Title: Health & Safety Annual Review September 2014 August 2015

Transcription

1 Report to: Board of Director (Public) Paper number: 3.3 Report for: Information Report type: Strategy Date: 29 October 2015 Report author: Gilly Ede, Health & Safety Manager Report of: David Wragg, Finance Director FoI status: Report can be made public Title: Health & Safety Annual Review September 2014 August 2015 Executive Summary: This report on Health and Safety matters provides the Board with assurance that there are satisfactory arrangements in place for managing Health and Safety risks across the Trust. This report provides analysis of the Trust s Health and Safety performance from September 2014 to August The report outlines key developments that have been undertaken during the reporting period and identifies work for improvement. Recommendation to the Board The Board of Directors is requested to: receive and accept this report and note the health and safety processes and procedures in place. Trust Strategic Priorities Supported by this Paper Excellence Continually improve the quality and safety of service delivery, service user experience and improving outcomes. Delivering the highest level of quality and financial performance.

2 Risk Implications The Trust is at risk of prosecution by external bodies if it fails to manage its health and safety risks appropriately. There could also be associated reputational damage following investigation or prosecution. Legal and Compliance Implications By not managing its health and safety risks, the Trust could fail to meet the required standards in relation to Monitor, CQC and NHSLA compliance. It could also be open to criminal charges and private prosecution. The cost of civil action against the Trust for health and safety related injuries may affect the NHSLA premium. Finance Implications The cost of not properly managing health and safety within the trust (staff, training and equipment) could be significant. The Corporate Manslaughter Act provides for unlimited organisational fines and also personal fines against senior management. Private prosecutions and personal injury claims could also possible and potentially costly. Single Equalities Impact Assessment N/A Requirement of External Assessor/Regulator None. 2

3 HEALTH AND SAFETY ANNUAL REPORT September 2014 to August 2015 This report provides analysis of the Trust s Health and Safety Management functions from September 2014 to August The report outlines activities undertaken during the reporting period. Furthermore, rather than just looking backwards the outline performance indicators ensure that robust H&S processes are in place. The purpose of this report is to provide assurance and information to the Board in relation to the Trust s management of health & safety matters. The Health & Safety function sits within the Estates and Facilities Department and the Finance Directorate. The Health, Safety and Fire Committee is responsible for all issues relating to Health and Safety management and oversees health & safety strategy including compliance with legislation, the Health and Safety Executive approved codes of practice (ACoPs) and other statutory and NHS requirements. The Health, Safety and Fire Committee meets quarterly and its minutes are provided to the Trust s Audit and Risk Committee. The Health and Safety at Work Act (1974) and the Management of Health and Safety at Work Regulations (1999), require that the Foundation Trust have systems in place to proactively manage and control health and safety risks. In order to meet the legal requirements the Foundation Trust manages its risks based on the Health and Safety Executive management model published in Managing for Health and Safety (HSG65). This model identifies four key objectives for the delivery and monitoring of a Health and Safety management system. These are Plan, Do, Check and Act. As with previous reports, this report outlines how Health and Safety has been managed within the Trust from September 2014 to August 2015 using the four objectives to consider the following questions: 1. Does the Trust have the core elements of managing for health and safety in place? 2. Is the Trust is doing what it needs to do in relation to Health and Safety Management? 3. Is the Trust delivering its Health and Safety arrangement in an effective manner? 4. What does the Trust need to do in the future to ensure and strengthen its Health and Safety Management? 1. Does the Trust have the core elements of managing for health and safety in place? (Plan) What are the core elements? a) Legal compliance; b) Health and Safety Accountability/Organisation; c) Policies and procedures; d) Monitoring processes; e) Statutory record keeping; and f) Statutory maintenance reporting. a) Legal compliance A number of key requirements need to be met for the successful management of Health and Safety. These requirements are stipulated in legislation and NHS procedures (such as Healthcare Technical Memoranda). The Health and Safety at Work Act 1974 requires that the Trust s Health and Safety Policy is underpinned by appropriate risk management though organisational arrangements and responsibilities to enable its full implementation. 3

