend relevant review 4.0 Definitions The following definitions are used in the risk assessment process: Risk Assessment A careful examination of what, in the workplace, could cause harm to people so that a decision can be made as to whether there are enough precautions in place or more should be done to prevent harm. Hazard Something that has the potential to cause harm, such as chemicals, electricity, working from ladders, an open drawer etc. For Example: Cytotoxic drugs are hazardous substances, as they can cause burns to the skin and injure the lungs if inhaled Sharps, such as syringes, have the potential to transmit infection if they puncture the skin after being injected into another person Risk Is the chance, (e.g. high, medium or low) that somebody could be harmed by the hazard, together with an indication of how serious the harm could be, for example: A sharps disposal bin left on the floor in a clinic presents a high risk of injury, especially to inquisitive children. Boards Specialist Advisors include: Occupational Health, Health and Safety, Clinical Governance, Infection Control, Violence and Aggression, Moving & Handling, Estates, Fire Safety, Radiation Protection, 1 Procedure Number: MP11 Page 5 of 24 Revision Number 1.2

102 102 Sharps correctly placed in bins which are out of reach, normally pose a low risk of injury to children. It is calculated by multiplying the likelihood and the severity (Risk = Likelihood x Severity). This will prioritise your risk into a High, Medium or Low category. See risk matrix below. Harm Is the actual injury or ill-health suffered by those exposed to the hazard. Task An activity carried out in the workplace. Control Measures Are measures which are put in place to manage and reduce the risk. In assessing the practicability of control measures it is usual to refer to a hierarchy of control measures. This is a list of approaches to reducing risk, starting with the most effective. Obviously, the best means of controlling a risk is to get rid of the thing that is the hazard, so that there is no more risk. However, this is impossible in many situations, so some other form of controlling the risk is required. This then gives rise to a hierarchy of control measures as follows: Eliminate if possible e.g. use of laminated floor panels that click into place (no adhesive required),purchasing prefabricated roofing sections, prevention of vehicles reversing by re-designing delivery areas Reduce the risk e.g. water based adhesive or paint (rather than toxic or flammable products), purchasing small lighter packages, use a safety blade rather than traditional knife for cutting open cardboard boxes and strappings, use of equipment with lower noise levels, reduce voltage/use battery operated tools, reduced speeds of vehicles, proper preventative maintenance) Isolate the staff from the hazard e.g enclose the process to avoid human contact, fixed guarding of machinery, noise reducing enclosure, isolation or locking off of electrical systems Control the risk by engineered devices and instruction (e.g. dust/fume extraction, machinery safety guards, reduction in exposure limits, written procedures, suitable and sufficient training, safe systems of work, method statements and permits-towork, warning notices, Local/organisational rules, personal hygiene (e.g. spread of HIV, Hepatitis) Personal protective equipment use as a last resort, correct use and timely replacement e.g. goggles, gloves, hard hats, safety shoes etc. Discipline e.g. adhering to procedures, method statements, safe systems of work etc. and supervision and the application of discipline when ignored. When selecting control measures you should start at the top of the hierarchy and only move down a level when you have decided that it is not reasonably practicable to use a control measure from that level. For example you should first consider whether it is reasonable to eliminate the task altogether, if not then you should look at risk reduction. Procedure Number: MP11 Page 6 of 24 Revision Number 1.2

103 103 So Far As Is Reasonably Practicable (SFRP) This is the level of liability laid down in the Health and Safety at Work Act. The term reasonably practicable implies a balance between the cost of introducing safety measures in terms of money time and inconvenience and the benefits to be expected from their introduction. Where the cost is greatly disproportionate to the risk the employers can claim in their defense that they have done all that is reasonably practicable, or conversely that they have discharged their duties by doing all that is reasonably practicable. 4.1 Specific Regulations and Requirements Risk assessment is not a new idea and there are a number of sets of Regulations which require specific risk assessments to be carried out in addition to a general risk assessment. These involve work with: High noise levels Display screen equipment Asbestos Ionizing radiation Lifting and moving Hazardous substances (including biological agents) Lead Vibrating equipment Fire Employment of young persons Pregnant workers Stress All of these require a specific risk assessment to be carried out by a competent person, guidance on these should be sought from the relevant Health and Safety Manager. Generally the process should include the following steps: Investigations to determine if a problem exists, If it does, can it be eliminated? If not, what can be done to reduce the risk to a minimum? Risk assessments to identify tasks involving significant risks are required by the Management of Health and Safety Regulations This means that risk assessments are a statutory requirement and the enforcing authorities may prosecute employers if written risk assessments are not available. This has been a requirement since Each department has a legal duty to determine the risks to health and safety of: Its staff Any others who may be affected by its activities. 4.2 Individual v General Risk Assessment Individual risk assessments of individual patients are carried out by clinical staff and include assessments for moving and handling, falls prevention, pressure sores, mental health. Although based on the same principles, this document does not refer to how these assessments are conducted. However, these are important assessments normally recorded in the clinical notes which must be up to date and available for all staff who need to know. This will sometimes include non-clinical staff such as porters and social carers where information such as safe handling techniques or information about aggressive behaviour will be as relevant to them as it is to clinical staff. Procedure Number: MP11 Page 7 of 24 Revision Number 1.2

