First Aid at Work HEALTH AND SAFETY POLICY AND PROCEDURE: 16.02

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1 SECTION: 16.0 HEALTH AND SAFETY POLICY AND PROCEDURE: NATURE AND SCOPE: SUBJECT: POLICY TRUSTWIDE FIRST AID AT WORK This policy has been produced in line with the requirements of First Aid at Work legislation and outlines the Trust duties and management responsibilities. DATE OF LATEST RATIFICATION: FEBRUARY 2017 RATIFIED BY: EXECUTIVE LEADERSHIP TEAM IMPLEMENTATION DATE: FEBRUARY 2017 REVIEW DATE: JANUARY 2020 (USUSAL RATIFYING COMMITTEE: HEALTH, SAFETY, SECURITY AND EMERGENCY PREPAREDNESS COMMITTEE) ASSOCIATED TRUST POLICIES & PROCEDURES: Health and Safety and Welfare Reporting of Accidents, Untoward Incidents and Near Miss Situations including Significant Event Reporting ISSUE 7 FEBRUARY 2017

2 NOTTINGHAMSHIRE HEALTHCARE NHS FOUNDATION TRUST FIRST AID AT WORK POLICY CONTENTS 1.0 Introduction 2.0 Policy/Procedure Principles 3.0 Definitions 4.0 Duties 4.14 Assessment of First Aid Needs 5.0 Implementation 6.0 Training 6.4 Reporting of Accidents & Dangerous Occurrences (RIDDOR) 7.0 Target Audience 8.0 Review Date 9.0 Consultation 10.0 Relevant Trust Policies 11.0 Monitoring Compliance 12.0 Equality Impact Assessment 13.0 Legislation Compliance 14.0 Champion & Expert Writer Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Appendix 7 Appendix 8 Appendix 9 Suggested Numbers of First Aid Personnel to be available at all times People are at Work Content of a First Aid at Work Course Content of an Emergency First Aid at Work Course Record of First Aid Provision First Aid at Work Training List of Contents of First Aid Boxes Guidance Assessment Checklist for First Aid Provision Equality Impact Assessment Screening Tool Record of Changes ISSUE 7 FEBRUARY

3 1.0 INTRODUCTION NOTTINGHAMSHIRE HEALTHCARE NHS FOUNDATION TRUST FIRST AID AT WORK POLICY 1.1 The purpose of this policy is to promote good practices with regard to the provision of First Aid at Work to employees whilst employed by Nottinghamshire Healthcare NHS Foundation Trust (the Trust). 1.2 The Health and Safety (First Aid) Regulations 1981 place a legal duty on the employer to make provision for first aid by way of providing adequate equipment, facilities and trained persons to render first aid to those employees who become injured or ill at work. 1.3 Whilst legislation exists to enforce good standards of safety, the aim of the Trust is not only to adhere to those standards but also to improve on them and ensuring that all employees employed by the Trust also recognise their responsibilities and actively ensure that this policy and any accompanying procedures are adhered to. 1.4 This Policy must be read in conjunction with any relevant local systems and procedure documents. 2.0 POLICY/PROCEDURE PRINCIPLES 2.1 The Trust recognises its duty of care to ensure so far as is reasonably practicable the health, safety and welfare at work of all its employees. 2.2 The Trust will ensure compliance with the Regulations by carrying out an assessment of first aid needs appropriate to each workplace area to determine how many first aiders and/or appointed persons are required in the workplace. A suitable number of first aiders and/or appointed persons will be nominated and trained in accordance with the Health and Safety Executive (HSE) first aid training requirements, see Appendix 1 Suggested numbers of first aid personnel to be available at all times people are at work. 2.3 This first aid policy is issued under the authority of the Chief Executive and will apply throughout the Trust. 3.0 DEFINITIONS 3.1 First Aid can be defined as treatment for the purpose of preserving life and minimising the consequence of injury and illness until qualified medical assistance is available. 3.2 A Certified First Aider is as a person who holds a valid certificate of competence in either First Aid at Work (FAW) or Emergency First Aid at Work (EFAW). Training in either FAW or EFAW will be provided by an HSE approved provider. See Appendix 2 for content of a first aid at work course and Appendix 3 for content of an emergency first aid at work course. 3.3 An Appointed Person takes charge of first aid arrangements and will call the emergency services if required. As part of their role they will check and replenish first aid boxes. They do not need first aid training as they are not first aiders and should not attempt to give first aid for which they have not been trained. 4.0 DUTIES 4.1 The Chief Executive shall be responsible for ensuring that this policy is implemented in order to enable the Trust to comply with the Health & Safety At Work etc Act 1974, The ISSUE 7 FEBRUARY