4 b) The Trust s Health and Safety Organisational arrangements Within the Trust, the organisational management structure that supports Health and Safety is as stated the: Board of Directors; Foundation Trust Executive; Director of Finance (Nominated Director); Audit and Risk Committee; Estates and Capital Planning Committee; Health Safety and Fire Committee; Associate Director of Estates and Facilities; Health and Safety Manager (Responsible Person); and Fire Safety Manager (Responsible Person). Local Managers This management structure is supported by policies, procedures and training as appropriate to the level of responsibility required. Local managers undertake day-to-day operational management of health and safety; they receive a full day training programme to support them in undertaking their duties and receive additional support as required from the Health and Safety Manager and the new Fire Safety Manager. The Health and Safety function is also is supported by other Trust Departments including Risk Management, Security, Occupational Health, Learning and Development, Infection Control, Medical Devices and Emergency Planning. The strong working relationship between these services ensures co-operation and communication and enables a coordinated multi-functional management approach when considering multi discipline policy, procedures and investigations. The Health and Safety Database and Risk Profiling The Health and Safety Manager maintains a comprehensive health and safety database which is continually updated. This details the health and safety arrangements across the Trust and notes detailed information about each service or department and their health and safety status and compliance. The database is arranged in relation to the health and safety risk profile each service/department/group presents. Different risk factors are considered in relation to the risk profiling including the nature of the service delivery model, nature of service users clinical conditions, size of team, hours of operation and geographical locations. The database also monitors H&S performance across the Trust. This information is reported monthly and provides senior managers with a monthly compliance report the Health and Safety Active Monitoring Plan (HSAMP). c) Policies and Procedures The Health and Safety Manager supervises or participates in the policy production process for the Estates & Facilities department and also for generic Trust health & safety policies. New or existing policies have been reviewed in 2014/2015 and have been ratified. The requirement for additional policies is under continuous review. 4

5 Notable progress in this area for 2014/15 includes: Environmental Ligature Risk Assessment Policy; Water Management Policy adopted; Asbestos Management Policy adopted; Electrical Works policy circulated for consultation; Control of Substances Hazardous to Health reviewed; Display Screen Equipment Policy reviewed; Lone Working Policy reviewed; Slip, Trip and Falls (non-clinical) Policy reviewed; Manual Handling Policy reviewed; First Aid policy drafted; and Accident Investigation Procedure drafted. The Trust s Health and Safety contract (see d)i below) will contains three new Train the trainer practical style courses which will support the implementation of three policies, namely: Conducting a Work station assessment Conducting a Manual handling assessment Practical process for Incident investigation and evidence gathering post incident In addition the Health and Safety Manager working with the Associate Director for Nursing drafted the Environmental Ligature Risk Assessment Policy. This was supported by the development and implementation of a bespoke practical ligature risk assessment training course for staff. In early 2015, the Health and Safety Manager assisted with the drafting and implementation of the new Tobacco Management policy, specifically with the introduction and management of e-cigarettes and other e-smoking products in to the ward environments. This policy has led and supported the introduction of the smoking cessation programme across all Trust locations both internally and externally. d) Monitoring processes Health and Safety performance is monitored in many ways within the Trust: i. On-site Independent Health and Safety Consultant inspections. The Health and Safety Manager oversees a contract of professional health and safety services which external consultants provide inspection, training, and other professional services to the Trust. Under the contract, a full site health and safety risk and fire risk assessment inspections are conducted on a six monthly basis for all sites where service users are seen and twelve monthly inspections are completed at all other sites. The consultants' reports are submitted to the Health and Safety Manager for review and comment and information entry on to the Health and Safety database and HSAMP. These reports form an independent audit and review process of the Trust Health and Safety management in action. ii. Health and Safety Active Monitoring Plan (HSAMP) Using the information from the auditing sources, a monthly report is produced and widely distributed. The HSAMP allows for accurate monitoring of health and safety and fire activities where there is a legal, NHS or Trust requirement to do so. These include: 5