104 104 General risk assessments are assessments of specific processes or areas rather than an individual person. This document refers to how these assessments are conducted. It is just as important that these assessments are kept up to date and made available to everyone who needs to know about them. However, review periods will normally be longer than individual assessments, which are reviewed sometimes on a daily basis. The term 'general risk assessment' may be misleading as perhaps it implies that one assessment considers all risks in an area, whereas in fact there are probably many general risk assessments. The term 'general' refers to the nature of the assessment being in a wider context than just one individual patient. A general assessment can be made of the risks of violence and aggression in a department or area, and the means for reducing the risk. A general moving and handling risk assessment will consider the normal working environment and the types of handling risks posed to staff. An individual risk assessment will relate to how a specific patient's mobility needs will be managed. Although the two are linked, they are quite different processes. General Principles The risk assessments need to be: 4.3 Written (this can be electronically) Made available to the relevant staff (NO use keeping it locked up). Kept up to date. Reviewed proportionately in relation to the level of risk2 and be revised if any significant changes have taken place. The Management Regulations give certain guidance including: Disregarding risks that are part of everyday life e.g. tripping up a kerb. Generic assessments may be produced to cover the activities of one department at a variety of locations, but the assessments must be applicable at each one. This may require a certain amount of alterations to ensure that the assessments truly reflect what staff are expected to do in an area. Risk assessments are not a one-off exercise but need to be revisited when for example a change of equipment takes place. Only reasonably foreseeable risks need to be considered, and you are not expected to deal with things that are very unlikely to occur e.g. Earthquakes, Tornadoes or other more minor but improbable events. Concentrate on what common sense tells you could happen to your staff or members of the public or patients visiting your area. In terms of who undertakes a risk assessment the Regulations do not prescribe that an expert, eg a safety manager, should carry it out, only that the person is competent. Once trained line managers, supervisor or individual member of staff in the department will have the competence to carry out and write up an adequate risk assessment due to his/her knowledge and experience of the tasks involved. It is important to remember to allocate actions to the appropriate individual with a reasonable close out date agreed. Identifying actions through risk assessment is an excellent tool in improving your working environment. Proportionate Review means review every 3 years for low risk, review every 2 years for medium risk, review every 1 year for high risk 2 Procedure Number: MP11 Page 8 of 24 Revision Number 1.2

105 The NHS Highland Procedure for Risk Assessment The following system has been developed for NHS Highland and can be applied successfully to all departments, including: Wards, offices, estates, hotel services, laundry, porters etc. It relies on the identification of 7 distinct steps: (detailed on Hazard Survey Form see below) 4.5 Step 1. Examination of Work Activities Agree the tasks that your staff do whilst they are at work. Try to consider and list all the different functions they are expected to perform. Think of their job descriptions, Where they will be working, Routine/non routine operations, Emergency situations, What equipment will be used, What work is done out of normal hours, What effect the environment may have, Accidents that have already happened, What PPE is provided. Be thorough as the rest of the assessment is built on points raised here. 4.6 Step 2. - What are the hazards? This is the process of identifying all the hazards that exist in the workplace. You need to be aware of all the possible hazards, but it is the significant ones which are important. One approach is to take each task and break it down into steps, assessing the hazards associated with each step. For example, the preparation of a meal could be broken down into preparation of meat and vegetables; cooking, to include boiling and roasting; serving, including the dishing-up and the moving to the table; and washing-up. Each step will have its own hazards. The staff actually performing the tasks are likely to be the best people to assess them, although their familiarity with the job may make them less objective about potential hazards. Procedure Number: MP11 Page 9 of 24 Revision Number 1.2

106 106 All risks in the workplace should be assessed in order to identify those that are significant. It is important to concentrate on these and not to get side-tracked into devoting too much time to trivial risks Sources and Form of Harm A hazard is something that has the potential to cause harm. In looking at the range of hazards that exist in the workplace, you need to look at all aspects of work -the way in which the work is carried out and the way it is organised as well as the substances and/or equipment used -to assess what harm may arise. Some hazards and their associated potential harm are very obvious because they naturally have an element of danger -for example, handling chemical substances may lead to exposure to chemical vapours or spills resulting in external and internal burns, or climbing up and down ladders may result in falls. There are many other instances where the hazards are less obvious, particularly where a normally safe operation may only become hazardous in particular situations. This may be as a result of defects in equipment (where handling simple electrical equipment may cause shocks or burns due to a wiring problem), or a change in circumstances, such as spillages or misplaced boxes and equipment making walking across a floor hazardous. It is, then, the various circumstances which also need to be looked at. Non-routine operations, such as maintenance operations, loading and unloading, changes in shift cycles, are particularly important. Further, interruptions to the work activity are a frequent cause of accidents, and the management of such incidents and the procedures to be followed should be looked at. There are essentially two ways of identifying these hazards: By looking at DATIX incident data - this is reactive in that we are looking at hazards which have already been identified by the fact that the risk they present has been realised, and By looking at the way work is performed - this is proactive in that we are trying to identify hazards before they are realised Legislation Information about hazards and risks may be identified from a consideration of any legislative requirements which apply to the workplace in general and to specific jobs in particular. This will most often be in the form of Regulations and associated Approved Codes of Practice (as well as any guidance notes) relating to the type of work carried out or the premises in general. Thus, for example, the COSHH Regulations or Manual Handling Regulations may be used to establish hazards where work involves, respectively, handling chemicals and lifting loads Manufacturer's Information Information about potential hazards and possible risks is generally available from the manufacturers and suppliers of equipment and materials, along with the instructions for use. Indeed, it is a legal requirement for them to provide such information and keep it up-to-date Incident Data NHS Highlands DATIX incident records are a valuable source of information about our hazards, but they are historic, so they need to be checked to establish whether the hazards still exist and whether appropriate safety precautions have now been implemented. This underlines the value of keeping detailed records of all incidents, including the losses (if any) which result from them. The types of incident data which may be used are: Maintenance and inspection records, which give details of problems with machinery and equipment. Procedure Number: MP11 Page 10 of 24 Revision Number 1.2

