Discussion Assurance Approval Regulatory requirement Mark relevant box with X

Transcription

1 Report to: Board of Directors Date of Meeting: 26 June 2014 Report Title: Health and Safety Annual Report Status: For information Discussion Assurance Approval Regulatory requirement Mark relevant box with X X X X Prepared by: Carol Woolgar Executive Stacey Hunter Sponsor (presenting): Appendices (list if applicable): Purpose of the Report Health and safety law places duties on organisations and employers, and directors can be personally liable when these duties are breached: members of the board have both collective and individual responsibility for health and safety. The Board are reminded that their obligations under the HSE Guidance require Health and Safety to be considered within the decision making framework of the Board. The attached Health and Safety Annual report details the organisation s activity relating to, and governance arrangements for all aspects of Health and Safety from 1st April 2013 to 31 st March Key points for information The governance structure for Health and Safety, which has also scrutinised the production of this report Reported incidents during the period covered by the report, any noted trends and adequacy of mitigating action Recommendation Consider and approve the Health and Safety annual report Page 1 of 22

2 Page 2 of 22 HEALTH AND SAFETY ANNUAL REPORT

3 Executive Summary Health and Safety is recognised by ANHSFT to be fundamental in the delivery of safe services for staff, patients, carers and visitors. Progress to ensure that the organisation meets the requirements for health and safety legislation was consistent throughout Going forward, based on the details contained within this report, the annual plan for will continue to progress its management of health and safety across the Trust, with particular focus on Reviewing existing H&S arrangements to ensure compliance with the expected revision of HSG65 to a Plan, do, check, act approach Assessing, monitoring and providing assurance that all premises are fit-forpurpose Validating the results of, and addressing issues identified by, the Selfinspection audit and gap analysis against the NHS Staff Council Workplace Health and Safety Standards Raising the level of mandatory training attendance across all aspects of H&S Monitoring policy compliance and addressing any resulting issues related to health and safety induction and mandatory training. 1. Background It is a requirement that the Trust Board of Directors receive an annual Health and Safety (H&S) report covering the Trust s H&S activities. For the purpose of this report the following statutory requirements of the Health and Safety at Work Act 1974 (HASAWA) are referred to; Section 2 - Duties of employers to employees; Section 3 - Duties to protect people who are not its employees from being exposed to the risks of its activities (e.g. patients, members of the public); Section 4 - Duties as a landlord by being in control of premises; The Management of Health and Safety at Work Regulations 1999 (HASAWR) extend the provisions of the HASAWA and in particular the requirement to undertake suitable and sufficient risk assessments and provide adequate training and supervision. Further regulations cover specific aspects of H&S for example the Control of Substances Hazardous to Health (COSHH) Regulations. Whilst not included under the HASAWA fire safety remains an essential requirement to ensure the H&S of people present on our sites. The Regulatory Reform (fire safety) Order 2005 (RRO) became law in 2005 and following on from this, in 2009, the Chief Fire Officers Association (CFOA) introduced a fire policy aimed at reducing Unwanted Fire Signals (UwFS). The Trust s fire procedure was reviewed in January 2010 to ensure that resulting changes to the fire policy issued by CFOA, particularly those around call filtering were integrated into the Trust Fire policy and arrangements. 'Call Filtering', means that before they mobilise a response the fire unit would determine whether it was a genuine fire or a false alarm. The fire authorities in West Yorkshire have now levied a 350+vat to attendances involving false alarms. This charge will take will come in to play on the fourth false alarm from the same fire alarm panel in one year Page 3 of 22

4 2. Introduction The JHSRC has delegated responsibility from the Board for all issues relating to H&S and oversees the overall H&S strategy to ensure it meets the standards required by the Health and Safety Executive and statutory regulation. The purpose of this report is to inform the Trust Board of Directors of activity relating to all aspects of H&S from 1 st April 2013 to 31 st March Key Legislation for The following piece of H&S Regulation relevant to ANHSFT came into force during this period; Enterprise and Regulatory Reform (ERR) Act Civil Liability for breaches of health and safety regulations This removed employers strict liability for injuries to employees in the work place. Reporting of Injuries, Diseases & Dangerous Occurrences Regulations (RIDDOR) Simplified and clarified the reporting arrangements of the regulations. Regulations to make an exception to section 69 of the Enterprise and Regulatory Reform Act 2013 for breaches of the Pregnant Workers Directive. To ensure that a pregnant worker continues to have the right to bring a claim for breach of statutory health and safety duty. Amendment to Health and Safety (First Aid) Regulations removed the requirement for HSE to approve training providers and qualifications of appointed first-aid personnel. Health and Safety (Miscellaneous Repeals, Revocations and Amendment) Regulations 2013 removed fourteen legislative measures, including Construction Head Protection, Notification of Conventional Tower Cranes. Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 implemented the Sharps Directive (2010/32/EU) covering prevention of injuries from medical sharps. 4. Health and Safety Requirements The HASAWA and the HASAWR require that ANHSFT has a system in place to proactively manage and control risks. In order to meet these legal requirements ANHSFT manages its risks based on the Health and Safety Executive model published in Successful Health and Safety Management (HSG65). This is a continuous improvement model based on 5 key objectives (see fig. 1) Policy; Organising; Planning and Implementation; Measuring performance; Reviewing performance and; Auditing. Figure 1. Presents HSG65 H&S Management Structure Page 4 of 22