6 Fire Drills It is a legal requirement to undertake fire drills and a NHS requirement to carry these out 6 monthly in areas where service users are seen or access. Trained fire marshals in sufficient numbers a legal requirement to have sufficient and suitable numbers of marshals available at all times. Compliant local fire procedure (legal requirement). Compliant Arson risk assessment (NHS security requirement). Completed Local Induction procedures or host document registered (legal requirement). Completed Lone working procedure or written notification that no lone working is practised (legal requirement). Trained manager with local safety responsibility and those they have attended the one day health and safety training course (legal requirement). Trained first aider or recorded first aid arrangements where hosted (legal requirement). Across the Trust or Trust premises, there are 46 locations and 96 teams currently which are required to comply with these activities or procedures. The table below shows the number of teams/locations that are compliant, those where work is currently in progress to achieve compliance and those where compliance is outstanding or not currently achieved. The table show the current percentage of compliance achieved or in progress and also a comparison against the position 12 months earlier. Working with the Trust Clinical lead and Business Managers, compliance has improved in all areas. Compliance will continue to improve with the recent appointment of an interim Trust Fire Safety Manager (pending recruitment of a permanent employee) In August 2015) who will be visiting sites to support and lead on fire management issues. As can be seen from the table below, compliance across these activities has improved significantly over the past 12 months particularly in those areas where previous compliance levels were not so good. For example - Completed fire drills 68% up to 82%. Fire procedures in place 73% up to 89%. Arson risk assessment 58% up to 83%. Local induction procedures 66% up to 83%. Our target is to reach and maintain 80% or higher compliance levels. We are now doing this in each category other than the trained manager with local H&S responsibility which currently stands at 77%. Improvements have been achieved by taking a more robust approach to health and safety compliance. Improvements have particularly been achieved in service divisions where business managers have played a central role by being the primary point of contact for all H&S matters across all of the teams within the division. This has yielded good results and the next step is to improve compliance in a similar way across corporate divisions. The Trust is unlikely to reach 100% compliance for a number of reasons. Natural gaps can occur, for example where staff members leave or transfer to other departments and others have to be identified and trained to fill their H&S role. Training has to be refreshed after defined periods and this can also mean there can gaps if courses do not align with or indeed conflict with operational requirements. 6

7 Summary of Key Performance Indicators as monitored on the Health and Safety Active Monitoring Plan Overall Trust Compliance FIRE DRILL COMPLETED FIRE PROCEDURE FIRE MARSHALS PRESENT ARSON FIRST AIDER PRESENT LOCAL INDUCTION LOCAL LONE WORKING MANAGER (trained) Year 14/15 13/14 14/15 13/14 14/15 13/14 14/15 13/14 14/15 13/14 14/15 13/14 14/15 13/14 14/15 13/14 Number Teams/Sites Compliant Number Teams/Sites Compliance in Progress Number Teams/Sites Not Compliant % Compliant or In Progress Yearly Increase - Decrease % 68% 89% 73% 92% 90% 83% 58% 91% 91% 83% 66% 82% 71% 77% 77% 14% 16% 2% 25% 0% 17% 11% 0% Note - As of 08/15 there are 99 teams included in the monthly monitoring. The number of sites/teams has fluctuated though out the 2014/2015 comparison period. Like for like direct comparisons should not there for be made other than the % figures.