107 Accident records, which should provide information about the causes of accidents (note the distinction here with the classification of accidents by cause of injury, which is not so relevant to identifying hazards). Ideally, accident data will indicate people, jobs, work areas, times of day and situations which need careful considerationill-health data, which might not be so readily available. Claims for time off work due to recognised industrial conditions will be there, but it will also be worth checking on absence records to see if there are individuals or groups of workers who might be at risk. Step 3 - Deciding who is likely to be harmed When considering people at risk, it is important to think not only of those carrying out particular activities, but also of all those who may be affected by those activities. This may include other workers who may be in the vicinity, both during working hours (such as maintenance staff, contractors and other staff who just happen to be passing) as well as those who may be present at other times, such as cleaners and security guards. In addition, the position of patients, visitors and other members of the public who may be affected must be assessed. IMPORTANT The following groups must also be considered: Children (under the minimum school leaving age) Young Person (under the age of 18) Inexperienced workers, Peripatetic (lone workers) Less able bodied staff Risks to pregnant women and nursing mothers These people may be subject to different levels of risk, depending on their personal attributes, competence, experience, age, physical condition, etc Workers / Staff Workers / Staff are those directly involved with the activity or other employees working nearby or in the workplace. They may be skilled workers, trainees and young or new workers. They may be disabled in some way or may work under special conditions (such as shift workers, home or lone workers). The way in which hazards may affect different groups needs to be clearly identified Maintenance Staff Particular considerations relate to maintenance staff (for example Estates staff) who will often be working under very different conditions to those applying during normal operations. They may face different hazards as a consequence Cleaners The position of cleaners is often overlooked, but because they are unlikely to be aware of the operational detail of safety measures associated with particular hazards, they may be at more risk if the hazards are still "live" when cleaning operations are taking place (often outside normal working hours). Cleaning operations also present their own hazards Contractors Contractors, by their very nature, will not be fully aware of all the hazards or control procedures at the workplace in which they are working. Their position in relation to identified hazards must be noted and the assessment needs to consider what additionally must be done to provide them with the same level of protection as employees Visitors / Patients Visitors / Patients are in a similar position to contractors in that they are unlikely to be aware of the hazards or control measures at the workplace they are visiting. In many ways, they may be more at risk since, unlike contractors who may be expected to have a general Procedure Number: MP11 Page 11 of 24 Revision Number 1.2

108 108 understanding of workplace risks, they may have no idea of the them. Again their position in relation to identified hazards must be noted and the assessment needs to consider what additionally must be done to provide them with the same level of protection as employees Members of the public This will include all other persons who may be affected by work activities, as well as trespassers (those who may be on the premises in an unauthorised capacity). Hazards affecting these groups may not be the same as those affected workers and it is unlikely that they may be expected to take any safety precautions themselves. Thus, there is a strong requirement to ensure that any hazards which they may face as a result of workplace activities are contained within the workplace. Particular issues need to be addressed in respect of the possibility of children coming onto the premises (for example, playing on building sites or near railway lines). 4.8 Step 4 Part 1 - Examining What Existing Control Measures Are In Place Control measures are things that an employer or manager uses to reduce the hazards to staff. For example Where an employer cannot eliminate a noise source such as Machinery, the hazard is controlled by the provision of ear defenders. Where materials needs to be moved around a site and the process cannot be mechanised, an employer can control the hazard of strain injury by providing staff with trolleys or lifting equipment to assist with the operation. Where harmful or irritant chemicals need to be used for cleaning purposes in wards or laboratories, a manager can control the hazard to staff by using the least harmful chemical, providing protective equipment such as gloves or goggles and providing training for staff as to how the material should be used/handled. Where staff is expected to work outside on the roads or car park, the hazard of collision with vehicles is controlled by the provision of High Visibility clothing. Certain control measures will appear on almost every assessment, as they should form an essential part of a department s procedures. These include:4.8.1 Training If staff are not adequately trained to use equipment or carry out a task safely, the risk of injury or mishaps is clearly increased! Written Instructions Following on from training. Important where hazardous chemicals or dangerous equipment needs to be used: there should be no room for misunderstanding!! PPE It will often be necessary to provide staff with personal protective equipment such rubber gloves, goggles, facemasks, safety shoes, High Viz. clothing and ear defenders Signage Warning staff of their presence may control hazards. e.g. electrical warning signage, labelling of chemicals, and even emergency exit signage. (Note this will be of no use in the event of fire if it is obstructed!) Procedure Number: MP11 Page 12 of 24 Revision Number 1.2

109 Other Considerations Once the existing control measures have been identified they should be recorded on the assessment form. When considering the level of risk which is the next stage, account must be taken of whether the control measures that are in place are effective as this will have an impact on the level of risk. For example: Training - Have all your staff been trained or is it just a fraction of them? How recent was the training, and is there a need for refresher? Can you prove that your staff have been adequately trained and have you kept written records? Instructions - If written instructions are in place, do all staff know of their existence? How current are the instructions? Do they need revising? Are they readily available to all staff for reference? Even if your staff know all of the above, do they take any notice or are they taking short cuts? Signage - Are all relevant signs there or have they fallen off or been removed by contractors and not replaced? Do all staff understand the significance of these signs? PPE - Have all staff been issued with appropriate PPE to enable them to carry out their job safely? Are there proper storage arrangements for these? Where do staff report defective items and can these be replaced easily? Responsibility - Who in the department is responsible for these? 4.9 Step 4 Part 2 - Evaluating the level of risk You have identified the task, the hazards, and existing control measures and now have to decide on the level of risk. This is rather subjective; however the risk matrix below should help. Risks may be defined as a combination of the following factors: How likely is it that an accident will occur (how often, how many will be injured). How serious will the accident be? Likelihood There are different views on what constitutes likelihood in the context of risk rating, however, the preferred measure of likelihood is the likelihood of a hazardous event. Hazardous event is used to mean an event which could lead to any type or severity of loss. This is probably best illustrated by example as follows. Example: If the hazard is a trailing cable, one hazardous event is someone tripping. The likelihood of someone tripping over a trailing cable will vary depending on a number of factors; location of the cable; lighting levels; type of person exposed to the cable etc. These factors should be taken into account when selecting the likelihood of a trip occuring These likelihoods are defined independently of the possible outcomes. For example, the likelihood of tripping is rated, irrespective of whether the person who trips will be hurt. When assessing likelihood, it is important to take into consideration the controls already in place. Procedure Number: MP11 Page 13 of 24 Revision Number 1.2

