HEALTH AND SAFETY POLICY

HEALTH AND SAFETY POLICY

Policy Title: Executive Summary: Health and Safety Policy The Health and Safety at Work etc Act 1974 and associated legislation and this policy aim to protect the health of people at work. This policy sets out best practice for the organisation to follow in order to demonstrate compliance with the legislation. Supersedes: Health and Safety Policy V.6.0 Description of Amendment(s): This policy will impact on: All staff working within the trust. Financial Implications: None Policy Area: Risk Management Document ECT002585 Reference: Version Number: 7.0 Effective Date: Dec 2017 Issued By: Andy Chambers Review Date: Dec 2018 Author: Head of Safety, Risk and Resilience Impact Assessment Date: APPROVAL RECORD Oct 2016 Consultation: Approved by Director: Ratified by: Received for information: Committees / Group Risk Management Sub Committee Operational Management Team Julie Green, Director of Corporate and Governance Risk Management Sub Committee Group Staff Health & Safety Reps. Heads of Service & clinical Directors Date December 2017 December 2017 December 2017 December 2017

Health and Safety Policy 2017 Table of Contents Statement of Intent Page 4 1. Scope of Policy Page 5 2. Organisation Structure and Responsibilities Page 5 3. Governance & Consultation Page 9 4. Arrangements Page 10 5. Audit & Management Review Page 11 6. Communication Page 11 7. Monitoring, Review and Revision of Policy Page 12 Appendix 1 Links to Health and Safety procedures and forms

Statement of Intent The Trust is committed to the prevention of injury and ill health through continually improving quality and safety for both patients and staff. We will comply with applicable legal and other requirements and promote best practice in healthcare and provide sufficient resources to meet this commitment. The Trust will ensure that systems are in place which will allow us to maintain, monitor and where necessary, improve our performance. Included in these sytems will be means to allow communication and consultation on matters of health and safety between all levels of the organisation. In return, the Trust expects employees at all levels to fulfil their responsibilities and legal duties as outlined within the Health and Safety Policy. This includes co-operating with us on health and safety matters and taking care of their own safety and that of others, including patients and staff, which may be affected by their actions. Any information, instruction, training or supervision necessary to meet these commitments will be provided. As part of our commitment to continual improvement of health and safety management and performance, the policy and the way it has operated will be reviewed at least annually. Any policy revision necessary to improve health and safety performance will be communicated. Print Name: John Wilbraham Position: Chief Executive Date: 27 th November 2017

1.0 Scope of Policy This policy applies to all employees, peripatetic staff, contractors, volunteers, stakeholders, premises and activities under the control of East Cheshire NHS Trust. 2.0 Organisation Structure and Responsibilities 2.1 The Trust Board, as employer, in law has ultimate responsibility for health and safety throughout the Trust. The Board has delegated authority to the Safety Quality and Standards Committee to provide assurance in relation to the implementation of this policy and the management of risks to health and safety. This committee is chaired by a nominated Non-Executive director, who acts as a Health and Safety Scrutineer. 2.2 The Chief Executive has responsibility for leadership of the trust on behalf of the Board and is responsible for ensuring that the executive directors understand and fulfil their health and safety roles, including; the appointment of an Executive Director with responsibility for ensuring effective systems and process are in place across the organisation for health and safety, and providing advice at Board level; ensuring that a risk profile is maintained for the trust which includes any significant health and safety risks; the provision of sufficient resources to implement the Health and Safety Policy and specific health and safety procedures that are introduced to support this general policy; ensuring that all employees are fully aware of their statutory responsibilities and that these responsibilities are fulfilled; ensuring that the trust complies with all statutory health and safety requirements; ensuring that the arrangements for the Health and Safety Policy and associated procedures are fully implemented by the inclusion of health and safety within all managers' performance reviews; monitoring the effectiveness of this policy and revising it where necessary; ensuring reports on incident statistics, trends and remedial measures are submitted to the appropriate committees. 2.3 The Director of Corporate Affairs and Governance is the appointed Executive Director with delegated accountability to ensure health and safety systems and processes are in place and provide advice and assurance to the board. Responsibilities include ensuring that the management team is made aware of the health and safety implications of strategic and operational developments. 2.4 The Director of Finance has delegated accountability for estates and facilities systems, processes and activities and ensuring that strategic planning and operational Estates works comply with health and safety regulations. To act as the trust s Security Management Director. They are also the designated person for the implementation of the Asbestos policy. 2.5 Director of Human Resources has delegated accountability for; the provision of appropriate occupational health services and health surveillance as required for all relevant staff in accordance with statutory requirements and guidance; the administration and recording of relevant education and training to meet statutory and job specific health and safety requirements in accordance with relevant legal and other requirements.