8 iii. Datix reporting system Datix is the Trust s online incident reporting system and all health and safety incidents are reported to the Health and Safety Manager for review and associated action. A summary of the incidents that have been reported though Datix from September 2014 to August 2015 are shown below. Nature of Event Reported: Numbers of reports made 09/14-08/15: Numbers of reports made 09/13 08/14: Accidental fire alarm Actual Fire 17 9 Collision with an Object 9 6 Contact with Electricity 2 3 Crushing Injury 6 3 Exposure to Hazard 7 2 Exposure to Heat 9 9 Fire Risk (Electrical) 9 25 Flood 3 3 Injury (e.g.: inhalation, ingestion, unknown cause) 18 7 Lift Failure 1 3 Lone working Issues 7 4 Manual Handling Incidents 5 2 Miscellaneous 3 39 Slips/Trips/Falls: non-clinical - Staff 9 5 Smoking Issues Struck by an Object 8 5 Total of HS Datix reports made The table above indicates a wide range event types. Reports submitted around false fire alarms and fire risks account for the majority of events reported through the system. In terms of actual fires, the following detail can be provided: 16 of these events affected/potentially affected service users. 10 of them occurred in service user bedrooms, 2 of them in service user en-suite bathrooms and 2 in service user re-hab kitchens. The fires were generally started by service users, the majority it appears with intent and the others by accident. No injuries to service users or staff occurred. Emergency services were only called to attend in 8 of the incidents. 8

9 Generally, the fire incidents which occurred were small scale and were detected by staff and or fire alarm activations and were dealt with appropriately. All incidents have been reviewed as part of the Datix process in order that procedures are reviewed and lessons learnt and investigations instigated where necessary. After fire, the Injury category accounts for the next largest number of events but these relate to a wide range of individual events where staff have suffered a minor injury during the course of work. Staff are encouraged to report all incidents even if trivial. A large number of these injury events reported on Datix, related to the staff working at the Hill House location during the construction phase of the works by the Landlord, Please refer to section 2 below for more details of the Hill House event. The Datix system is managed by the Risk Management function within Clinical Governance. The numbers of incidents reported on Datix for a twelve-month period is considered low for the size of the organisation, although reporting is on the increase. The issue of under-reporting is common in NHS organisations with staff not realising how important this information is in terms of both legal compliance but also in relation to the organisation being able to identify trends. Working with the Risk Managers, the Health and Safety Manager arranged for further information and training around the importance of reporting incidents. It is hope that this information will be delivered through the organisational induction programme. The reporting system has now been greatly supported by guidance information which can be accessed thought the Intranet how to report an incident tab. Information about Datix and incident reporting is already a required component of the local induction process. For 2015/16, we are also giving Cofely, the Trust s facilities management provider access to Datix in order that they can directly input incidents that their staff are involved in or that the see. Information from the Datix system is incorporated in to the database and HSAMP. iv. RIDDOR Reporting The legal responsibility for the Reporting of Incidents, Death and Dangerous Occurrences Regulations (RIDDOR) as required by Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 is with the Health and Safety Manager. The actual report is made by the Datix officer who has been trained to monitor for any RIDDOR qualifying events that are reported thought Datix. Over the time frame under consideration, there were 18 RIDDOR reportable incidents with in the Trust of which 8 were caused by Slip, Trip and Falls incidents, 6 were caused by Violence and Aggression incidents. 12 of the incidents occurred within a ward environment. All RIDDOR S affected staff. By comparison to the previously years report of 13 RIDDOR reported incident In 2013 there was a change to the RIDDOR reporting criteria, the absence period triggering a report for staff who could not attend work following a work related incident increased from three working days to five days which, for the first time included weekends, bank holidays and pre-booked holidays. This change of requirement was communicated to staff though the ebullient and the one day Health and Safety training course for managers. 9

