BRIEFING REPORT ON VERBAL FEEDBACK FROM HEALTH & SAFETY MANAGEMENT AUDIT 2012/13

Transcription

1 AGENDA ITEM 4.1 BRIEFING REPORT ON VERBAL FEEDBACK FROM HEALTH & SAFETY MANAGEMENT AUDIT 2012/13 Executive Lead: Deputy Chief Executive Author: Head of Health and Safety Contact Details for further information: Charles Dalton SITUATION Audit Context The Chief Executive of NHS Wales wrote to each Health Board Chief Executive on the 10 th August 2012, outlining the need for NHS Wales Shared Services Partnership - NWSSP: Audit & Assurance services to conduct a thematic audit of health and safety management in each Health Board. These audits were recommended by Dr Clive Grace within his independent commission to review the management of asbestos at Bronglais Hospital. The Auditors undertook the review within the Health Board from the 4 th to the 8 th of February BACKGROUND This brief was actioned under the 2012/13 NWSSP Audit & Assurance operational plan agreed with the Health Board. The review was being undertaken to determine the adequacy of, and operational compliance with, the systems and procedures of the Health Board, taking account of relevant NHS and other supporting regulatory and procedural requirements, as appropriate. An objective of the audit was to evaluate the systems and controls in place within the Health Board, with a view to delivering reasonable assurances that risks are appropriately managed. Accordingly, the focus of the audit was directed to the following areas: Board level priority Comprehensive policy framework Health & Safety Management Audit 2012/13 Page 1 of 9 Health and Safety Committee

2 Responsibility and accountability Risk assessment Incident reporting and response systems Training strategy Follow-up of any previous H&S audit work performed Audit Approach The audit was undertaken using a risk based auditing methodology. Following interviews with relevant personnel and a review of key documents, files and computer data, an evaluation was being made against the Health Board procedures and other supporting regulatory and procedural requirements as appropriate. Where a control objective had not been achieved, or where it is viewed that improvements to the current internal control systems can be attained, recommendations will be made. A basic aim is to provide proactive advice, identifying good practice and any systems weaknesses for management consideration. Feedback On completion of the Audit a verbal feedback was given as detailed in Appendix 1. It was initially planned to produce a draft report by the end of March, however this has been delayed due to other Health Boards not submitting required data within the timescale and therefore cross references to ensure standardisation on audit outcomes cannot yet be completed. Once this cross referencing has been completed a draft report will be produced for the Health Board to comment on prior to the completed report being issued. ASSESSMENT The report identified that the Health Board were in the main, meeting the requirements of the audit criteria, however there were some areas which were identified as requiring remedy. It was considered due to the importance of the audit and the feedback, that it was justified to bring these issues to the attention of the Committee at this point, rather than awaiting the receipt of the formal audit report. The identified shortfalls have been added to the Health & Safety Priority Action Plan and as relevant, added to the Corporate Risk Register. On receipt of the formal report, actions will be reviewed to ensure the findings are comprehensive and the formal report will be submitted to the next Health and Safety Committee. Health & Safety Management Audit 2012/13 Page 2 of 9 Health and Safety Committee

3 RECOMMENDATIONS NOTE the content of the report. NOTE the current status of compliance. AGREE to receive a formal report at the next Committee meeting. Financial Impact Quality, Safety and Experience Standards for Health Services The report has no financial consequences. This report is fundamental to the management of Health and Safety and quality of both staff and patients. The impact of this report on the delivery of the Standards for Health Services is as follows: 22. Managing Risk and Health and Safety Organisations and services will have systems and processes in place which comply with legislation and guidance that: Risks and Assurance a) Applies best practice in assessing, managing and mitigating risk; b) Implements policies and arrangements for reviewing and continuously improving all aspects of their activities and environment to protect and improve the health, safety and wellbeing of their patients, service users, carers, staff and the public; and c) Acts upon safety notices, alerts and other such communications. The report supports the risk register by ensuring that those identified actions are appropriately recorded on the central risk register. Health & Safety Management Audit 2012/13 Page 3 of 9 Health and Safety Committee

4 Equality and diversity An equality impact assessment has been undertaken and identifies that there is no obvious evidence of any equality concerns, in relation to the Health and Safety management audit and findings. Health & Safety Management Audit 2012/13 Page 4 of 9 Health and Safety Committee