110 110 The following table should be used when deciding on the LIKELIHOOD Descriptor 1. Rare 2. Unlikely Likelihood Can t believe this event would happen again will only happen in exceptional circumstances. Not expected to occur for years Not expected to Happen/recur but it is possible it may do so. Expected to occur at least annually. 3. Possible Might happen or recur occasionally. Expected to occur at least monthly 5. Almost Certain Will probably Will happen/recur, undoubtedly happen/recur, but it is not a possibly persisting issue/circumstan frequently. ce. Expected to Expected to occur at least occur at least daily. weekly 4. Likely Severity There are a number of different definitions of severity which could be used in severity ratings and some examples are given below. The severity of the most serious harm which could occur. For example, if a person trips, the most severe harm could be a fatality. The severity of the most probable harm in the circumstances. For example, if a person trips in an office, the most probable harm is a bruise. The last of these is to be preferred, it should be remembered however, that the severity will vary depending on the nature of the individual being affected. The following tables should be used when deciding on SEVERITY: Descriptor Patient experience 1. Negligible Reduced quality of patient experience / clinical outcome not directly related to delivery of clinical care. 2. Minor Unsatisfactory patient experience / clinical outcome directly related to care provision readily resolvable. 3. Moderate Unsatisfactory patient experience / clinical outcome, short term effects expect recovery <1wk. 4. Major Unsatisfactory patient experience / clinical outcome: long term effects expect recovery >1wk. Injury (physical and psychological) to patient/ visitor/ staff. Adverse event leading to minor injury not requiring first aid Minor injury or illness, first aid treatment required Complaints/ Claims Locally resolved verbal complaint Justified written complaint peripheral to clinical care. Agency reportable, e.g. Police (violent and aggressive acts) Significant injury requiring medical treatment and/or counselling. Below excess claim. Justified complaint involving lack of appropriate care. Major injuries/long term incapacity or disability (loss of limb) requiring medical treatment and/or counselling. Claim above excess level. Multiple justified complaints. Staffing and Competence Short term low staffing level temporarily reduces service quality (< than 1 day). Short term low staffing level (> 1day), where there is no disruption to patient care. Ongoing low staffing level reduces service quality. Minor error due to ineffective training/implement ation of training. Late delivery of key objective / service due to lack of staff. Moderate error due to ineffective training/implementation of training. Ongoing problems with staffing levels. Uncertain delivery of key objective / service due to lack of staff. Major error due to ineffective training/implement ation of training. Procedure Number: MP11 Page 14 of 24 Revision Number Extreme Unsatisfactory patient experience / clinical outcome: continued ongoing long term effects. Incident leading to death or major permanent incapacity. Multiple claims or single major claim. Complex justified complaint. Non-delivery of key objective / service due to lack of staff. Loss of key staff. Critical error due to ineffective training/implem entation of training.

111 111 Financial (including damage/ loss/ fraud) Adverse Publicity/ Reputation Negligible organisational/per sonal financial loss (< 1k) (NB. Please adjust for context) Rumours, no media coverage Little effect on staff morale Minor organisational/pers onal financial loss ( 1-10k). Significant organisational/personal financial loss ( k). Major organisational/per sonal financial loss ( 100k 1m). Severe organisational /personal financial loss (> 1m). Local media coverage short term. Some public embarrassment. Minor effect on staff morale / public attitudes. Local media longterm adverse publicity. Significant effect on staff morale and public perception of the organisation National media / adverse publicity, less than 3 days. Public confidence in the organization undermined Use of services affected National / International media / adverse publicity, more than 3 days. MSP / MP concern (Questions in Parliament). Court Enforcement Public Enquiry/FAI Risk Matrix Each hazard should be assessed and scored for likelihood and severity and the results plotted on the risk matrix. If the above factors are taken into account, there is usually agreement on whether a Low, Medium, High or Very High risk exists. Risk Score = Likelihood Score X Severity Score 1. SEVERITY / IMPACT LIKELIHOOD AC = Almost Certain L = Likely P = Possible U = Unlikely R = Rare Insignificant (Ins) Minor (Min) Moderate (Mod) Major (Maj) Extreme (Ext) MEDIUM HIGH HIGH VERY HIGH VERY HIGH MEDIUM MEDIUM HIGH HIGH VERY HIGH LOW MEDIUM MEDIUM HIGH HIGH LOW LOW MEDIUM MEDIUM HIGH LOW LOW LOW MEDIUM MEDIUM The likelihood, severity and risk scores should be entered into the risk rating column on the RA1 form. Procedure Number: MP11 Page 15 of 24 Revision Number 1.2

112 Step 5 Decide on What Else Needs To Be Done and What Level of Risk Remains Risk Score Risk Rating Action Required to Reduce Risk Score Acceptable Risk LOW MEDIUM Manage by monitoring and review of existing control measures, any further actions to reduce risk should take place within 2-3 months Manageable Risk Decide on any new control measures and develop action plan aim to implement these actions within 4 weeks HIGH VERY HIGH Unacceptable risk Task must be stopped immediately. Decide on any new control measures and develop action plan, new controls must be implemented prior to resuming/starting the task Unacceptable risk Task must be stopped immediately. Decide on any new control measures and develop action plan, new controls must be implemented prior to resuming/starting the task The above table should be used to decide the level of action and timescales that are required as a result of the estimation of the level of risk. New control measures should be selected following the principles of the hierarchy of control as outlined in the definitions section. Once the new control measures have been selected the level of residual risk should be estimated using the risk matrix, and recorded on the RA1. This will allow a judgement to be made of whether the proposed new control measures will be sufficient to reduce the level of risk to an acceptable level 4.11 Step 6 - Who Is Responsible For Getting These New Controls Done? (Action Plans) As a result of steps 4 and 5 you may have decided that some action is required, this could be prohibiting the task as the risk is too high or implementing some new control measures, in either case you will need to do something about it. To do this the Management Action Plan columns of the RA1 form should be used to identify who the owner of the action is, the targeted date for completion and the actual date of completion. The person responsible would need to be informed of the required actions and for putting them into effect. The method of communication is important to ensure that the problems and timescales involved are agreed and understood. Procedure Number: MP11 Page 16 of 24 Revision Number 1.2