10 v. Specialist health and safety training courses Learning and Development continue to improve the attendance compliance rates on Health and Safety courses. The compliance for staff mandatory courses, fire awareness and manual handling for loads continue to show a steady rate of progress towards the Trust s target of achieving 80% attendance or better. Clearly this is critical to improving and maintaining health & safety compliance levels indicated in the table above. Attendance figures for non-mandatory health and safety courses continue to climb steadily. Clinical staff are sometimes unable to attend due to operational nursing requirements. The Health and Safety trainers do train at locations other than St Pancras to elevate the commitment requirements from staff (away from the ward). The Learning and Development department are working towards offering more courses to staff as a part of the review of training for the new Health and Safety contract (see below). This training drive will also be supported by the appointment of the new Fire Safety Manager who will be able to provide all fire and evacuation training courses at times and in locations as needed by the teams. A monthly training report is commissioned and incorporated in to the database and HSAMP. A quarterly report is also submitted to the Health and Safety Group summarising training compliance levels. The Learning and Development team facilitate a number of specialist health and safety-training courses which are mainly delivered by the external health and safety consultants. A summary of the training provided over September 2014 to August 2015 is shown in the table below: Summary of Health and Safety Training Course run 08/2014 to 09/2015. Course Name: Total 14/15: Total 13/14: Induction Health and Safety (New course) 475 N/A Emergency First Aid at Work/Appointed Persons First Aid (one day course withdrawn in 2015) Evacuation Chair Training 6 31 Fire Awareness Training (including the on line E-workbook) Fire Marshal Training First Aider at Work (Three Day Course) Ligature Risk assessment training 6 16 Lone Working training (New course) N/A N/A Managers one day Health and Safety Training Course Manual Handling Loads Manual Handling Patients Ski Sheet Evacuation Training

11 In 2015, the Health and Safety Manager directed that the one day Emergency First Aid at Work (EFAW) / Appointed Persons First Aid course be withdrawn. This was as a result of staff booking on to the EFAW course in preference to the full three day First Aid at Work course (FAW). The one day EFAW course was suitable for those working alone in the community and to provide first aid cover for small staff teams that do not directly host service users. This direction will ensure that all Trust services will be supported by fully trained first aiders at the appropriate level. vi. External inspections The Trust can obviously be subject to a number of statutory or regulatory inspections. In addition, inspections are carried out by our health & safety consultants under the H&S contract (see below External Health & Safety Consultancy Support). CQC Inspection The CQC re-visited parts of the Trust in August to review the progress taken by the Trust in relation to the actions following their inspection in 2014 Their interim inspection report is favourable and reflects the work that the Trust has undertaken in relation the management of self-harm environmental issues. The physical and clinical management of slip, trip and fall incidents were noted as areas of improvement. London Fire Brigade Inspections Stacey Street Nursing Home Inspection August 2015 On the 21 July 2015, the Fire Brigade carried out a full and rigorous inspection of the Stacey Street Nursing Home. The site passed the inspection with only verbal advice being given in relation to the presentation and content of the fire risk assessments. The new Fire safety Manager is taking these issues forward. Highgate Mental Health Centre On the 20 th August 2015, the Fire Brigade carried out an unannounced inspection of Highgate Mental Health Centre including the ward currently under refurbishment. The site passed the inspection with only verbal advice being given in relation to the management of the alarm systems during the refurbishment and staff training. The new Fire Safety Manager is taking these actions forward. 154 Camden Road Residential Unit On the 21st August 2015, the Fire Brigade carried out a full and rigorous inspection of the 154 Camden Road residential service location. The site passed the inspection again with only verbal advice being given as to staff familiarisation of the procedures, more training is required. The new Fire Safety Manager hosted the inspection and is supporting the site to take the actions forward. 11