5 Health & Safety Management Audit 2012/13 Page 5 of 9 Health and Safety Committee

6 Area Requirement Verbal feedback Appendix I Board priority level Comprehensive policy framework Responsibility and accountability Improving health and safety is identified as a core requirement of the future strategy the implementation of which is led by the Board. The Board regularly receives, discusses and scrutinises reports on the management of health and safety risks within the organisation. An executive director has responsibility for management of all Health & Safety matters. There is a health and safety policy which is discussed and ratified by the board. The policy is aligned with relevant national legislation, guidance and best practice Policies and procedures are reviewed and updates on a periodic basis according to an agreed timetable for policy review. Policies are in place to cover issues including (but not exclusively): Provision of an Occupational Health Service; Musculoskeletal Disorders Manual Handling; Display Screen Equipment; Lone Workers; Bullying and Harassment; Violence and Aggression; Slips, trips and falls; Stress; COSHH; Contractors; Asbestos; Fire; Legionella; Working Time Directive; Pregnancy and New Mothers; Radiation; The Workplace; Workplace Transport; Work Equipment; First Aid. The identified executive lead has delegated operational responsibility for health and safety matters to a suitable qualified individual. This individual is given sufficient time and resources to carry out their duties effectively. Compliant Auditor accepted Priority Action Plan was a strategy document. All relevant Policies made available. Commented that not all H&S Policies (Those approved by other committees) were in review date, notable Risk Management Policy. Considered that our Policy schedule document could be expanded to include other H&S Policies approved by other Committees for information to the H&S Committee Compliant Operational H&S Group include suitable membership Health & Safety Management Audit 2012/13 Page 6 of 9 Health and Safety Committee

7 This individual is accountable to a safety committee (or equivalent). The committee operates effectively and is: Adequately attended by e.g. occupational health, infection control, risk management, local security management specialist, the Health and Safety officer; Members have the necessary knowledge, expertise and delegated authority to ensure the actions of the committee align with general strategies and organisational thinking; The committee has sufficient authority to provide proper consideration to views and recommendations; Assigned delegated responsibility to oversee matters such as (but not limited to): o the study of accident and notifiable events/ issues; o examination of management s safety audit reports; o consideration of reports and factual information provided by inspectors of the enforcing authority appointed under the Health and Safety at Work Act 1974; o agreement of any subsequent action required; o assistance in the development of works safety rules and safe systems of work; o oversee the effectiveness of the health and safety training; o oversee the adequacy of safety and health communication and publicity in the workplace; Wider roles and responsibilities in respect of health and safety are clearly defined at all levels throughout the organisation and are set out in the individual job descriptions. Risk assessment There is an agreed documented approach on risk assessment There is a systematic approach to the completion of risk Auditor aware of previous internal audit but accepted we Health & Safety Management Audit 2012/13 Page 7 of 9 Health and Safety Committee

8 Incident reporting and response systems (picking up issues and escalating) assessments. Risk assessments are completed by competent persons and involve relevant people. The risk assessments are suitable and sufficient based on analysis of task, environment, equipment and people involved/affected. The risk assessments identify the preventative and protective measures needed to control the risk. Preventative and protective measures identified are prioritised and implemented so far as is reasonably practicable. Risk assessments are regularly reviewed, for example annually or subject to change. Outcomes of risk assessments, for example risk action plans, are taken to the appropriate level for action. The Health Board has an incident reporting policy in place which sets out the requirements of accident and incident reporting under RIDDOR and other statutory requirements. The policy identifies the roles and responsibilities of individuals differentiating between staff, patients and members of the public. The policy explains how and what to report as an incident. The policy is properly communicated and accessible to staff. The Health Board has systems to ensure an adequate record is maintained of all incidents (including near misses) including a record of the investigation and action arising. Staff, managers and others receive feedback on investigations and how improvements are implemented. The Board (or safety committee) analyses trends and patterns of incidents reported utilising data to target improvements. The Health Board shares relevant RIDDOR information with were working towards the identified shortfalls Commented that we were not using E Datix (the only HB in Wales) But of greater concern was that there was a significant time delay from the time of event to receipt of form and entering onto Datix system, with the current paper based forms. Health & Safety Management Audit 2012/13 Page 8 of 9 Health and Safety Committee

9 safety representatives as required by the under the Safety Representatives and Safety Committees Regulations Training strategy All board members and senior managers are sufficiently trained and competent with respect to their health and safety responsibilities. Sufficient resource is provided to ensure the health and safety representative undertakes training in their role. All staff, including managers, receive training in health and safety, which is tailored for their needs and is recorded. The Health Board has identified the need for health and safety refresher training, has a system for managing this and refresher training is up-to-date. Follow-up of any previous H&S audit work performed An assessment of the progress made to address any previous recommendations made at prior reviews of health and safety. Compliant Noted that Mental Health Training records were not on the centralised system (ESR), and was therefore not giving the appropriate level of assurance. Commented about low level of Manual Handling compliance No comment made Health & Safety Management Audit 2012/13 Page 9 of 9 Health and Safety Committee