113 Step 7 Record and Review the Assessment Review Clearly, events within a department change and this may render the risk assessment obsolete. The assessments need to be live working documents that should be reviewed: Re-visit and review the assessment, proportionate to the risk, whether or not changes are apparent as follows: Level of Residual RiskRisk Assessment Review Period High Every 1 Year Medium Every 2 Years Low Every 3 Years Periodically Following an accident or, If new equipment, new premises, new working practices are being considered or have already been introduced! Clearly all the above could alter the risk posed to staff or others. Where your department is altering premises or equipment, it may be a good idea to assess the risk to staff or others whilst the changes are in progress. Reviews of risk assessments should be recorded in the Line Manager s Assessment Review columns of the RA1 form each time the assessment is reviewed Records All records must be retained by the department, ward, directorate etc. The essential content of the risk assessment record should be: hazards or risks associated with the work activity; any employees identified as especially at risk; precautions which are (or should be) in place to control the risks (with comments on their effectiveness); and Improvements identified as being necessary to comply with the law. Date for next review of the assessment. 5.0 Competence / Training Requirements Managers / Staff who undertake risk assessments should undergo training relevant to their involvement in the process. Training is delivered in a variety of ways. 6.0 Corporate induction As part of Health & Safety e-learning through LearnPro Health & Safety Risk Assessment Workshops IOSH Training, which is held as and when appropriate Departmental / locally delivered update training Measuring Performance It is essential that the contents of this procedure are monitored and accurately evaluated in order to ensure its continued effectiveness. This will be done by the Health & Safety Team under the Measuring Performance aspects of the NHS Highlands Health and Safety audit process. Procedure Number: MP11 Page 17 of 24 Revision Number 1.2

114 Review of Procedure Arrangements will be made by the Health & Safety Team to review this procedure, as a minimum; on a biennial basis to ensure any statutory/legislative changes are addressed. 8.0 References and Additional Guidance 8.1 References Health and Safety at Work Act 1974 Management of Health and Safety at Work Regulations 1999 Workplace (Health, Safety and Welfare) Regulations 1992 Manual Handling Operations Regulations 1992 Control of Substances Hazardous to Health Regulations 2002 (COSHH) Personal Protective Equipment (PPE) Regulations 1992 Health and Safety (Display Screen Equipment) Regulations 1992 Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR) 8.2 Guidance The UK s Health and Safety Executive, and the European Agency for Safety and Health at Work provide additional user friendly guidance on a range of health and social care sector related hazards as well as guidance on risk assessment and control. The websites can be found here: HSE Risk Management HSE Health and Social Care Sector EU Agency for Safety and Health at Work Procedure Number: MP11 Page 18 of 24 Revision Number 1.2

115 115 Appendix 1 - NHS Highland Hazard Survey Template - RA1 (Revised Apr 2013) NHS Highland Risk Assessment Form Note 1 Operational Unit/Site Ward/Department Assessment No Assessment Date Activity/Process: Please indicate if a specific risk assessment is required Note 2 What are the Hazards? Manual Handling Noise Hazardous Substances (inc biological agents Use of Display Screens Confined Spaces Lead Asbestos Vibrating equipment Fire PPE Who is at Risk? Control Measures (Specific existing Control measures) Risk Rating Note 3 L S R Additional Controls (Each Control Measure is to be specific and managed) Residual Risk Rating Note 4 L S R Ionizing Radiatio n Violence & Aggression Management Action Plan Owner Assessor s Name: Designation: Signature: Line Manager s Name: Designation: Signature: Line Manager s Assessment Review (See Notes 5 and 6) Review Date Review Date Review Date Review Date Name Name Name Name Designation Designation Designation Designation Signature Signature Signature Signature Likelihood, Severity & Risk Rating is abbreviated in the RA1 form to: L / S / R Procedure Number: MP11 Page 19 of 24 Revision Number 1.2 Targe t Date Completion Date

116 116 Notes: 2. If using a Generic risk assessment, Assessors and Line Managers are to satisfy themselves that the assessment is valid for the task and that all significant hazards have been identified and assessed. If additional hazards are identified they are to be recorded and attached to the Generic assessment. 3. Certain hazards require specific risk assessments under various sets of Regulations. Managers should indicate which of these are applicable, and ensure that the assessments are undertaken. 4. Risk Matrix SEVERITY / IMPACT LIKELIHOOD AC = Almost Certain L = Likely P = Possible U = Unlikely R = Rare Procedure Number: MP11 Page 20 of 24 Insignificant (Ins) Minor (Min) Moderate (Mod) Major (Maj) Extreme (Ext) MEDIUM HIGH HIGH VERY HIGH VERY HIGH MEDIUM MEDIUM HIGH HIGH VERY HIGH LOW MEDIUM MEDIUM HIGH HIGH LOW LOW MEDIUM MEDIUM HIGH LOW LOW LOW MEDIUM MEDIUM Revision Number 1.2

117 117 Risk Rating LOW MEDIUM HIGH VERY HIGH Action Required to Reduce Risk Score Acceptable Risk Manage by monitoring and review of existing control measures, any further actions to reduce risk should take place within 2-3 months Manageable Risk Decide on any new control measures and develop action plan aim to implement these actions within 4 weeks Unacceptable risk Task must be stopped immediately. Decide on any new control measures and develop action plan, new controls must be implemented prior to resuming/starting the task Unacceptable risk Task must be stopped immediately. Decide on any new control measures and develop action plan, new controls must be implemented prior to resuming/starting the task 4. Record the residual Risk Rating to demonstrate that the risk has been reduced to an acceptable level; record Likelihood and Consequence scores. 5. Line Managers are to note that they are responsible for production of the risk assessment and that they are signing to indicate that the risk assessment is suitable and sufficient and they consider the risks to be acceptable. 6. Risk Assessments are to be reviewed: In the following timescales: Level of Residual Risk High Medium Low Risk Assessment Review Period Every 1 Year Every 2 Years Every 3 Years If there is reason to doubt the effectiveness of the assessment. Following an accident or near miss. Following significant changes to the task, process, procedure or Line Management. Following the introduction of more vulnerable personnel. If Generic prior to use. Procedure Number: MP11 Page 21 of 24 Revision Number 1.2