12 Other Health & Safety Activities St Pancras Fire Management Review and Drill Event Programme In early 2015 the Health and Safety Manager reviewed the fire management arrangements for the St Pancras site with a view as to arranging fire drills for the site for the non-clinical and non-residential teams. The HSAMP documented the non-compliance of drills. As the drills had not been undertaken by the teams individually, a decision was made for the Health and Safety Manager to lead the event for the entire site. A new external assembly point location was identified in the St Pancras Gardens, with the permission of Camden Council. This new assembly point being the focus for all non-clinical and clinical day services. The new assembly point location information was communicated to all departments and to tenant organisations. It was also listed on the new Fire Action Notices displayed through-out. With all of the necessary arrangements in place, the Health and Safety Manager ran two days of drill events, the 9 April and the 26 July The event provided both practice and assurance to the Trust in its fire responses. Generally the drills went well with appropriate responses from staff to evacuation of buildings and transfer to assembly points. Some buildings did perform better than others and the H&S manager has taken this up with local management and staff as appropriate. Follow up drills will be arranged on a regular basis in accordance with appropriate regulations. The Introduction of the new St Pancras emergency response telephone number 2222 In April 2015, following the installation of new telephony services, the new 2222 St Pancras site wide emergency response telephone number was introduced. The new emergency number was communicated to all Trust site users; reinforcement of the new procedure is required. This action is under discussion with the Communication Team. 2. Is the Trust doing what needs to do in relation to Health and Safety Management? (DO, CHECK) From the core health and safety management components, the Trust can be assured that it has the key structures of a proactive Health and Safety management system in place. It remains necessary for the management and employees of the Trust to continue developing a strong health and safety culture. By advising, informing, and publicising the Health and Safety Manager seeks to achieve a positive health and safety culture though there advisory remit, training course content stipulation and attendance at meetings. The success of implementing the health and safety culture can be gauged though the increased compliance figures as noted in the HSAMP. It can also be established from the external inspection processes. The Health and Safety response does also need to be reactive because of the diverse nature of the hazards associated with managing the mental health care service. This response can be demonstrated by the Health and Safety support to the Trust during the Hill House event in May/June

13 Hill House Health and Safety support In May 2015, the landlord of the Hill House building commenced major refurbishment works. They did not communicate the full extent of the works and the Trust staff soon found themselves the sole occupier in a building that had become a construction site. The Health and Safety Manager met with the Trust staff and the developers agents on many occasions during the preparation stage of the demolition project to agree operational rules for the continuation of services, dust and noise control. The Health and Safety Manager ensured staff safety by reviewing the agents contractors risk assessments in relation to the work operations and specifically in relation to the removal of asbestos and fire management as the works were commencing with Trust staff in occupation. The Trust installed noise monitoring equipment and commissioned dust sampling reports. These showed that whilst the building provided a far from ideal working environment, the staff where not being exposed to any illegal noises levels or particle containments. However, as a precaution the local Environmental Health Office and Health and Safety Executive were consulted. Having examined the evidence and following communication directly with the agents, they also concluded that no health and safety legal requirements had been breached. Ultimately, the matter was concluded by relocating the staff to new premises and agreeing a financial settlement with the landlord to reflect early surrender of the lease and recompense for the disruption to service and costs associated with relocating. 3. Is the Trust doing what its need to do? (CHECK, ACT) The core elements in place to manage a successful health and safety system within the Trust, evidence that the Trust is correctly addressing the Health and Safety risks presented. This is proved by external audits. External Health & Safety Consultancy Support The contract for these services is to be re-tendered with effect from 31 January Working with the Procurement Manager and the Learning and Development team, the Health and Safety Contract has been developed into two contracts. Professional services (Inspections and specialist health and safety services) and Training. With the recruitment of the Fire Safety Manager in place, all fire related elements of the contracts have now been removed with the exception of the provision of specialist support personal which to support the out of hours drill testing events offering the Trust cost savings. Board Corporate Manslaughter Training Working with the Head of Emergency Planning, Corporate Manslaughter training will be included in the forthcoming senior management emergency planning away day training sessions. Health and Safety Management specialist training The competence of the Health and Safety Manager and Estates and Facilitate department needs to be strengthen by completing specialist health and safety related training courses. Water Management and Asbestos Management have been highlighted as areas for consideration. 13