4 Management of Health and Safety At Work Regulations 1999, (as amended) The Health and Safety (First Aid) Regulations Each Director/Head of Service within the Trust has responsibility for compliance with the requirements of this policy and for ensuring that there are suitable and sufficient first aid facilities. 4.3 Each Director/Head of Service within the Trust also has the responsibility for ensuring that there are sufficient first aiders to render first aid where required (see appendix 1 for guidance). 4.4 Local managers will ensure that, through the risk assessment process, they have identified the first aid needs and ensure that suitable first aid arrangements are in place. 4.5 Local managers will ensure that the first aid arrangements are communicated to all employees, that first aid equipment is suitably identified and the location of first aiders and appointed persons are displayed in the workplace. 4.6 Local managers will also ensure that the first aid arrangements are regularly reviewed and updated in the light of any changes. They will also ensure that first aiders and appointed persons FAW or EFAW certificates remain valid. 4.7 Line managers will notify the Training and Development Department of all trained first aiders and appointed persons. 4.8 Line managers will also ensure that during Induction that first aid is covered which informs staff of all the first aid arrangements within their workplace area and the names and location of the first aider or appointed person. 4.9 Line managers will ensure an up to date record of first aid provision for each workplace area, is in place, see Appendix 4 Record of first aid provision The Learning and Development Department will implement and maintain a database holding the names, locations and qualification(s) of all Trust first aiders and appointed persons 4.11 First aiders will administer first aid to employees and non employees in accordance with the training they have undertaken. They will ensure they comply with the Health and Safety (First Aid) Regulations and attend all relevant training as per Appendix 5 First aid at work training. Where first aid treatment has been administered they will record the treatment in accordance with the Trusts incident reporting procedures Appointed persons must not administer first aid unless they have undertaken and hold a valid EFAW certificate. If an appointed person who holds the EFAW certificate administers first aid treatment they will record the treatment given in accordance with the Trusts incident reporting procedures. They will take charge of first aid arrangements which will include calling the emergency services. They will ensure all first aid boxes are stocked and replenished as necessary, see Appendix 6 List of contents of first aid boxes Employees should ensure they know of all the first aid arrangements within their workplace area and the names and location of their first aider or appointed person Assessment of First Aid Needs Risk assessments will identity sufficient numbers of personnel, facilities and first aid equipment as is necessary to ensure adequate and appropriate provision of first aid in the circumstances. ISSUE 7 FEBRUARY

5 The following factors should be considered to determine the nature and extent of first aid provision required for each workplace area: the common hazards and risks in the workplace (also consider injuries or illnesses that might occur) the nature of the work carried out within the Trust the nature, size and location of the workforce the history of accidents that have occurred in the workplace area the distribution of the workforce distance of site from emergency medical services the sharing of first aiders in multi-occupied premises travelling, remote and lone workers, especially for those whose job is considered as high risk. In such circumstances EFAW training and personal first aid kits may be required work and shift patterns, normal and out of hours occupation of premises cover for absence or leave of first aiders provision for non-employees (service users, visitors, contractors, member of the public, carers etc). The Regulations do not require provision of first aid to non employees, however due of the nature of the Trusts business consideration of non employees should be included review of current first aid provision in each workplace area See Appendix 7 Checklist for assessment of first aid needs A record of first aid provision should be kept for each workplace area. 5.0 IMPLEMENTATION 5.1 In implementing this policy all areas must be assessed to ensure suitable and sufficient first aid cover is in place, in line with Regulatory requirements and the guidance contained within this Policy document. 6.0 TRAINING 6.1 The Trust will ensure that all employees are provided with sufficient information regarding first aid at work and the location of first aid facilities. 6.2 The Trust acknowledges that FAW or EFAW training for first aiders and appointed persons is essential and will make available resources to support the training arrangements. 6.3 The HSE requirements are in addition to any internal Trust training e.g. Basic Life Support. 6.4 Reporting of Accidents and Dangerous Occurrences (RIDDOR) The incident reporting procedure meets the Trust s legal obligations to report all accidents, injuries, dangerous occurrences and reportable diseases (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995). Such events may involve Trust employees, contractors, service users, visitors or any other member of the public. ISSUE 7 FEBRUARY