5 The following provides an overview of activity referenced to HSG65 requirements Table 1 ANHSFT Evidence for HSG65 Compliance HSG 65 ANHST Evidence monitored by the JHSRC Requirement Policy monitor The following policies were updated during the period and maintain a Violence and Aggression and Lone working Policy coordinated Slip, Trip and Fall Policy approach to H&S Manual Handling Policy management and Infection Prevention and Control Policy arrangements COSHH - Control of Substances Hazardous to Health with clearly Policy defined Notification of Diseases Policy responsibilities. Contamination Injuries Prevention and Management Policy Breastfeeding and Returning to Work Policy Fire Safety Policy Waste Policy Security Policy Page 5 of 22 The following polices remain in date for the period and have not required amendment Management of the Estate Policy Control of Contractors Policy Emergency Planning Policy Serious Incidents Requiring Investigation (SIRI) Policy Display screen equipment policy Induction Policy Training and Development Policy Latex Policy Stress Management of occupational stress policy

6 Occupational Health Policy Mobile Phone Policy Mandatory Training Policy Organising encourage and support staff to actively participate in H&S management systems. The JHSRC provides assurance to the Executive Assurance Group and Trust Board of Directors. Its work is supported by the H&S Operational Group and specific sub-groups for slips, trips and falls, manual handling, COSHH, contamination injuries and violence and aggression. Director of Operations is responsible for H&S and chairs the JHSRC Assistant Director of Estates and Facilities is delegated chair of the H&S Operational Group Head of Facilities assumes responsibility for the local security management specialist services (LSMS) Head of Technical Services is responsible for Fire. A Fire Safety Manager and dedicated Fire Safety Advisor are in place The Compliance Manager is designated as the competent person and holds the NEBOSH diploma. Staff side health and safety representatives are involved in all aspects of health and safety decision making, this includes membership on all health and safety groups and committees. Mandatory and local training are provided for the following Quality & Safety; Manual handling; Infection prevention; Conflict resolution; Incident reporting; and Fire warden; Planning and Implementation develop and implement risk control systems and workplace precautions through proactive risk assessment and hazard spotting and promote a positive health and safety culture Measuring Performance To minimise hazards and reduce risk, requires an effective health and safety risk management system. Risk assessment methods support this approach and are used to prioritise areas of identified risk or hazard to inform organisational objectives Full site risk assessments for o Slips, trips and falls; o Fire; o Security; and o COSHH. Where appropriate, risk assessments are completed for o Manual handling; o Lone Working; o Stress; and o Display screen equipment. Other risk assessments are carried out as identified, for example for expectant mothers Measuring performance systems are divided into two types: Proactive systems monitor the achievement of plans and the Page 6 of 22

7 actively monitor performance in terms of accidents and incidents reported, so that themes and trends are analysed and lessons are learned. Audit and Review systematically review overall performance to ensure a coherent and consistent approach throughout the organisation. extent of compliance with standards. o NHSLA contains H&S aspects including slips, trips and falls, manual handling and stress (since the revision of the NHSLA risk management process this will not apply for ) o Dissemination of safety alerts from organisations such as the Medicines and Healthcare products Regulatory Agency (MHRA), DH Estates and Facilities Department and the National Patient Safety Agency (NPSA) o Self-assessment of compliance with Workplace Health and Safety standards Reactive systems monitor accidents, ill health and incidents. Adverse event reports are received by the Quality and Safety team and entered onto the Ulysses database; regular reports are produced for all H&S Committees and sub-groups, SPI initiative, QSOG and local governance groups. Further bespoke reports are produced when specific risks are identified. A summary of the findings for this period is presented in section 5. Periodic reviews are undertaken to provide assurance that performance is consistent across the Trust and meets the annual objectives; this includes the Self Inspection Audit. Audit is used to assess implementation progress and as a benchmark tool. ANHSFT ensures, by regular reporting to the JHSRC that we: Learn from experience; Improve performance; Develop the health and safety management system (SMS); and Respond to change. The self-inspection audit process, based on a database of questions, covers all aspects of H&S and provides for significantly more detailed monitoring and analysis of the results and any identification of gaps. An assurance process ensures the accuracy and completeness of the responses. The results of these are reported to the H&S Operational Group and monitored by the JHSRC. In early 2014 the HSG released a new version of HSG65 based on a plan-docheck-act approach. This will be discussed at the May 2014 H&S Operational Group and the JHSRC and the Trust s H&S management arrangements will be mapped against the guidance during Page 7 of 22

8 5 Achievement of Objectives Table 2 Achievement of Objectives Objectives Status Reviewing existing H&S arrangements Publication of guidance was delayed to ensure compliance with the expected until early This work is now revision of HSG65 to a Plan, do, check, underway. act approach publication expected September 2013 Assessing, monitoring and providing assurance that all premises are fit-forpurpose Validating the results of, and addressing issues identified by, the Self-inspection audit and gap analysis against the NHS Staff Council Workplace Health and Safety Standards The H&S Self-inspection audit has been completed for each location where ANHSFT has staff based. Where issues have been identified these have been escalated and risk assessed where appropriate Each section of the Self-inspection audit has been assigned a lead individual or group to provide assurance. Exceptions are escalated to the H&S Operational Group Risk Assessments leads have been identified and completed risk assessments are recorded on the H&S Risk Register. The completion of risk assessments and the implementation of identified actions are monitored by the H&S Operational Group. Raising the level of mandatory training attendance across all aspects of H&S Monitoring policy compliance and addressing any resulting issues related to health and safety induction and mandatory training. Setting KPI s for the top 4 staff H&S incidents. Mandatory training rates are monitored through the JHSRC and H&S Operational Group. Mandatory training rates have shown a steady increase since the roll-out of the new mandatory training strategy Where issues have been identified these have been escalated to the H&S Operational Group and the JHS&RC as required. Where appropriate risk assessments have been completed and recorded on the H&S Risk Register. KPI s have been set for Manual handling Slips, trips and falls Violence and aggression Contaminating injuries Achievement of these KPI s is the responsibility of the dedicated sub- Page 8 of 22