118 118 Appendix 2 - Guidance on Completion - NHS Highland Hazard Survey Form How to Complete - NHS Highland RA1 (Rev Aug 11) Risk Assessment Form Procedure Number: MP11 Page 22 of 24 Revision Number 1.2

119 119 Notes: 1. If using a Generic risk assessment, Assessors and Line Managers are to satisfy themselves that the assessment is valid for the task and that all significant hazards have been identified and assessed. If additional hazards are identified they are to be recorded and attached to the Generic assessment. 2. Certain hazards require specific risk assessments under various sets of Regulations. Managers should indicate which of these are applicable, and ensure that the assessments are undertaken. 3. Risk Matrix SEVERITY / IMPACT LIKELIHOOD AC = Almost Certain L = Likely P = Possible U = Unlikely R = Rare Risk Rating LOW Score 1-3 MEDIUM Score 4-9 HIGH Score VERY HIGH Score Insignificant (Ins) Minor (Min) Moderate (Mod) Major (Maj) Extreme (Ext) MEDIUM HIGH HIGH VERY HIGH VERY HIGH MEDIUM MEDIUM HIGH HIGH VERY HIGH LOW MEDIUM MEDIUM HIGH HIGH LOW LOW MEDIUM MEDIUM HIGH LOW LOW LOW MEDIUM MEDIUM Action Required to Reduce Risk Score Acceptable Risk Manage by monitoring and review of existing control measures, any further actions to reduce risk should take place within 2-3 months Manageable Risk Decide on any new control measures and develop action plan aim to implement these actions within 4 weeks Unacceptable risk Task must be stopped immediately. Decide on any new control measures and develop action plan, new controls must be implemented prior to resuming/starting the task Unacceptable risk Task must be stopped immediately. Decide on any new control measures and develop action plan, new controls must be implemented prior to resuming/starting the task 4. Record the residual Risk Rating to demonstrate that the risk has been reduced to an acceptable level; record Likelihood and Consequence scores. 5. Line Managers are to note that they are responsible for production of the risk assessment and that they are signing to indicate that the risk assessment is suitable and sufficient and they consider the risks to be acceptable. 6. Risk Assessments are to be reviewed as follows: Procedure Number: MP11 Page 23 of 24 Revision Number 1.2

120 120 Level of Residual Risk Risk Assessment Review Period High Every 1 Year Medium Every 2 Years Low Every 3 Years If there is reason to doubt the effectiveness of the assessment. Following an accident or near miss. Following significant changes to the task, process, procedure or Line Management. Following the introduction of more vulnerable personnel. If Generic prior to use. Procedure Number: MP11 Page 24 of 24 Revision Number 1.2

121 121 Health & Safety Committee 2 November 2017 Item _NHS Highland HS Plan_Estates Item DRAFT Estates Health and Safety Management Plan PRINT ON A3 Serial Topic for Action Action Required Target to be Achieved Estates Priority Accountable Person Action Owner Manual Handling Training 80% of all staff to have completed the LearnPro M&H Modules (Module A "nonpeople handling") Harry Maclean Team Leads Fire Safety Training Ensure that ALL new members of staff have recieved fire safety training as part of the local induction and ensure that exisiting staff are in date. A written record of trained persons is to be maintained Harry Maclean Team Leads Violence & Agression Training Harry Maclean Team Leads Create a "safety conversation" walkround methodology for EO's / Create the system Supervisors, based on the princples of Visible Felt Leadership (VFL). Pilot, Provide training for EO/Supervisors test and adjust and rollout. VFL is where those in management / supervisory roles eg those who set the standards, are seen visibly demonstrating organisational commitment to safety at the "shop floor" level. Eric Green Harry Maclean Action Status RAG ESC ESC1 Estates Safety Culture Project (See old Corp Plan Row 9) Estates STATMAN training ESC2 Estates Safety leadership walkrounds 7 NOTE: This is NOT an Inspection or an Audit. Its purpose is evidence based and it is used to raise safety awareness and motivate staff to work safetly. 8 Estates Work Performance & Quality Spot Checks EO's / Supervisors to conduct 4 spot checks per month Harry Maclean Team Leads 9 ECC3 Adverse Event Investigation Course Create and deliver a basic level adverse event investigation course for Estate Officers & Supervisors Harry Maclean Karen-Anne Wilson Risk Assessments for Job Plans Review and update mandatory / statutory job plans and risk assessments in 4 job plan and risk assessment reviews line with existing legislation / NHS mandatory guidance per month Eric Green Team Leads Permit to Work System Create a documented permit to work system for NHSH Estates Department. Creat a PTW system and supporting The system and arrangements should set out clear responsibilities for EO's procedure Supervisors, Authorised and Competent Persons and Contractors so that work is clearly defined and controlled. Eric Green Bruce Barr 10 SS 11 SS1 SS2 Safe Systems of Work FS 14 Conduct 4 spot checks per month Fire Safety (See old Corp Plan Rows 19-23) FS1 NHSH Fire Safety Policy (HBP 25) The current fire policy is outdated. Review, Update, Ratify and Distribute NHSH Fire Safety Policy (HBP 25). Bruce Barr Andy Knox FS2 NHS Highlands Fire Safety Training Model Advise and articulate to NHSH Health & Safety Committee on the model of Be clear on the fire safe training model fire safety training required in NHS Highland. This is to include advice on refresher periods and the target audiences, along with the arrnegements for managing and recording FS training Bruce Barr Andy Knox FS3 Fire Risk Assessments Continue to create, review and update Fire Risk Assessments. This is an ongoing activity. Number of high risk FRA's NOT been completed or reviewed within the approriate timeframe. Report annually at May HS Committee Bruce Barr Andy Knox 3i Site based FRA are stored locally on Smartsheet at present but there is no clear method to share and follow up those actions, which may be actioned by estates or the duty holder. This is counter to the principles of risk assessment and requires to be resolved as soon as. In essence there is no one monitoring the progress / implementation of actions.estates are required to devise a method to share the FRA's by May 17 Devise a system to share actions with Op Units Bruce Barr Various actions Continue to deliver, in a risk based manner, on site Emergency Fire Evacuation Exercises. This is an ongoing activity Number of requests made for fire evacuation exercises per year. Report annually at May HS Committee Bruce Barr Andy Knox FS3a Fire Risk Assessment Actions - Sharing & Communication of Fire Plans with Op Units 17 FS4 Fire Evacuation Exercises COC Control of Contractors (See old Corp Plan Rows 26-30) COC1 Create a resourced plan to improve current arrangements and compliance regarding the controls of contractors. Create a plan, and identify a resource, to establish the current compliance gaps between the existing arrngements and those that are deemed compliant. Create a plan Eric Green Bob Summers COC2 Employer Level 1 Control of Contractors Procedures Finalise, based on the above event and the outcome of the Electrical Isolation Review, the Employer Level 1 Control of Contractors Procedure. This should also include agreement by HS and Estates on the level, extent and type of pre-qualifification. Create, publish and communicate the procedure(s). Bruce Barr Bob Summers COC3 Operational Procedures for Ad Hoc and Maintenance Contracts Create and agree the operational procedures for ad-hoc and maintenace contract work. This is to include local site rules, control procedures onto sites and induction processes. Bruce Barr 23 COC4 Capital Project / Frameworks / HubCo CoC & CDM Procedures Create the Capital Project / Frameworks / HubCo procedures for controlling contractors and implementing CDM 2017 requirements Eric Green Kim Corbett COC5 Establish Site Rules To create 1 document for NHSH that details the sites rules for all contractors working on NHSH premises. They should include details on: the use of PPE, traffic management systems, pedestrian routes, site house keeping, fire prevention, emergency procedures or permit-to-work systems etc. Bruce Barr Amanda Glen 25 COC6 Contractor Induction Create a client based site induction package / processes for contractors Bruce Barr Amanda Glen Exported on 25 October :27:31 o'clock WEST Page 1 of 2