6 6.5 Contractors and those employed by the Trust must comply with the policy requiring the reporting of accidents, incidents, occupational diseases and dangerous occurrences. 6.6 Where first aid provision has been carried out the first aider or appointed person should complete an IR1 in accordance with the Trusts incident reporting procedures. This should record the following details: date, time and the nature of first aid treatment given details if injured/ill person place of incident type of injury/illness after the event (e.g. did the person return to work, go home or go to hospital?) name and signature of the person giving first aid treatment/dealing with the incident 7.0 TARGET AUDIENCE 7.1 The target audience for this policy is all employees of the Trust. 8.0 REVIEW DATE 8.1 This policy will be reviewed in three years or in light of legislative or organisational changes. 8.2 This policy supplements the Nottinghamshire Healthcare Health, Safety and Welfare Policy and arrangements, which are an obligation under the Health and Safety at Work etc Act CONSULTATION 9.1 Trust Health, Safety, Security and Emergency Preparedness Committee 9.2 Leadership Council 10.0 RELEVANT TRUST POLICIES 10.1 Health and Safety and Welfare Reporting of Accidents, Untoward Incidents and Near Miss Situations including Significant Event Reporting MONITORING COMPLIANCE 11.1 This policy will be monitored for compliance and effectiveness at regular intervals by the Trust Health and Safety Committee Monitoring will include areas such as: incident analysis, risk assessments, accident investigations and audit as well as other areas as indicated in the Terms of Reference EQUALITY IMPACT ASSESSMENT 12.1 This policy has been assessed using the Equality Impact Assessment Screening Tool. The assessment concluded that the policy would have no adverse impact on, or result in the positive discrimination of, any of the diverse groups detailed. These include the strands of ISSUE 7 FEBRUARY

7 disability, ethnicity, gender, gender identity, age, sexual orientation, religion/belief, social inclusion and community cohesion LEGISLATION COMPLIANCE 13.1 Health & Safety at Work etc Act Management of Health and Safety at Work Regulations 1999, (as amended) 13.3 Health and Safety (First Aid) Regulations Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR) 14.0 CHAMPION AND EXPERT WRITER 14.1 The Champion of this policy is the Executive Director of Nursing: and the Expert Writer is Ian Freegard, Trust Health and Safety Manager. ISSUE 7 FEBRUARY

8 SUGGESTED NUMBERS OF FIRST AID PERSONNEL TO BE AVAILABLE AT ALL TIMES PEOPLE ARE AT WORK (FROM HSE) APPENDIX 1 1 From your risk assessment, what degree of hazard is associated with your work activities? 2 How many employees do you have? 3 What first-aid personnel do you need? 4 What injuries and illness have previously occurred in your workplace? 5 Have you taken account of the factors below that may affect your first aid provision? Low Hazard eg offices, shops, libraries Higher Hazard eg light engineering and assembly work, food processing, warehousing, extensive work with dangerous machinery or sharp instruments, construction, chemical manufacture Less than More than 50 Less than More than 50 At least one appointed person At least one first aider trained in EFAW At least one first aider trained in FAW for every 100 employed (or part thereof) At least one appointed person At least one first aider trained in EFAW or FAW depending on the type of injuries that might occur At least one first aider trained in FAW for every 50 employed (or part thereof) Ensure any injuries and illness that might occur can be dealt with by the first aid personnel you provide Where first aiders are shown to be unnecessary, there is still a possibility of an accident or sudden illness, so you may wish to consider providing qualified first aiders Inexperienced workers or employees with disabilities or particular health problems Employees who travel a lot, work remotely or work alone Employees who work shifts or out of hours Premises spread out across buildings / floors Workplace remote from emergency medical services Employees working at sites occupied by other employers Planned and unplanned absences of first aiders / appointed persons Member of the public who visit the workplace ISSUE 7 FEBRUARY