9 group. Assurance is provided by reporting to the H&S Operational Group and the JHSRC. 6 Adverse Events Reports All incidents and accidents occurring on Trust premises or affecting Trust staff are required to be recorded. These reports are collated and analysed using the Trust Incident Management system (Ulysses). Quarterly incident reports demonstrating trends and themes are presented to the JHSRC and H&S Operational Group. In addition specific quarterly reports are discussed at sub-groups covering slip, trip, falls, contamination injuries, manual handling, hazardous substances and Violence & Aggression. The lessons learnt during the last year are summarised below for the top 4 categories, which remain unchanged from Table 3 Lessons identified from the top 4 categories for H&S Adverse event reports Lesson Identified Action Taken 1. Contamination Contamination Injuries Prevention and Management Policy injuries updated. Contamination injuries question and prompt to update risk assessments included in the Self-Inspection Audit completed by all departments annually. A number of safety devices successfully implemented trials on other devices ongoing Safety and Quality matters and SQUID newsletter used to promote good practice information for Doctors/medical staff. Introduction of safety devices wherever possible / appropriate to comply with EU Directive Yearly audit undertaken by Daniels re: use of sharps containers Safe sharps tips presented at all clinical mandatory training sessions Contamination injuries incidents reviewed quarterly by the Contamination Injuries Working Group to identify trends and key lessons to be learnt. The group s minutes are reported to the H&S Operational Group. 2. Manual handling injuries Improvement of booking/follow-up for mandatory training sessions Manual handling question section included in the in Self- Inspection Audit completed by all departments annually. E-learning package for object handlers launched Manual handling incidents reviewed quarterly by the Manual Handling Assurance Group to identify any trends and key lessons to be learnt. The group s minutes are reported to the H&S Operational Group. Page 9 of 22

10 Lesson Identified Action Taken 3. Slip, trip, falls Slip, trip, fall questions section included in the in Self- Inspection Audit to be completed by all departments annually. Annual floor assessments of hospital entrances and Airedale staff based community buildings carried out by use of specialised machine in conjunction with the HSE slip assessment tool to measure floor suitability. Corrective action taken for areas identified as significant or high risk. External walkaround risk assessment of external paths, stairs, ramps, etc carried out throughout the year. Findings discussed at slip, trip, fall group and remedial action taken by estates maintenance department. Community sites external risk assessments in progress completed for Settle Health Centre and Castleberg, Skipton General Hospital to be carried out. Extensive tarmac work of all entrances currently in progress. At time of this report entrances that have been completed are main, consultants car park, out-patients, west car park, behind ward 24, labour suite and theatres. Remaining areas to be covered are ante-natal, ward 20, IT ramp and bottom of the tunnel. Weather monitored by estates maintenance in winter months to ensure sufficient gritting. Gritting process in place. Quarterly Slips, Trips, Falls incidents to staff and others are reviewed by the Slip, Trip, Fall Group. This group has raised its status due to the increase of slip, trip, fall claims. The group is now estates maintenance budget holder led with inclusion of the domestic manager, matron and patient carer panel member. This provides assurance on robust processes in the event of claims. The group s minutes are reported to the H&S Operational Group. Additional footwear information added to the revised workwear and uniform policy to remind staff of importance of wearing suitable shoes in the workplace. Slip, trip, fall awareness delivered to staff via the Trust induction and quality and safety updates with incident prevention information given. This includes relevant extension numbers for reporting of hazards and risks. 4. Violence and Aggression, includes Verbal abuse non-patient on staff Violence No Injury - Patient On Staff Violence With Injury - Patient Conflict resolution training is a Trust mandatory training requirement for staff All incidents of violence are investigated by the department/ward manager and discussed at the Violence and aggression Group meetings chaired by the Head of Facilities Support and advice provided to staff by line managers, security and Employee Health and Wellbeing Individually verbal abuse by non-patients against Trust staff is the third most common incident affecting staff across the Trust. Page 10 of 22

11 On Staff 6.1 Total Incidents The following table compares the total number of reported incidents for patients and staff for with as reported via the Adverse Event Forms (AEF) and input into the Ulysses database system. Table 4 All recorded Incidents (patient, staff & others) at ANHSFT for date range 01/04/ /03/2014 Year Quarter Quarter Quarter Quarter Total The number of AEFs reported in shows an increase from over the first two quarters of the year, demonstrating an improving reporting culture, which is a key requirement of a healthy and safe workplace. Quarter 3 shows a similar level of reporting. The decrease in quarter 4 of is to be a result of delays in receiving adverse events reports into the Quality and Safety team for logging on the database. 6.2 Numbers and Types of Staff Health and Safety Related Incidents Reported The range of incidents received are categorised by Cause 1 allowing further analysis of the reports. Cause 1 categories are used to record individual incident causes, for example contamination injury is divided into 11 individual cause 1s. All reported incidents are then grouped together to provide high level incident causes and allow trends and themes to be identified. Table 5 Provides all reported incidents received by Quality and Safety for the financial year, date range 01/03/ /03/2014 and compares these to the figures for Table 5: All Reported Incidents by Cause 1 Cause Trend Verbal Abuse Manual Handling Incident Slip/Trip/Fall Contamination Injuries* Violence No Injury Collision With Object Violence With Injury Work Related Stress 14 4 Traffic Accident 10 4 Trapped/caught in between objects, e.g. door or lid 9 18 Page 11 of 22