2.6 Executive Directors have given the accountability for ensuring; the implementation of the Health and Safety Policy, and specific health and safety procedures that are introduced to support this general policy, corporately and within their areas of control; leadership and the promotion of a positive safety culture which enables all employees to fulfil their statutory duties; effective delegation of health and safety responsibilities within their areas of responsibility; measures for planning, setting priorities and objectives to address specific hazards to health and safety in line with the trust policy, objectives, risk profile and their directorate risk assessments; health and safety performance is monitored and that heads of department, general managers, managers and supervisors take appropriate action to effectively implement health and safety management arrangements, procedures and codes of practice, both corporate and specific; ensuring resources are allocated to areas of health and safety improvement activity within the business planning and strategic direction of their area of responsibility; preventative and protective measures to reduce risk are developed and implemented within their area of responsibility; effective support for their managers decisions and recommendations in terms of the provision of appropriate resources for health and safety; that staff have adequate experience and training to undertake their work safely; that a programme of health and safety risk assessment is developed and implemented within their area of responsibility and a status report is provided to the Risk Management Sub-committee as may be required; that arrangements are made for consultation with safety representatives and all employees in the workplace. 2.7 The Deputy Director of Corporate Affairs and Governance is responsible for ensuring the systems and process is in place to support the implementation of this policy in practice and that arrangements are in place to facilitate this. Also responsible for the effective management and monitoring of associated risks on the corporate risk register. 2.8 Head of Estates is responsible for; establishing and maintaining procedures for the management and control of Estates contractors, implementing arrangements for the statutory inspection, examination and maintenance of lifting equipment, pressure vessels, electrical and gas systems, medical gas systems, portable electrical appliances, asbestos management and water systems in accordance with relevant statutory requirements; ensuring all aspects of building and equipment design, purchasing, use, decommissioning, inspection, maintenance and repair activities are carried out in compliance with relevant legislation and safe practice within available resources; 2.9 The Head of Safety, Risk and Resilience is responsible for ensuring effective clinical and nonclinical risk management, such as health and safety. The role does not necessitate the duty holder to possess health and safety competencies however the post holder is responsible for ensuring the trust has sufficient access to competent health and safety advice. They are responsible for risk review and management of actions to address any gaps, controls and to identify assurance where appropriate. 2.10 The Health and Safety Manager is the appointed competent person in addition and will assist in undertaking the measures the employer needs to take to comply with the requirements and prohibitions imposed on the employer by or under relevant statutory provisions. See Provision of Health and Safety Assistance Procedure for further details. They will also be responsible for advising on the assessment of hazardous biological substances under Control of Substances Hazardous to Health regulations (COSHH).