9 CONTENT OF A FIRST AID AT WORK COURSE (FROM HSE) First Aid at Work APPENDIX 2 On completion of training, successful candidates should be able to: a) provide emergency first aid at work (see Appendix 5). b) administer first aid to a casualty with: i. injuries to bones, muscles and joints, including suspected spinal injuries, ii. chest injuries, iii. burns and scalds, iv. eye injuries, v. sudden poisoning, vi. anaphylactic shock. c) recognise the presence of major illness and provide appropriate first aid. ISSUE 7 FEBRUARY

10 APPENDIX 3 CONTENT OF AN EMERGENCY FIRST AID AT WORK COURSE (FROM HSE) On completion of training, successful candidates should be able to: a) understand the role of the first aider including reference to: i. the importance of preventing cross-infection, ii. the need for recording incidents and actions undertaken, iii. use of available equipment. b) assess the situation and circumstances in order to act safely, promptly and effectively in an emergency; c) administer first aid to a casualty who is unconscious (including seizure); d) administer cardiopulmonary resuscitation; e) administer first aid to a casualty who is choking; f) administer first aid to a casualty who is wounded and bleeding; g) administer first aid to a casualty who is suffering from shock; h) provide appropriate first aid for minor injuries. ISSUE 7 FEBRUARY

11 RECORD OF FIRST AID PROVISION* (FROM HSE) First Aid at Work APPENDIX 4 First aid personnel First aider with a first aid at work certificate Required Yes / No Number needed First aider with an emergency first aid at work certificate First aider with additional training (specify) Appointed person First aid equipment and facilities First aid container Required Yes / No Number needed Additional equipment (specify) Travelling first aid kit First aid room *The minimum first aid provision for each worksite is: b) an appointed person to take charge of first aid arrangements. c) a suitably stocked first aid box. d) information for employees about the first aid arrangements. ISSUE 7 FEBRUARY

12 FIRST AID AT WORK TRAINING APPENDIX 5 Emergency First Aid At Work (EFAW) Certificate Course duration one day Valid 3 years Year 1 annual refresher training in basic skills Year 2 annual refresher training in basic skills Year 3 requalification course First Aid At Work (FAW) Certificate Course duration three days Valid 3 years Year 1 annual refresher training in basic skills Year 2 annual refresher training in basic skills Year 3 requalification course NB: Annual refresher training is not mandatory but it is strongly recommended by the HSE to ensure up to date changes to first aid procedures for First Aiders. ISSUE 7 FEBRUARY

13 LIST OF CONTENTS OF FIRST AID BOXES (FROM HSE) APPENDIX 6 First aid boxes and travelling first aid kits should contain suitable and sufficient first aid materials. They should not contain tablets or medication in any form. This list below is only a suggested guide given by the HSE. There is no mandatory list of items however the following is considered to be the minimum stock required where the hazards are deemed to be low: a leaflet providing guidance on first aid; 20 individually wrapped sterile plasters (assorted sizes), appropriate to the type of work (you can provide hypoallergenic plasters); two sterile eye pads; four individually wrapped triangular bandages, preferably sterile; six safety pins; two large, individually wrapped, sterile, un-medicated wound dressings; six medium-sized, individually wrapped, sterile, un-medicated wound dressings; a pair of disposable gloves. First aid boxes and travelling first aid kits should be replenished soon after use and checked regularly to ensure that stock that has reached its expiry date is removed and not used. ISSUE 7 FEBRUARY

14 APPENDIX 7 GUIDANCE ASSESSMENT CHECKLIST FOR FIRST AID PROVISION NB: This Assessment for First Aid requirements has been compiled using the HSE checklist of first aid needs. This is not intended to be a comprehensive checklist. You must decide what is required within your own workplace area. Hazards Have you identified all the different types of work activities/hazards/risks in your specific areas, (internally and externally), that may require different levels of first aid based on risk assessments? Are the hazards identified low level? (by low level we mean the types you would find in an office) Are the hazards identified high level? (by high level we mean chemicals, machinery, violence and aggression) Additionally you must be aware of and take in to account previous types of accidents, incidents, injuries and ill health that have occurred within your workplace area. Employees What is the total number of employees within your workplace area? Yes No Consider/Actions If no consider doing so before continuing If yes the minimum provision may be: An appointed person (see Trust First Aid At Work Policy section 3.3 for duties of an Appointed Person) First aid box If yes you will need A first aider Consider specialised training Consider specialised first aid equipment Consider provision of a first aid room Informing emergency services in some circumstances Ensure first aid provision caters for these types. See Appendix 1 for suggested numbers of first aid personnel. Where there are small numbers then a suitably stocked first aid box should be enough. For large numbers of staff you should consider additional first-aid equipment and a first aid room. ISSUE 7 FEBRUARY