122 122 Serial 26 WR Topic for Action Action Required Target to be Achieved Create, publish and communicate the procedure. WR1 Develop a window management procedure Finalise and publish the Window Management procedure, it should include: roles & responsibilities, risk assessment, planned preventative maintenance, restrictor standards, a ward monitoring tool, fault reporting etc. WR2 Risk Assess & Establish a PPM Programme for Health & Social Care sites ES Estates Priority Accountable Person Action Owner Bruce Barr Amanda Glen Provide clarity to Estate Officers / Supervisors on whether WR will be assetted or not Provide appropriate guidance on installation, fitting and maintenance (including the frequency) of WR Ensure that SPM / PPM programme is created and embedded within Maximo Bruce Barr Bruce Barr Bruce Barr Bruce Barr Electrical Safety Sub Group and Action Plan Create the group Esatblish terms of referernce Agree the governance, monitoring & assurance routes Agree & establish a plan of work ES2 Electrical Safety Policy Create a Electrical Safety Policy and Procedures in line with requirements specified in SHTM Create, publish and communicate the procedure(s). Create an implementation plan. Eric Green Bruce Barr ES3 Authorising Engineers (AE) Electrical Report Prioritise and complete actions from last Electrical Audit, including access to switch rooms, legends on boards, checking electrical permits etc Include update on progress in Estates Annual Report to the HS Committee (May each year) Confirm that remedial actions have been acted upon within the specified timeframe Bruce Barr Brian Johnstone ES4 Electrical Test Equipment Testing of test equipment (for proving dead) and training for staff to be put in place Bruce Barr Harry Maclean 34 ES5 Auditing and Monitoring of Staff Regular reviews and monitoring to ensure professional competence is maintained and problems sorted early (Electrical Audit requirement) Bruce Barr Brian Johnstone 35 ES6 Lock off Devices Review and use manufacturer recommended devices that match a board where possible. Bruce Barr Confined Spaces Process Safety System of work to be established and implemented for confined space working ( including creation of NHSH confined spaces registers) Bruce Barr Confined Spaces Documented Arrangements Establish Local / Site based Confined Spaces Responsibilities as per SHTM Create, publish and communicate the / NHSH Confined Spaces Policy procedure(s). Create an implementation plan. 39 CP3 Training Requirements Frontline managers to ensure that all relevant staff have received approriate confined spaces training Harry Maclean 40 CP4 Confined Spaces Implementation and awareness When NHSH procedure is ratified, cascade, ensure local managers have local systems in place to undertake routine checks. Harry Maclean Auditing and Monitoring of Staff Monitor / audit the progress of confined spaces planning at a local level CP 37 CP1 CP2 Confined Spaces (See old Corp Plan Row 41) CP5 42 EPB EPB1 Fiona Miller Electrical Profiling Bed Maintenance (See old Corp Plan Row 50) Establish and Fund a SPM Programme for EPB's WS Agree, Establish and Fund a SPM Programme for EPB's. This has been on the HS Committee agenda for 4 years with no movement forward. A recent HFS safety action notice (2016) has also altered Boards to the risks, HSE have also taken recently (2016) fined an English Trust for the lack of maintenance. A paper to be submitted to the Nov 17 HS Committee outlining options Action plan to be submitted and agreed at Feb 18 HS Committee Review of progress against actions to be taken to May 18 HS Committee Eric Green Bruce Barr Create, publish and communicate the procedures(s) Eric Green Bruce Barr Water Safety (See Actions from WSG) 45 WS1 Water Safety Procedure Revise, update, ratify, promulgate and communicate the water safety procedure in line with HSE ACOP L8 & SHTM WS2 Risk Register Create a risk register for the Water Safety Group Bruce Barr Robert MacDonald 47 WS3 Authorising Engineer Appoint Authorising Engineer Bruce Barr Robert MacDonald 48 AM RAG Electrical Safety (Actions Taken from SAER Review DATIX ID 90517) ES1 33 Action Status Window Restrictors (See old Corp Plan Rows 32-35) Asbestos Management 49 AM1 Procedures Revise, Rewrite, Publish and Communicate the Asbestos management Procedure Create, publish and communicate the procedures(s) Bruce Barr Fiona Miller 50 AM2 Management Plans Develop management plans from reinspections Number of asbestos management plans completed each month/year? Bruce Barr Fiona Miller 51 AM3 Reinspection Ensure that NHSH has in place an abestos re-inspection programme 52 AM4 Training Frontline managers to ensure that all relevant staff have received approriate 80% of staff to have attended asbestos asbestos awareness training awareness training on an annual base 53 AM5 Auditing and Monitoring Monitor / audit the progress of asbestos management at a local level Bruce Barr Annual audit of arrangements by NHSH asbestos consultant Exported on 25 October :27:31 o'clock WEST Page 2 of 2