2.11 The Infection Control Lead Nurse is responsible for providing the Trust with advice on all infection control issues. They will be responsible for arranging suitable training and for ensuring that adequate monitoring is provided to detect any infection control risks or problems. 2.12 The Manual Handling Advisers will assist managers to fulfil their moving and handling responsibilities and provide specialist moving and handling advice. Also provide audits in conjunction with appropriately supporting the management of associated risks within the workplace. 2.13 Local Security Management Specialists will assist managers to fulfil their security related responsibilities and provide specialist security advice. This includes; ensuring appropriate links are made with the trust s risk assessment process, including the health and safety representatives, so that security-related issues are an integral part of that process; taking appropriate steps to create a pro-security culture within the trust and amongst contractors so that staff and patients accept responsibility for this issue and ensure that any security incidents or breaches that occur are detected and reported; develop and deliver security awareness sessions for staff and stakeholders; ensure appropriate security incidents and breaches are publicised in accordance with guidelines issued by the NHS Protect so that a deterrent effect is created; ensure lessons learnt from security incidents and breaches are fed into risk analysis, both locally and nationally, so that appropriate preventative measures can be developed ensure security incidents are reported using the NHS Protect reporting system, ensuring that investigations take place where appropriate, risks are assessed and preventative measures are developed (this will include participation in local and national risk identification projects; investigate security incidents and breaches in a fair, objective and professional manner so that the appropriate sanctions are applied and measures put in place to prevent recurrence ensuring consideration is given to cases not progressed by the police or Crown Prosecution Service and, where appropriate, work is undertaken with the NHS Protect Legal Protection Unit and the trust, and redress is sought where appropriate. 2.14 Clinical Directors/ Associate Directors and Heads of Service are responsible for ensuring; they understand the trust s general Health and Safety Policy and associated procedures and ensure they are communicated to all staff within their area of responsibility; the health and safety of patients, staff and visitors is considered in the planning and delivery of all services and activities within their areas of responsibility; detailed analysis of all incident statistics and the development of strategies for the reduction of injury, loss or damage to equipment and risk to persons; the purchase of appropriate equipment and facilities that are safely used and properly maintained; health and safety compliance is monitored locally and any non-compliance is addressed as soon as reasonably practical; suitable and sufficient documented risk assessments are carried out where appropriate identifying necessary control measures and that these assessments are reviewed regularly and communicated to all relevant staff; that training needs of staff are assessed and staff are released when required to attend statutory and mandatory and any other identified training; involvement of staff and staff side safety representatives in the implementation of this policy; that any risk that is not being managed effectively in line with Risk Management Strategy and Trust Board follows the escalation process. adherence of contractors to the prescribed health and safety standards; the development and implementation of any emergency procedures that may be relevant to their areas of responsibility.

ensure health and safety representatives are given sufficient and appropriate time to undertake their roles. ensure that staff side Health & Safety monitors are allowed sufficient time to conduct inspections, attend training & Forums within the Trust. Participate in Risk Management Sub-Committee. Heads of Service responsible for commissioning the work of contractors and have a responsibility to ensure that contractors adhere to Health and Safety guidelines in order to protect staff and patients. 2.15 Nominated Safety Monitors are required to; liaise with staff in their work area on matters of health and safety in consultation with the line managers/departmental and service line managers; attend relevant health and safety training courses, where appropriate; assist with health and safety risk assessments and workplace inspections for their relevant work areas. Support the completion of Fire, Health & Safety Manual Bi-yearly. 2.16 All Managers/ Supervisors, in addition to their duties as employees, must ensure that: they understand the trust s Health and Safety Policy and associated procedures and ensure they are communicated to all staff within their area of responsibility; they provide leadership in health and safety for their area of responsibility and ensure safety representatives are appointed and trained to assist with risk assessments and inspections; risk assessments which identify significant risks to health and safety are undertaken and the results of those assessments are communicated to employees along with the required operational control procedures before they are exposed to such risks; provide support and assistance as required throughout the assessment process including review of completed assessments and participation in follow-up meetings; ensure that risk assessment records are maintained and enter all significant residual risks into the relevant Datix risk register, in line with Risk Assessment and Risk Register Policy regular inspections of the workplace and equipment are undertaken and that steps are taken to eliminate or minimise any hazards identified; all staff are provided with such training and adequate supervision as is considered appropriate for them to perform their work safely; Ensure Fire, Health & Safety Manual is up to date. operational control procedures are developed and monitored taking into account the risk levels and the competence level of the personnel involved; ensure all accidents and incidents are investigated, and take appropriate measures to prevent recurrence; ensure the Health and Safety Manager is notified of all RIDDOR reportable accidents; the provision of first aid in the workplace is commensurate with the level of risk associated with work activities; staff with work related health problems are referred to the Occupational Health Provider. Ensure that an individual Risk Assessment is carried out for employees with a disability which may affect the ability to adhere to the Health and Safety Policy. 2.17 All Employees' must; take reasonable care of their own health and safety and that of others who may be affected by their acts or omissions; undertake their tasks as instructed and in line with training received; report to their manager any health and safety concerns, including the activities of outside contractors; not misuse or interfere with any equipment provided to ensure safe working practice in the workplace; report any accident, involving injury, damage to plant, equipment or potential injury, damage or loss and incidents that result in a near miss on datix. co-operate with, and assist, colleagues in implementing this policy and specific health and safety procedures that are introduced to support this general policy.