15 Do you have inexperienced staff within your workplace area? Do you have staff with disabilities or health problems? Do you have staff from other employers who work in your workplace area? Non employees - Types of Groups Yes No Consider/Actions For example students/work placements Ensure First Aiders are appropriately trained to deal with individual needs or requirements. Ensure they know what first aid provision is provided and available to them. Consider the types hazards and risks for each type of group. This will help you identify additional training for first aiders, additional first aid equipment and local siting of first aid equipment. Consider especially vulnerabilities to susceptible persons. Service Users Young Persons/Child Older Persons Contractors External Persons visiting workplace area Internal staff to the workplace area Violence and aggression, self harm, harm to others (staff/non staff) A young person is anyone under 18 years old and a child is anyone who has not yet reached the official age at which they may leave school, just before or just after their 16 th birthday Falls and trips may be areas of susceptibility Type of work being undertaken within the work place area or site Areas visiting and people they will be coming in to contact with As above Working Arrangements You need to consider the work patterns for all your staff groups: Do staff work shifts? Do staff work out of hours? Ensure there is adequate first aid provision at all times As above ISSUE 7 FEBRUARY

16 Do staff work alone or remotely? Do staff travel a lot? Yes No Consider/Actions Consider issuing personal first aid equipment and work in line with Lone Workers Risk Assessments e.g. personal communication needs As above Do staff work on sites occupied by other employers For each workplace/site consider if: It covers more than one site? It is multi floor? It is it remote from medical services? You must check with the other employer(s) and ensure that there is suitable and sufficient first aid provision for your staff and that these arrangements are written down and communicated to each member of your staff working at the other employer s sites. Consider first aid provision for each site. Consider first aid provision for each floor or building. Inform emergency services of your location and consider if special arrangements may be required with the emergency services. Signage Is first aid signage displayed in your workplace area? Is the signage green with a white cross? Does the signage contain the names and contact details of your appointed person and/or first aider? Is there signage in place which states the location of first aid equipment? Cover for annual leave, sickness, planned absences and unplanned absence Do you have cover in place for absence of any kind for appointed persons and or first aiders? If not this must be displayed. If not this must be replaced with one that is. Ensure names and contact details are kept up to date. Ensure one is displayed for each first aid box location. If not you must make arrangements for there to suitable and appropriate cover at all times. Ensure all staff know of any cover arrangements that are in place. ISSUE 7 FEBRUARY

17 Yes No Consider/Actions Do you know what the arrangements are with regards to other employers cover for appointed persons and/or first aiders? Would you at anytime expect an appointed person to cover for a First Aider? Records of First Aid Provision Do you have an up to date record of your first aid provision? Review of First Aid Provision Your first aid risk assessment should be reviewed annually or if there are any significant changes to any of the above. Ensure you are kept informed and communicate this to all your appropriate staff. If yes, see The Trust First Aid at Work Policy with regard to the Appointed Persons duties section 3.3 A person must not administer first aid for which they have not been trained therefore if you require an appointed person to cover in the absence of a First Aider then they must as a minimum have undertaken the Emergency First Aid at Work (EFAW) course, see Appendix 3 of the Trust First Aid at Work Policy. If not you must ensure records are kept, see The Trust First Aid at Work Policy Appendix 4. Monitor accidents, ill health, injuries and incidents and review your first aid provisions as appropriate. ISSUE 7 FEBRUARY

18 APPENDIX 8 EQUALITY IMPACT ASSESSMENT (EIA) SCREENING TOOL Name of policy/procedure/strategy/plan/function etc being assessed: FIRST AID AT WORK Brief description of policy/procedure/strategy/plan/ function etc and reason for EIA: The purpose of this Policy is to advise on the requirements of first aid in the workplace Names and designations of EIA group members: List of key groups/organisations consulted Data, Intelligence and Evidence used to conduct the screening exercise Ian Freegard Trust Health and Safety Manager John Frazer Senior Health and Safety Adviser Trust Health, Safety, Security and Emergency Preparedness Committee Leadership Council Health and Safety Legislation and Guidance Approved Codes if Practice ISSUE 7 FEBRUARY