14 Future Development of Health and Safety within the Trust Working with senior staff, the Health and Safety Manager has sought out views on the effectiveness and relevance of the Health and Safety management within the Trust on an operational level, with a view to identifying areas for improvement. The three common themes identified were the security of the ward environment in relation to Service Users going absent without leave (AWOL), assaults on staff and the use of Bank staff out of hours to cover shifts. Absence Without Leave (AWOL) At St Pancras, in the Huntley Centre, the rear fire exit doors security was increased in the spring of 2015 following a number of AWOL events. Ash House does not appear to be greatly effected with AWL incidents. At Highgate Mental Health Centre, the physical security of the wards is being upgraded as a part of improvement works currently under way. Door lock strength is being increased, the remote ward front door release buttons, which are activated from the nursing station, are being removed. The main reception door access release button has been removed so that those leaving the secure hospital environment cannot do so without the direct manual intervention of staff. The Health and Safety Manager working in consultation with the Local Security Management Specialist (LSMS) who is continuing to monitor the AWOL situation. Staff Assaults The management of the assaults on staff has risen over the reporting period. Senior clinical staff have identified the necessity for the current training programme to be expanded to include the training of staff in the disarmament of service users armed with weapons, a trend which appears to be increasing. There is evidence that some cases of antisocial behaviour and verbal aggression have not always been reported on Datix. Reports are not regularly completed for these low level" assaults so the information is not captured. The aim for the future is that all incidents must be reported on Datix so that the whole picture of the aggression the staff are subjected to is identified. The Health and Safety Manager will work with the Datix reporting officer, the LSMS to establish a set of uniform zero tolerance levels of behaviour and reinforce the requirement to report all incidents on Datix. The Trust has recently set up the therapeutic management of violence group to consider the issue. With the support of the LSMS, staff are supported to make reports to the police. Agency Staff Use The use of agency staff, mainly out of hours, may cause the Trust to have a somewhat higher risk of health and safety hazard as the agency staff are not routinely trained in Trust policies and procedures i.e. fire evacuation procedures. The Matrons have identified this weakness and talks have started with Leaning and Development, the Head of Emergency Planning and the Information Technology department to develop the staff booking system to cross reference with staff training. The proposed system will allow the ward managers to allocate staff to cover a shift with the correct skills base to ensure that the required health and safety and clinical skills are present at all times. For example, that a trained First Aider is present at all times. 14

15 Fire Safety Manager The Trust appointed an interim fire safety manager in August 2015 pending recruitment of a permanent appointee. Whilst his appointment falls at the end of this annual review period, it is clear that his knowledge and expertise (and additional resource) is already having an immediate and positive effect on fire safety issues. This will be of significant benefit to the Trust s health and safety performance going forward. Conclusion The content of this report indicates that the Trust does have the appropriate policies and procedures in place for managing health and safety. It is, Planning, Doing, Checking and Acting. Clearly, there should be no reason for complacency arising from this and we should continue to seek improvement and reinforcement of a strong health and safety culture. KPMG Audit of Health and Safety The Board should also note that the Health and Safety function was audited by KPMG who reported on this matter in January The audit was generally positive and KPMG identified areas of good practice: The Trust has in place a comprehensive health and safety policy which meets the requirement of the HSE etc.; and Membership of the Health Safety and Fire Committee comprises a wide range of departments...ensuring that health and safety is considered across the Trust. It identified four medium and two low recommendations for development (improvement). The four medium were that: a. external fire and health and safety risk assessments should be monitored to ensure that they are taking place in line with expected timescales; b. resolution of actions from these assessments should be centrally monitored to ensure required action; c. the Trust should implement a standardised policy of supporting the investigation of incidents that do not meet serious incident criteria; and d. levels of H&S compliance across Trust sites should be reported to the Health Safety and Fire Committee to ensure there is a mechanism for escalating compliance levels if necessary. All of these matters have been actioned as appropriate. 15