12 Cause Trend Exposure/contact With Hazardous Substance 8 7 Incorrect radiation dose 7 5 Health Risk Concerns (e.g. Noise, Vibration) 6 0 Burns And Scalds 6 11 Waste disposal 1 0 Failure To Use Equipment Guarding 1 0 Diathermetic Burn 0 0 Total as reported via infection prevention Overall the number of reported staff incidents for the have increased since Review of the individual numbers shows that in a number of areas the number of adverse events has decreased showing the mitigating actions put in place have worked. However, in eight areas an increased number of reports have been made. Detailed analysis of the most common events and those where a substantial increase has been noted is provided in section 6.4 below. To support managers and service leads, the Quality and Safety team continues to develop and produce a range of incident data reports which capture trends and themes across the Trust. The team also continues to support Trust staff at all levels in the quality of the data submitted on the Adverse Event Forms. Quality of data is vital to analyse and improve safety for staff and patients. 6.3 Grade (severity) of incidents Part of the reporting process is to allocate a grading of severity to the incident. None of the 476 reported Health and Safety incidents was graded as red for this is the same as The grading used is the Trust s standard consequence and impact scoring system (appendix A) as defined in the Risk Management Procedure. To ensure that staff are consistent in their appraisal of the incident, grading is a core component of both induction and mandatory training. Managers are advised to re-review the grade and work collaboratively with staff. 6.4 Top Four Health and Safety Incident Causes As an organisation we proactively monitor all health and safety incidents with specific reference to the top four. The following table indicates the top four incidents by frequency for and is compared to the previous reporting year. In addition areas where a significant increase from has been noted Table 4: Top Four Staff and increased Health and Safety incident causes Top Four Staff Health and Safety incident causes Violence and Abuse (all types) Contamination Injuries* Slip, Trip, Fall Manual Handling Incorrect radiation dose 5 7 Page 12 of 22

13 Top Four Staff Health and Safety incident causes Work Related Stress 4 14 Traffic Accident 4 10 Health Risk Concerns (e.g. Noise, Vibration) 0 6 as reported via infection prevention Violence and Abuse (all types) Violence and abuse figures have increased due to increased reporting and crossreferencing between Adverse Event Forms submitted to Quality and Safety and reports made directly to Security. Violence and Aggression Group has been set up during to discuss these incidents and identify trends and key lessons. In there were 50 reported physical assaults on staff by patients. All assaults, as well as being reported locally, are also reported nationally to NHS Protect. The number of reported violence and aggression incidents demonstrates a very slight increase when compared to the previous year s figures of 48, of those incidents reported the trends and themes relate to aggression and abusive behaviour towards both healthcare professionals and / or other colleagues. In addition to planned work, i.e. patrols, lock up, etc, 4678 incidents required attendance by Security Officers this is a decrease from the previous year s 4708 Conflict Resolution Training (CRT) - CRT training has been provided to members of staff who come into contact with members of the public. To date 1738 members of staff have been trained. Refresher training has commenced and 472 members of staff have attended this training. Access Control - This is now operational in 34 areas of the Hospital. Vehicle Crime There have been no reported instances of vehicle crime. (The Hospital has again been awarded with Secure Car Park status by the Police. CCTV - 71 cameras are installed and are overtly monitoring the site both internally and externally. The drop in camera numbers is because of the new Emergency Department build, and the use of temporary Emergency Department. The CCTV cameras located at Skipton General Hospital are now also fed back to Airedale and all are managed within Data Protection requirements and CCTV Government guidelines. Partnership Working - The LSMS and the Police Inspector meet monthly to discuss crime trends and any incidents of note. Police Community Support Officers (PCSOs) undertake regular patrols of the site, both internally and externally. The Police have spent time on site checking speeds of vehicles on perimeter road and warning people driving above the speed limit. Annual LSMS Work plan - The annual Local Security Management Specialist (LSMS) Work plan will be submitted in November which details work completed against the action plan. Some examples of actions are continued close working Page 13 of 22