Staff with responsibility for purchasing items will be required to ensure that any products purchased comply with relevant legal and other requirements. This will include obtaining safety data sheets for hazardous substances to enable Control of Substances Hazardous to Health (COSHH) assessments to be undertaken for these products. Inform their line Manager of any Disability which may affect their ability to adhere to this policy. An individual Risk assessment will need to be completed and reasonable adjustments made where possible. Follow workplace procedures. 3.0 Governance and Consultation 3.1 Safety, Quality and Standards Committee (SQS) As the employer, the Trust Board has delegated responsibility for health and safety oversight to the Safety, Quality and Standards Committee, which is led by the Director of Nursing, Performance and Quality and chaired by a Non-Executive director. This includes receiving assurance reports on health and safety arrangements via the Risk Management subcommittee reports and recommendations regarding health and safety matters. The responsibilities of the Safety, Quality and Standards Committee are provided in the Risk Management Strategy. This reviews all risks (16+) quarterly, including receiving deep dive presentations in line with committee work programme. 3.2 Risk Management Sub-committee The Risk Management Sub-committee supports the work of SQS with regards to the effective identification, management and monitoring of clinical and non-clinical health and safety risks on the corporate risk register scoring 9-12, relevant policies, incidents, complaints and claims. Staff-side safety representatives have an open invitation to attend, propose agenda items and contribute. This committee will provide a central forum through which the trust can consult staff representatives on health and safety matters. 3.3 Emergency Planning and Business Continuity Group The Trust s Emergency Planning & Business Continuity Group has been established to ensure the organisation is compliant with the Civil Contingencies Act, which references the Health and Safety at Work Act 1974. 4.0 Arrangements 4.1 Identification of hazards and requirements All hazards and relevant legal/other requirements will be identified in line with the Legal and Other Requirements Procedure. Each hazard will be evaluated and significant risks will be recorded on the trust s risk register. 4.2 Objectives and Management Programme The Risk Management Sub Committee will be responsible for informing the strategic aims for health and safety matters within the Trust and the Chief Executive will ensure, through the trust s line management arrangements, that those aims are translated into action plans for future implementation. Directors are responsible for ensuring health and safety considerations are integral to their business planning process, in order to ensure that needs are identified, prioritised, and that appropriate resources are allocated.

4.3 Training Awareness and Competence Health and safety training records for all staff will be held and maintained in line with the Learning and Development Policy. This includes Health and Safety, Display Screen Equipment (DSE) e-learning, Conflict resolution, Manual Handling, fire training. Safety monitors and staff side Health and Safety Representative s will be involved in to cascading information/training to colleagues 4.4 Documentation and Document Control Health and safety documents will be issued and controlled in line with the Policy on Procedural Documents. Health and Safety policies, procedures, forms and guidance are available in electronic format via the Trust s Infonet. Each Ward/Department/Service will have their own risk assessments and operational control procedures for risks specific to their particular area. All staff are encouraged to seek out and familiarise themselves with local and corporate health and safety arrangements to ensure that they have a good understanding of all health and safety measures. All Health and Safety Risk Assessments to be held within the Fire, Health & Safety manual and reviewed yearly unless anything changes. 4.5 Emergency Preparedness, Response and Resilience The Trust will identify all potential emergencies and measures to prevent them, respond to them and mitigate any resulting damage to persons, plant or the environment. The Emergency Planning and Business Continuity Group will oversee all emergency plans. These will be tested periodically, recorded and, where appropriate, risk assessments will be reviewed. The Trust Board will review and approve the Major Incident Plan on an annual basis. 4.6 Operational Control Procedures Where a significant risk has been identified, a risk assessment will be undertaken and an operational control procedure devised in order to adequately control the risk, so far as is reasonably practicable. Operational control procedures should be detailed in the control measures section of the risk assessment and incorporated into any safe systems of work and standard operating procedures which are implemented following the risk assessment. Refer to the Safe Systems Procedure. 4.7 Performance Monitoring and Measurement Health and safety inspections will be carried by staff side Health and Safety Monitors throughout the trust in line with the Workplace Inspections Procedure. All Trust equipment will be monitored and measured. Safety performance indicators and health and safety objectives, appropriate to the workplace, will be set and monitored, in line with the Health and Safety Performance Monitoring Procedure. The involvement of staff side Health and Safety representatives where available, or safety monitors in this process, will be encouraged both to support and review this method of active monitoring and also to assist in promoting a positive health and safety culture. 4.8 Incident Management Management of injuries, ill health and other "loss events" will take place to complement active monitoring. This monitoring process will involve both managers and safety representatives. The investigation of such accidents/losses, together with analysis of incidents, will be used as a tool to identify causation, lessons learned and reduce future incidence. This may include the reporting of RIDDOR reportable incidents and liaising with external enforcement authorities. See Liaising with Health, Safety & Fire Enforcement Authorities Procedure for further details. The Trust has an external contract for the provision of occupational health services, which can be accessed directly by staff or via line management. A full professional occupational health service is provided, which includes staff support and guidance, health surveillance and preemployment screening. See Occupation Health Policy for further details.