19 Equality Strand Race Gender Incl. Transgender Disability Incl. Mental Health and LD Does the proposed policy/procedure/ strategy/ plan/ function etc have a positive or negative (adverse) impact on people from these key equality groups? Please describe No impact identified. This policy complied with Health and Safety Legislation and is equally applicable to all, with exceptions in relation to disabilities/mobility issues. No impact identified. This policy complied with Health and Safety Legislation and is equally applicable to all, with exceptions in relation to disabilities/mobility issues. No impact identified. This policy complied with Health and Safety Legislation and is equally applicable to all, with exceptions in relation to disabilities/mobility issues. Are there any changes which could be made to the proposals which would minimise any adverse impact identified? What changes can be made to the proposals to ensure that a positive impact is achieved? Please describe Have any mitigating circumstances been identified? Please describe Areas for Review/Actions Taken (with timescales and name of responsible officer) No, this is legislative compliance. Not applicable. Author to review in 3 years No, this is legislative compliance. Not applicable. Author to review in 3 years No, this is legislative compliance. Not applicable. Author to review in 3 years Religion/Belief As race. No, this is legislative compliance. Not applicable. Author to review in 3 years Sexual Orientation As race. No, this is legislative compliance. Not applicable. Author to review in 3 years Age As race. No, this is legislative compliance. Not applicable. Author to review in 3 years Social Inclusion* 1 Not applicable. Not applicable. Not applicable. Author to review in 3 years Community Not applicable. Not applicable. Not applicable. Author to review in 3 years Cohesion* 2 Human Rights * 3 Not applicable. Not applicable. Not applicable. Author to review in 3 years * 1 for Social Inclusion please consider any issues which contribute to or act as barriers, resulting in people being excluded from society e.g. homelessness, unemployment, poor educational outcomes, health inequalities, poverty etc ISSUE 7 FEBRUARY

20 * 2 Community Cohesion essentially means ensuring that people from different groups and communities interact with each other and do not exclusively live parallel lives. Actions which you may consider, where appropriate, could include ensuring that people with disabilities and non-disabled people interact, or that people from different areas of the City or County have the chance to meet, discuss issues and are given the opportunity to learn from and understand each other. * 3 The Human Rights Act 1998 prevents discrimination in the enjoyment of a set of fundamental human rights including: The right to a fair trial, Freedom of thought, conscience and Religion, Freedom of expression, Freedom of assembly and association and the right to education Conclusions and Further Action (including whether a full EIA is deemed necessary and agreed date for completion) Screening Tool Consultation End Date Name of Equality and Diversity (E&D) Group Approving EIA (i.e. Directorate E&D Group, Divisional E&D Forum or Trustwide E&D Steering Group) Name of Responsible Officer Name and Contact Details (tel. , postal) Having completed the EIA Screening Tool, it has been identified that a full Equality Impact Assessment is not required. February 2017 EIA reviewed, no amendments required. Equality and Diversity Sub-Committee of the Board of Directors Ian Freegard Trust Health and Safety Manager ISSUE 7 FEBRUARY

21 APPENDIX 9 Policy/Procedure for: First Aid at Work Issue: 07 Status: Author Name and Title: APPROVED Ian Freegard, Trust Health & Safety Manager Issue Date: 28 FEBRUARY 2017 Review Date: JANUARY 2020 Approved by: EXECUTIVE LEADERSHIP TEAM (22/02/2017) (USUAL RATIFYING COMMITTEE: TRUST HEALTH, SAFETY, SECURITY AND EMERGENCY PREPAREDNESS COMMITTEE) Distribution/Access: Normal RECORD OF CHANGES DATE AUTHOR PROCEDURE DETAILS OF CHANGE I Freegard HS/GS/02 Change to review date and house style only I Freegard I Freegard 03/14 I Freegard 03/15 I Freegard 01/17 I Freegard (Issue 4) (Issue 5) (Issue 6) (Issue 6) Significant changes throughout, review and policy number. Changes to review date and issue number Changes to review date and issue number Changes to champion, review date and issue number Review undertaken and changes to Champion, review date. ISSUE 7 FEBRUARY