14 with Police counter terrorism team, development of lockdown procedure and working closely with Estates on various upgrades to departments. Further actions for include Attendance at the Annual Trust Open Day; Development of a site-wide Lockdown Plan. Several areas of the site can be automatically locked down (See Access Control) Contamination injuries These again account for 25% of the staff accident/injury incidents reported, the same as for An established Contamination Injuries Working Group which reports to the H&S Operational Group has a remit to investigate reported incidents and provide a consistent approach in monitoring and sharing the lessons learnt. Employee Health and Wellbeing Service and the Infection Prevention Team provide feedback to the group on their investigation of contamination injuries. The working group also correlate reports to ensure consistency of actions taken, for example the raising of awareness through sharps safety and incident reporting at both induction and mandatory training sessions. An audit programme initiated in October 2008 has influenced the on-going requirement of bespoke educational sessions for both clinical and non-clinical staff.. Further work planned for includes Reminders to staff on sharps safety and reporting injuries; Implementation of actions resulting from the inoculation contamination injuries audit; Continuing analysis of adverse events forms to identify trends; Compliance with the EU Directive on prevention of sharps injuries: Progressive introduction of safety devices where available with training provided by company representatives On-going targeted training for high risk staff groups: nurses/ doctors this increases awareness and therefore reporting rates increase as a result. On-going risk assessments with clinical areas to identify specific risks and where safety devices cannot be used and how risks can be minimised Slips, Trips, Falls Unlike in previous years the number of slip/trip/fall reports has remained broadly stable since demonstrating the work done by the Slip/Trip/Fall group. To further raise the importance of slip/trip/falls at the Trust the group has been developed and considerable external work has already been completed. The Slip, Trip and Fall Group monitors the incidents that are reported for trends and themes. The self-inspection audit, slip, trip, fall section, monitors that all areas have proactive slip, trip and fall assessments in place, both for Trust based staff and non-trust based staff working in external buildings. These risk assessments are managed by the relevant ward/department and uploaded to departmental sections on SharePoint. Any slip, trip, fall risk assessments graded 9 or over to go through this group and are escalated to the H&S Operational Group and JHSRC and placed on the relevant risk register. Local monitoring of slip, trip and fall risk assessments also takes place including post-accident risk assessments (required for claim evidence purposes). Departmental managers and sisters/charge nurses are responsible for the local monitoring of risk assessments scoring under 9. Page 14 of 22

15 All staff slip, trip and fall incidents are discussed at the Slip, Trip and Fall Group meetings with these sub-group minutes being a set agenda item on the H&S Operational Group. The Health and Safety Co-ordinator monitors investigations and action plan implementation and presents quality dashboard reports including risk reduction plans to the H&S Operational Group and JHSRC. Further work planned for includes Compliance of annual completion of self-inspection audit for all areas and monitoring of proactive slip, trip and fall risk assessments; Revision of the slip, trip and fall, policy; Continued risk assessments to be carried out prior to commencement of tarmac work in the remaining identified entrances/areas. Monitoring of external slip, trip and fall hazards and risks, these to include community site buildings (Skipton General Hospital, Castleberg and Settle Health Centre). Ensuring completion of a post-accident risk assessment for all RIDDOR reportable slip, trip and falls to ensure that process is followed and feed into claims evidence as required To feed in lessons learnt from claims to take to slip, trip, fall group and escalate to Health and Safety Operational Group for information/further discussion. To produce a fluid spillage flow chart, communicate it to staff and mirror this process for the reporting of external flooring issues/lighting etc. Periodic reminders to staff on the importance to clean up spillages promptly and any other issues identified Manual Handling Manual handling and musculo-skeletal incident reports are reported to the Manual Handling Steering Group. The minutes are received by the Operational H&S Group. All manual handling risk assessments are managed locally; non-patient manual handling risk assessments are located by ward/department on SharePoint. Patient manual handling assessments are located within the patient s notes. Grading of risk assessments scoring 9 or above are presented to the JHSRC and escalated as appropriate. They are also recorded on the appropriate risk register. A number of Key Trainers have undergone extensive training to enable local delivery of Moving Handling Training and promotion of best practice. The Key Trainers are also used as a resource to support managers in carrying out Risk Assessments. Following the review of Mandatory training a number of additional sessions have been provided to ensure sufficient provision of Moving and Handling Training is available to all staff. Further work planned for includes The Moving and Handling Assurance group will review its terms of reference to ensure that all Moving and Handling AEF s and Risk Assessments are reviewed, to ensure risks across the trust are monitored and escalated appropriately. Page 15 of 22

16 Provision for moving and handling training will be further increased to meet increasing demand. Completion of all Mandatory training (including manual handling) will be linked to appraisal and incremental progression Work Related Stress The number of work related stress incidences have increased from the figures. This is due to An improved reporting system on the Employee Health and Wellbeing Cohort system to capture data on work related stress. Delivery of managing health wellbeing and attendance training which includes greater emphasis regarding work related stress leading to an improved reporting culture Further work planned for includes To take a more proactive approach in identifying the risk of work related stress: To include department stress risk assessments in the stress policy Involvement in NHS Employers pilot project for mentally healthy workplaces. Awaiting confirmation if ANSHFT has been chosen as one of the pilot sites to deliver training in mentally healthy workplaces. Staff from the HR directorate, including Employee Health & Wellbeing Nurses are receiving training to deliver a health and wellbeing program to improve the health and wellness of staff Traffic Accident The number of traffic accidents have increased in the last year, 4 were the result of inappropriate parking at AGH and it is believed the new staff car park will lead to a reduction in these events. 6 were accidents in the community / public roads the last was a cyclist slipping on ice. Further work planned for includes Detailed review of these incidents to identify trends and mitigating actions Monitoring to establish if new staff car park has reduced parking accidents Health Risk Concerns (e.g. Noise, Vibration) During there was a significant increase in the reporting of incident within this category, of these 12 (out of a total of 21) were related to temperatures being either too high or too low. This was driven by the extreme temperatures in both winter and summer during this period. Further work planned for includes Analysis of the results of the Self Inspection Audit and completion of risk assessments where appropriate Monitoring of all Risk assessments by the H&S Operational Group Incorrect radiation dose Radiation incidents reported at ANHSFT over the last 2 years have been due to Radiographer error, however this is in the context of over 90,000 examinations involving ionizing radiation carried out per annum by the Trust. All incidents involving incorrect radiation dose are referred to Medical Physics experts at Bradford to assess the risk. All incidents reported in 2012/13 and Page 16 of 22