4.9 Communication Internal communication on Health and Safety will be made available to all staff through Health and Safety representatives, Staff Matters and Learning and Practice Bulletin. Significant health and safety messages may be communicated via the Trust s team briefing process, which is led by the Chief Executive. Notice boards will be made available for displaying health and safety related information. 5.0 Audit Management and Review 5.1 Health and safety audits, including non-conformity, corrective action and preventative action/ records, will be carried out to measure the trust s compliance with this policy and the associated procedures in line with the Health and Safety Performance Monitoring Procedure. 5.2 On the basis of audit reports, the Risk Management Sub Committee may make appropriate recommendations for policy/procedure review. The Deputy Director will provide assurance via the six monthly report on the activity of the Risk Management Sub-Committee to trust Safety, Quality and Standards Committee, via the Director of Corporate Affairs and Governance. 5.3 The Health and safety Manager will provide assurance to the Risk Management Subcommittee. 6.0 Communication 6.1 This policy will be cascaded to managers via the DATIX policy cascade process and managers are responsible for bringing the policy to the attention of their staff. The policy is also to be made available to all persons working under the control of the trust and interested parties via the trust s infonet and internet web sites. 6.2 Contractors Contractors health and safety requirements are stated in the trusts Control of Contractors Policy. 7.0 Monitoring 7.1 The Risk Management Sub-committee is responsible for the successful implementation and operational monitoring of this policy. The policy will be reviewed every twelve months, or when there has been a significant change in the organisation or the health and safety arrangements. The Risk Management Sub-committee will receive an update on health and safety issues six times a year, including assurance in relation to systems and processes and risk reduction strategies. The Safety Quality and Standards Committee has delegated authority from the Trust Board for ratifying this policy, in line with the policy schedule. The Safety Quality and Standards Committee has delegated authority to monitor and provide assurance via the Chair to the Trust Board in relation to the implementation of this policy and the management of risks to health and safety.

7.2 Performance KPI s Monitored by Monitoring Frequency Ongoing monitoring of datix incidents Completion of Fire, Health & Safety Inspections Number of RIDDOR reportable Incidents % of Incidents reported that result in harm. Health & Safety Team meeting Staff side Health & safety Reps. Health & Safety Manager Health & Safety Manager Health & Safety Team meeting Assurance Information reported to Weekly Risk Management Sub- Committee 6 times/year by Health & Safety Manager Yearly Risk Management Sub- Committee, 6 times/year by Health & Safety Manager Bi Monthly Risk Management Sub- Committee, 6 times/year by Health & Safety Manager Bi Monthly Risk Management Sub- Committee, 6 times/year by Health & Safety Manager Number and Outcome of claims relating to Health and Safety. Legal services Bi Monthly Risk Management Sub- Committee, 6 times/year by Health & Safety Manager Appendix 1 Links to Health and Safety procedures and forms Health and Safety Procedures accessed on the Trust Infonet under policies followed by Health & Safety Forms & Guidance documents, Health & Safety Procedures. Health and Safety Forms accessed on the Trust Infonet under forms & templates.

