Apologies were received from Linda Boyd, Lesley Cantell, Dan Doherty, Elaine McFadden, Linda Mair, Sinclair Molloy and Marlene Murty.

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1 HEALTH, SAFETY & WELLBEING COMMITTEE Friday 18 March 2011 Board Room, Biggart Hospital, Prestwick Present: Dr Wai-yin Hatton, (Co-Chair) (In the Chair) Mr S Donnelly, Partnership Facilitator (Co-Chair) (In the Chair) Mr M Adderley, Director, People & Organisation Development Mr K Brown, Co-Chair Safer Handling Sub-Group Mr J Callaghan, Employee Director Mr J Crichton, Director of Mental Health Services Mr H Currie, Head of Occupational Health & Safety Mr D Donaghey, Joint Chair, South Locality Partnership Mrs J Heaney, Chair Risk Assessment & Training Sub-Group Mr G McKay, Joint Chair, North Locality Partnership Mrs K Montgomerie, Joint Chair, Biggart Site Safety Group Mrs L Moore, Director of Integrated Care & Emergency Services Mr J Somerville, Chair, Occupational Health Sub-Group Mr J Wright, Director of Information and Clinical Support Services Mrs M Yule, Director of Integrated Care & Partner Services In Attendance: Mr D Harvey, Fire Safety Officer, Presentation of Improvement Plan Fire Safety Advisory Group and Fire Safety Report Items 11 and 14. Mrs M Paton, Administration Manager - Minute Recording 1 APOLOGIES Action Apologies were received from Linda Boyd, Lesley Cantell, Dan Doherty, Elaine McFadden, Linda Mair, Sinclair Molloy and Marlene Murty. 2 MINUTES OF MEETING OF 15 DECEMBER 2010 The minutes of the meeting held on 15 December 2010 were approved. 3 MATTERS ARISING All matters arising concluded. The Director of Information and Clinical Support Services reported that dialogue had taken place with Information Governance regarding the Health & Safety Team Datix access which has been restricted due to Caldicott concerns. A proposal has been suggested whereby the Datix Administrator is able to block-out patient details for those categories perceived to have the potential to contain patient identifiable information. This would allow for access to all incidents. Should there be a need for the Health and Safety Team to have access to Patient then this would need to be requested through the Assistant Director Healthcare Quality, This proposal will comply with both the Data Protection and Caldicott legislation 1

2 whilst allowing the organisation to fulfil its legal responsibilities in respect of Section 3 of the Health and Safety at Work etc, Act The Committee endorsed the recommendation. 4 POLICIES & PROCEDURES ACTION PLAN A paper on Policies and Procedures (Health & Safety Manual) was submitted for consideration. After discussion, the Committee: 1. noted the submission of the revised Glove Selection SOI and approved this for inclusion in the Health & Safety Manual. 2. approved the revision of target dates for documents identified at Section 2 and the revised target date of August 2011 for PN32 Managing Stress in the Workplace. 3. approved the proposed Policies and Procedures (Health and Safety Manual) Action Plan for 2011/12. 5 LIGATURE RISK PROCEDURE A draft Environmental Ligature Risk Procedure was submitted for consideration and approval. The Committee agreed that Environmental Ligature Risk Procedure Section 5.5 Estates Project Managers required to be more explicit and include clarity for action responsibility. The Head of Occupational Health and Safety agreed to discuss re-wording of this paragraph and submit to the Director of Information and Clinical Support Services for approval. HC 6 PODIATRYSERVICES IN CARE HOMES PROCEDURE A paper and Procedure PN16.1 Employee Safety in non-nhs Premise Podiatry Services in Care Homes in relation to the management of health and safety of podiatry staff and patients receiving treatment in care homes was submitted for consideration. The Committee approved Procedure PN16.1 subject to amendment of the title from Podiatry Services in Care Homes to Podiatry Services in Care Homes and other non-nhs Premises and agreed that similar procedures should be produced for other services providing clinical services in non NHS environments. These procedures would be progressed through the RATS Group. JH 7 AMALGAMATION OF SITE SAFETY COMMITTEES INTO LPF S Consideration was given to a paper on Review Terms of Reference of Site and Locality Health & Safety Groups. Further information had been required following discussion at the December 2010 Health, Safety & Wellbeing Committee meeting when it had been agreed that communication was a major issue in this process. The Head of Occupational Health & Safety, the Partnership Facilitator Co-Chair and the Staff Side Joint Chair, Ayr Hospital, had met to discuss concerns 2