17 were deemed to have insignificant risk to the patient. None of the incidents were reported to the CQC as per Medical Physics expert advice. Ionising radiation matters are monitored by the Ionising Radiation Protection Group, notes and actions are reported to the Joint Health, Safety and Resilience Committee and all incidents are discussed at the monthly Radiology Risk Management Team meetings. Incidents due to human error are notified to the Radiographer and discussed to reduce the risk of repeated mistakes RIDDOR reporting ANHSFT are required to report specific injuries and any absence of over a defined to the Health and Safety Executive (HSE) via the RIDDOR reporting system. The following table indicates the total number of staff incidents reported for compared to Note: as noted in section 3 above the updated RIDDOR regulations came into force on 1 st October This extended the requirement to report incapacitation from 3 to 7 days. Table 7: RIDDOR Reported Incidents Q1 Q2 Q3 Q4 Total This shows an increase of 5 from and accounted for 148 days absence compared to 145 days absence (based on a 5 day week) taken for The most common cause of RIDDOR reportable incidents are slips, trips, falls (8) followed by, manual handling incidents (2), and two violence with injury (patient on staff). The increase in Q3 is the result of 4 slips, trips, falls resulting from a slip on water following cleaning (3) a trip over the tail of a delivery wagon (1). These were investigated by the slip, trip, fall group as described in section Fire Airedale NHS Foundation Trust introduced local call filtering in 2012, this means all fire alarm activations are investigated before a 999 call is made to ensure the correct response by the Fire & Rescue Service (F&RS). Fire emergency calls are filtered by our own switchboard staff and none of the 63 false alarms generated this year resulted in Unwanted Fire Signals (UwFS), West Yorkshire F&RS announced this year that from April 1st they will be charging for attendances to commercial premises where the call turns out to be the result of a false alarm. it is the forth and consecutive false alarm will be charged at 350+vat per fire engine in attendance (commercial premises are allowed 3 false alarms in a twelve month period) Other conditions are being considered and final plans are yet to be confirmed. The firecode suite of documents, (the best practice guidance for healthcare premises) is undergoing a review, because of this there are several re-writes Page 17 of 22

18 taking place, during this period HTM-05:01 Managing Fire Safety in Healthcare Premises was revised. This document sets out the management system required in Healthcare Premises to ensure the correct level of compliance with the Regulatory Reform (fire safety) Order The Trust has made changes to procedures and policies to ensure we are conforming to the changes. An action plan was issued to the Trust by the Fire Authority in December 2009 with the exception of one item the action plan is complete. The outstanding action is for ramps to be installed behind all lower level wards to aid wheelchair evacuation where necessary. This was added to the capital work for wards and was expected to be complete by Dec 2012; unfortunately the work has still to be completed, In the event of a fire audit we will need to report non-compliance with the action plan. Fire Audits are unannounced so a time frame cannot be provided. Until this work is completed horizontal evacuation will be used where practical, if necessary an evacuation sheet/ski pad will ensure safe evacuation. Fire risk assessments - Significant finding in wards and departments have been identified through previous risk assessments, with the exception of the ramps at the rear of some of the wards, most significant finding are being dealt with. Going forward assurance will be provided by submitting the Fire Risk Register to H&S Operational Group significant risks (scoring 9+) will be identified and escalated to the JHS&RC and EAG if appropriate. Fire drills - All wards and departments had a fire drill in , two areas failed and had to be re-tested, when they passed. Records were retained for audit. Mandatory Fire Training - The mandatory fire training programme is managed by the education department. The new on-line e-learning package for mandatory fire training has improved the fire training figure for Arrangements are in place to start local training courses within wards and departments and e-learning for fire mandatory training is also in place to replicate local fire arrangements in community buildings. The fire drill now incorporate basic fire safety awareness so staff can be brought up to date with any alterations to the ward/department and practice the fire procedure, this gives us confidence that under an audit, if questioned, staff have a good understanding of what to do in a real fire situation, or when the continuous fire alarm sounds Fire Wardens - Due to the re-write of HTM-05:01 the requirement for fire warden training has been diluted, this means the mandatory fire training meets the minimum requirements for fire warden training, i.e. all staff are deemed to be trained to Fire Warden standard if they have attended mandatory fire training. Therefore, any member of staff can now be called upon to carryout fire warden duties under the Trusts fire emergency plan. Fire Response Team - As a results of the changes to fire warden training, to ensure we keep the same level of response to all fire alarms we have (under guidance from HTM-05:01) trained a fire response team to pick up from the fire wardens old role. The fire response teams are trained to a high standard which Page 18 of 22