123 123 Health & Safety Committee 2 November 2017 Health and Safety Committee Item 4.2 Item November 2017 Operational Health and Safety Management Plan Performance Update Report by Bob Summers Committee is asked to: Note: the progress so far Recognise: that only approximately one third of the plans have been updated Discuss: and provide direction on how best to improve progress 1.0 Background. The Operational Health and Safety Management Plan was revised, updated and agreed at Feb 17 Health and Safety Committee. It set out a range of generic and risk based compliance actions and targets for service managers and team leads to achieve for Actions to Date The plans were hosted in a hierarchical format within Smartsheet and linked to a series of simple dashboards. Approximately 191 (out of 304 attendees, made up of 54 dashboard viewers and 250 plan owners) managers were trained on; how to view and access dashboards, the plans content and structure, the expectations required by local management, and on how to use and access Smartsheet in Jul 17. Offline training materials were also produced for those who either missed the training or required additional support after the initial training in Jul 17. The link for the offline training is here: Continuing Communications. Each of the Operational Units Senior Management / Core Team (SMT s) were briefed in early 2017 about the; structure, management, actions, expectations, monitoring arrangements, rollout process and the supporting Smartsheet training for dashboard viewers and plan owners. Updates on progress were also communicated routinely through the Health & Safety Committee, the Operational Health, Safety and Fire Groups and the Operational SMT s by Health and Safety Managers. 1.3 Performance to Date. The table below provides an overview of performance. The plans were last checked on 24 Oct 17. Performance is defined simply as; those who have attended or received training from their Operational Health and Safety Manager, worked through the relevant time based actions in line with the Committee timelines and updated their plans in Smartsheet. To date 63% of managers are trained and 31% (77) of the plans have been updated with November s actions. Whilst it is unrealistic to expect all plans to have been updated, it is concerning that 69% have not accessed or undertaken any form of update. The committee, operational units, and an area/divisional dashboard breakdowns are shown in Appendix 1 where the actions for Nov 17 have been highlighted.

124 124 Health and Safety Committee Item November Conclusion. 77 plans to date have been accessed and populated which is encouraging, however the overall level of activity is limited, and 173 plans still remain incomplete. This is concerning because the implementation of these actions will help to keep our patients, visitors, staff and others safe, as well as aiding NHS Highland to comply with its basic statutory duties. 1.5 Recommendations Senior Operational management s support and leadership is required to encourage plan owners to review their actions, put steps in place to work through the actions, update their plans, and provide assurance upwards that they are managing their Health and Safety risks. Plan progress should be monitored and discussed at SMT (or equivalent), and other management related meetings to raise awareness and drive improvement. The dashboards within Smartsheet should facilitate this process. If support about working through the plan and actions is required then plan owners should contact their Operational Unit Health and Safety Manager in the first instance. Details can be found here: If technical Smartsheet support is required then the Health and Safety Administrator in Assynt House ( irene.stewart1@nhs.net ) should be contacted. The Operational Health, Safety and Fire Group is an important platform to monitor and discuss progress and should meet and encourage attendance routinely. The better the support for this group by the right people the more likely the chance of improvement. Bob Summers Head of Occupational Health and Safety 30 Oct 17

125 125 Health and Safety Committee Item November 2017 Appendix 1 Dashboard Status 29 Oct Health & Safety Committee Dashboard

126 126 Health and Safety Committee Item November North & West Status Consists of 100 plans, 11 dashboard, 57% attend the webinar training or have been given offline training by Health and Safety.

127 127 Health and Safety Committee Item November North Status Consists of 36 plans and includes: Caithness, Caithness General, Primary Care and Sutherland Units.

128 128 Health and Safety Committee Item November West Status Consists of 63 plans and includes: Belford, Lochaber, Skye, Lochalsh and Wester Ross and various other units

129 129 Health and Safety Committee Item November Raigmore Status Consists of 4 divisions, 32 dashboards and 115 plans. 62% attend the webinar training or have been given offline training by Health and Safety

130 130 Health and Safety Committee Item November 2017 Raigmore Continued://

131 131 Health and Safety Committee Item November 2017 Raigmore Continued://

132 132 Health and Safety Committee Item November South & Mid Consists of 21 plans, 2 dashboards, 74% attend the webinar training or have been given offline training by Health and Safety

133 133 Health and Safety Committee Item November Argyll & Bute HSCP

134 134 Health and Safety Committee Item November 2017 Argyll & Bute HSCP Continued://