3 around the effective communication of the proposed changes and agreed the tools to be used to promote the change which included an Algorithm poster to be displayed beside existing Health & Safety Law Posters. After consideration, the Committee agreed: 1. The amalgamation of the Site Safety Groups into the Local Partnership Forums and the development of local points of contacts. 2. Appropriate Site Committee representation to be included on the Local Partnership Forums. 3. The Partnership Representatives included within Local Contacts should be accredited Health & Safety representatives. 4. The contacts for Local Advisers to be extended to include Trade Union Representatives. 5. A standing health and safety item to be included on the agenda of LPFs to enable a measuring process on effectiveness to be undertaken. 6. The LPFs to report by exception to the Health, Safety & Wellbeing Committee. SD/EH/HC 8 IMPROVEMENT PLAN RATS SUB-GROUP The Committee considered the Risk Assessment & Training Sub-Group Improvement Plan and Key Performance Indicators (KPI) for It was noted that the KPI in relation to lone working now relates to percentage trained against those registered, with a target of 85%. Some discussion took place around the previous year s KPI which was set around system utilisation, and that whilst some teams would require to use the system frequently, others would require to log on only occasionally. The 50% utilisation target would, therefore, be inappropriate and not achievable for some. A question was raised regarding categorising staff as lone workers and it was noted that they are presently identified by line managers and reports on utilisation are issued to these managers on a monthly basis. The need for introducing a method of differentiation when monitoring utilisation was stressed and this will be explored by the Risk Assessment & Training Sub-Group. Reference was made to the Health & Safety Audit Programme when the question was raised regarding responsibility for staff facilities in third party premises. It was noted that this requirement should be included within Occupiers Liability to ensure premises are fit for purpose. Alternative arrangements should be made to ensure business continuity when it is necessary to temporarily remove NHS Ayrshire & Arran services if required standards were not implemented within these premises. JH The Committee approved the Risk Assessment & Training Sub-Group Improvement Plan and Key Performance Indicators for IMPROVEMENT PLAN V&A SUB-GROUP The Committee considered and approved the Violence & Aggression Sub- Group Improvement Plan and Key Performance Indicators IMPROVEMENT PLAN OH SUB-GROUP Consideration was given to the Occupational Health Sub Group Improvement Plan and Key Performance Indicators

4 The Committee approved the Occupational Health Sub Group Improvement Plan and Key Performance Indicators and agreed that: 1. Item 1 on the Occupational Health Improvement Plan Complete implementation of electronic Occupational Health records investigate the possibility of replacing OPAS with the new Patient Management System. 2. An action to be taken to raise manager awareness in accordance with the Promoting Attendance Policy to ensure that staff medical exclusion absences are being recorded correctly and not as sickness absences. JS MA 11 IMPROVEMENT PLAN SAFER HANDLING GROUP The Committee considered and approved the Safer Handling Group Action Plan and Key Performance Indicators IMPROVEMENT PLAN FIRE SAFETY ADVISORY GROUP The Committee approved the Fire Safety Update Report Improvement Plan and Key Performance Indicators and agreed that a formal proposal providing details of Unwanted Fire Alarm Signals should be produced for submission to an appropriate Committee, e.g. Area Partnership Forum to raise awareness and consider proposals for reducing these incidents within NHS Ayrshire and Arran. DD/DH 13 HEALTH, SAFETY & WELLBEING FORWARD PLAN FOR 2011 The Committee considered, welcomed and approved the Health, Safety and Wellbeing Committee Forward Plan HEALTH AND SAFETY AUDIT AND MEASURING PERFORMANCE PROGRAMME The Committee considered the progress to date against the Health and Safety Audit Measuring Performance Programme and approved the revised schedules for the remainder of the programme 15 FIRE SAFETY REPORT A Fire Safety Update Report Fire Evacuation was submitted for consideration and approval. The Committee noted the ongoing works to provide enhanced evacuation procedures for hospital in-patient areas and agreed to provide the necessary corporate support to facilitate its introduction. 16 QUARTERLY PEFORMANCE REPORT The Committee endorsed the Performance Management Report providing clear and concise information on the progress of the Health, Safety and Wellbeing Agenda for the period April 2010 to January AOCB HSE VISIT MANAGEMENT OF ROAD RISK 4

5 The Head of Occupational Health & Safety provided a verbal report on the recent HSE Inspector visit regarding the implementation of the Management of Road Risk procedures within the organisation. The visit had been productive but some car parking issues had been identified. A further visit will be undertaken on the 1 st April DATE OF NEXT MEETING The next Health, Safety & Wellbeing Committee meeting will be held on Thursday 16 th June 2011 in the Board Room, Biggart Hospital, at 2.00 pm. 5

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