19 includes fire extinguisher training in a live fire situation, they are on site 24 hours a day 7 days a week all year round. Fire Safety Log Books - A fire safety log book is issued to all wards, and to departments over a certain size, for example a department such as dietetics would not have a local fire safety log book, they would come under the log book of the admin corridor. The primary function of the log books are to aid fire wardens in the running of a fire incident and also to help with the day to day functions of fire safety through daily, weekly and monthly checks. All fire safety log books were audited through where these were found not to be up to date this was brought to the attention of the senior staff in the area. Fire Alarms - The Trust had no events to report to the Fire & Rescue Service in False alarms - The Trust recorded 63 False alarms during the , all were investigated and remedial action advised where necessary, all remedial actions have been completed. Unwanted Fire Signals (UwFS) - The Trust recorded 0 UwFS during , an UwFS is a false alarm which involves the fire and rescue service (F&RS), the most common cause of a UwFS is the 6 minute delay time lapsing which would trigger the switchboard personnel to automatically call the F&RS. We have been running the new staff procedure since 9 th January 2010 and we have not had an unwanted fire signal in that time. Other - There were 5 operational fire authority inspections throughout 2013/14 there were no major problems found by the fire authorities. A fire Audit was undertaken in April which looked at the fire emergency plans, Fire risk assessments, policies and a range of fire related measures in place by the Trust. This audit identified a number of areas for improvement not having a completed premises compartmentation study, loose furniture on the hospital street in the main reception displaying goods from the shop on the main hospital street in the main reception. These issues are being dealt with and rectification will take place. Carol Woolgar Health, Safety and Emergency Planning Manager Dawn Bracewell Health and Safety Coordinator Mel Jackson Fire Safety Officer Wendy Firth Head of Facilities Chris Williamson LSMS Page 19 of 22

20 Matthew Smales-Cresswell Training and Education manager Allison Charlesworth Matron Infection Prevention June 2014 Page 20 of 22

21 Appendix A Adverse Event Scoring Criteria Table 1: Consequence Grades 5=Catastrophic Death, malicious or otherwise and/or significant loss of reputation for the Trust and/or loss of key Trust services which prevent the Trust meeting its responsibilities 4=Major 3=Moderate 2=Minor 1=Insignificant Permanent injury, amputation, major damage and/or start of a national investigation into the Trust and/or disruption of key Trust services which significantly hinder the Trust in meeting its responsibilities Semi-permanent injury or damage(recovery takes longer than 1 month but no more than 1 year) and/or adverse publicity for the Trust Short term injury or damage (recovery within 1 month) No injury or adverse outcome Table 2: Likelihood Grades 5=Almost Certain A persistent issue (more than once a week) 4=Likely Will probably occur (once or twice a month) 3=Possible May occur occasionally (once or twice per year) 2=Unlikely Do not expect it to happen but it is possible (once every 3 to 5 years) 1=Rare Can t believe this will ever happen (that is to say not in the next 5 years) % % 26 50% 6 25% 1 5% Table 3: Classification Matrix Most likely Impact/Consequences Likelihood of None Minor Moderate Major Catastrophic occurrence/ (1) (2) (3) (4) (5) recurrence Almost certain (5) Likely (4) Possible (3) Unlikely (2) Rare (1) Classification of Incident Page 21 of 22

22 Very Low Low to Moderate Moderate to High High Monitored Executive Management Committee by Risk Monitored by The Trust Board Page 22 of 22

23 Number Directorate Description Gaps In Controls Cons Like Risk Score Actions Internal Assurance External Assurance Gaps In Assurance Monitoring Group Owner HS HS HS Director Of Nursing Director Of Operations Director Of Operations Estates repairs on Community Buildings, required works are outside SLA and below capital schemes. Failure to comply with legal requirements to provide suitable and sufficient first aid support to Trust staff, patients and visitors. At present there are inadequate trained numbers of first aiders especially in non clinical areas. Workplace Standards - First Aid (O) - Employers have effective arrangements in place to provide adequate and appropriate equipment, facilities and personnel to ensure that employees receive immediate attention if they are injured or taken ill at work. No control process for IT contractors who require access to Comms cabinets at the community buildings Skipton Hospital, Castleberg Hospital and Settle Health Centre. Remedial maintenance under 500 is covered under the SLA arrangement with NYYPCT. Any work above 500 charged to the site budget when this should be picked up by the landlord and not create an Airedale overspend Lack of nominated staff for first aid training. No first aid policy in place for the Trust. Where training figures are reported Where are first aid courses advertised Issue to be discussed at the mandatory trainer facilitator meeting. No assessment of first aid needs / policy / procedures first aid policy / procedure The access procedure is not overseen by any IT staff on behalf of the site but access is approved by site manager who does not have technical knowledge to do this. Some contractors attend site without making site coordinator aware. Loss of networking for staff on site has happened on more than one occasion as a result of none of the organisations on site taking control of access. On two occasions the loss of service lasted for seven days. Need to identify which organisation is responsible for the IT comms cabinets and also identify a process for approving work to reflect current arrangements which are in place with estates for issuing work permits Two monthly cleaning audits and environmetn checks highlight estes issues requiring attention in addtion to planned maintenance by estates team. Recharging process for rooms now in place to try and general income towards budget overspend Continue to record trained first aiders numbers. Identify first aid lead First aid lead to complete risk assessment 14/05/2014 Escalate to EAG All requests for access are controlled by Airedale Trust IT Dept. in conjunction with Site Coordinator. New approval process put in place via IT Services to approve access requests. AGH IT to obtain agreement from other Trusts on site to take control of the comms areas for the sites. Tim Rycroft to present at Joint Health & Safety Opps Group as there are still further actions required by IT to further reduce the risk. Process now in place - outstanding actions: TR/DM to arrange coordination meeting resulting in updated processes & control of contractors policy. Following a meeting with Airedale IT Services Site Coordinator has written to all IT providers ( ) at the community sites to put a revised process in place. All IT providers asked to label their own IT equipment so it can be easily identified. Letter sent requested that the Head of IT for each provider nominates a rep to act on behalf of their organisation to confirm access approval for their comms area and an assurance that the work carried out will not affect services on site. Where IT requests require installation of a line or affect the fabric of the building the requestor of the work makes contact through the Micad Helpdesk to arrange necessary access permits before access will be allowed. Trial process for 6 months. Overspend will reduce if minor works are not charged to the Airedale Site Budgets. Trained first aider numbers will increase with the Trust being sufficiently covered. Health and Safety Operational Group If Airedale Trust control any requests for access then the organisation has assurance that there will be no disruption or loss of networking as a result of other trusts completing work in the comms area. Agreement with PCT to pick up landlord responsibility for repairs. Compliance with first aid regulations. If control of access assumed by Airedale this would fulfil the safe management of contractors under Health & Safety regulations. None identified No consistency in regular release of staff. Airedale IT Services need to obtain agreement from other trusts who occupy the community premises for their agreement for them to take control of the comms room for the sites. Operational H&S Group Joint H&S Committee Joint H&S Committee David Moss Stacey Hunter Trudy Balderson Next Update 23/07/2014 Date Placed 08/01/ /12/ /12/ /07/ /01/2014

24 Number Directorate Description Gaps In Controls Cons Like Risk Score Actions Internal Assurance External Assurance Gaps In Assurance Monitoring Group Owner Director Of Operations HS Workplace Standards - Competence (A) - Duty holders need competent staff to identify and manage risks. Competence is required at all levels throughout the organisation, from board level downwards. Board members only attend mandatory training - there is no specific H&S leadership training in place. Training attendance levels are low Rollout new training strategy Link between training attendance and PDR Reporting staff attendance at mandatory training to line managers and Directors Training reports received by Health and Safety operational group None identified None identified Operational H&S Group Matthew Smales- Cresswell Next Update 31/12/2013 Date Placed 15/10/2013 HS Assistant Director Facilities & Estates Lack of walkways around the perimeter road for use by staff, visitors, out patients and other. Limited control over inappropriate parking when car parks are full. Walkways not considered for smoking shelter access for staff and others. Drop kerbs and disabled access not adequate on some routes from car park to required entrance Areas requiring remedial action to be mapped on a floor plan for consideration of putting additional walkways and zebra crossings in place. Also to consider parking spaces that pose a current hazard to action. To ensure that area around intersperse becomes a no parking on pavement zone. Bollards to be put in place. To look at identifying walking zones in car parks for pedestrian access. To replace signage at top of path as letter missing. Also to place signage on top path directing pedestrians to the tunnel. 22/04/2014 External walk ways are currently being costed along with the signage being picked up with the way finding group, we should have costs in the next week and capital funding can then be pursued. Walkways will be present in pedestrian areas and routes to smoking shelters. Compliance with health and safety legislation. Budget for walkway work unknown. Operational H&S Group Martin Quirk 23/07/ /01/2014 HS /VS/0403 Director of Operations Director of Estates & Facilities Lighting in areas of the Craven Premises is beyond the required replacement programme to ensure compliance with lighting legislation. Inadequate lighting could impinge on clinical services and increase health and safety risk to slips, trips and falls, eyestrain, risk to patients with medical conditions, i.e. dementia, partially sighted. No PPM for lighting currently in place. Breach of Fire Regulations and Health and Safety Legislation regarding the change of use to the Main Reception area and contradicts the recommendations of the Trust Fire Risk Assessment. (Please see Appendices A, B, C attached) and possibly the building regulations for change of use. Lack of available funding to replace lighting via landlord related processes. No lifecycle replacement programme in place. Replacement programme works for Community Buildings deferred for 2012/13. Unknown whether this work included in the 2013/14 programme. No definitive escalation process to senior management level for Procurement process not followed/understood. Change of use of area not taken through the Capital Meeting for agreement. Fire officer not informed/consulted fully. Initial risk assessment process not followed to identify hazards and risks Six Facet survey arranged by NHS Property Services Ltd to be carried out in Craven premises. Remind staff to ensure that inadequate lighting is reported to site manager and via the adverse event form. Remind staff to ensure that internal and external flooring issues and lighting issues are reported promptly for remedial repair. Awaiting decision on funding from the landlord from capital. Replaced lighting will eliminate the risk of inadequate lighting hazards Inform Chair FOA to procure suitable seating by using the procurement policy and procedure through Supplies Department and for this to be designed to be secured to the floor. Arrange to meet with Eileen Proud Chair of Friends of Airedale and Gurmit Jauhal regarding requirement for adhering to procedures for change of use, involving Estates and Fire Safety Advisor and safe positioning of furniture replacement of table and chairs. Purchase replacement closed suitable bins for the area Notice to be placed in seating area to ask visitors to ensure rubbish is placed in bins Notice to be placed to designate Bereavement Services area to state visitors only. Compliant with legislation and internal processes. Craven Work approved by Landlord under premises will be capital funding cancelled at the last compliant with minute due to timescales to complete CIBSE lighting the work. Lack of communication levels. regarding replacement of system. Compliant with legislation. In breach of Fire Regulations, Health and Safety Legislation and possibly building regulations in respect of change of use. Operational H&S Group Operational H&S Group David Moss David Moss 23/07/ /11/ /07/ /03/2014