Equality Analysis (Impact assessment) Please START this assessment BEFORE writing your policy, procedure, proposal, strategy or service so that you can identify any adverse impacts and include action to mitigate these in your finished policy, procedure, proposal, strategy or service. Use it to help you develop fair and equal services. Eg. If there is an impact on Deaf people, then include in the policy how Deaf people will have equal access. 1. What is being assessed? Health & Safety Policy Details of person responsible for completing the assessment: Name: Andy Chambers Position: Head of Safety, Risk and Resilience Team/service: Corporate Affairs and Governance State main purpose or aim of the policy, procedure, proposal, strategy or service: (usually the first paragraph of what you are writing. Also include details of legislation, guidance, regulations etc which have shaped or informed the document) Health and Safety at Work 1974 and associated legislation and this policy aims to protect the health of the people at work. This policy sets out best practice for the Organization to follow, in order to demonstrate compliance with the legislation. 2. Consideration of Data and Research To carry out the equality analysis you will need to consider information about the people who use the service and the staff that provide it. Think about the information below how does this apply to your policy, procedure, proposal, strategy or service 2.1 Give details of RELEVANT information available that gives you an understanding of who will be affected by this document Cheshire East (CE) covers Eastern Cheshire CCG and South Cheshire CCG. Cheshire West & Chester (CWAC) covers Vale Royal CCG and Cheshire West CCG. In 2011, 370,100 people resided in CE and 329,608 people resided in CWAC. Age: East Cheshire and South Cheshire CCG s serve a predominantly older population than the national average, with 19.3% aged over 65 (71,400 people) and 2.6% aged over 85 (9,700 people). Vale Royal CCGs registered population in general has a younger age profile compared to the CWAC average, with 14% aged over 65 (14,561 people) and 2% aged over 85 (2,111 people). Since the 2001 census the number of over 65s has increased by 26% compared with 20% nationally. The number of over 85s has increased by 35% compared with 24% nationally. Race: In 2011, 93.6% of CE residents, and 94.7% of CWAC residents were White British 5.1% of CE residents, and 4.9% of CWAC residents were born outside the UK Poland and India being the most common

3% of CE households have members for whom English is not the main language (11,103 people) and 1.2% of CWAC households have no people for whom English is their main language. Gypsies & travellers estimated 18,600 in England in 2011. Gender: In 2011, c. 49% of the population in both CE and CWAC were male and 51% female. For CE, the assumption from national figures is that 20 per 100,000 are likely to be transgender and for CWAC 1,500 transgender people will be living in the CWAC area. Disability: In 2011, 7.9% of the population in CE and 8.7% in CWAC had a long term health problem or disability In CE, there are c.4500 people aged 65+ with dementia, and c.1430 aged 65+ with dementia in CWAC. 1 in 20 people over 65 has a form of dementia Over 10 million (c. 1 in 6) people in the UK have a degree of hearing impairment or deafness. C. 2 million people in the UK have visual impairment, of these around 365,000 are registered as blind or partially sighted. In CE, it is estimated that around 7000 people have learning disabilities and 6500 people in CWAC. Mental health 1 in 4 will have mental health problems at some time in their lives. Sexual Orientation: CE - In 2011, the lesbian, gay, bisexual and transgender (LGBT) population in CE was estimated at18,700, based on assumptions that 5-7% of the population are likely to be lesbian, gay or bisexual and 20 per 100,000 are likely to be transgender (The Lesbian & Gay Foundation). CWAC - In 2011, the LGBT population in CWAC is unknown, but in 2010 there were c. 20,000 LGB people in the area and as many as 1,500 transgender people residing in CWAC. Religion/Belief: The proportion of CE people classing themselves as Christian has fallen from 80.3% in 2001 to 68.9% In 2011 and in CWAC a similar picture from 80.7% to 70.1%, the proportion saying they had no religion doubled in both areas from around 11%-22%. Christian: 68.9% of Cheshire East and 70.1% of Cheshire West & Chester Sikh: 0.07% of Cheshire East and 0.1% of Cheshire West & Chester Buddhist: 0.24% of Cheshire East and 0.2% of Cheshire West & Chester Hindu: 0.36% of Cheshire East and 0.2% of Cheshire West & Chester Jewish: 0.16% of Cheshire East and 0.1% of Cheshire West & Chester Muslim: 0.66% of Cheshire East and 0.5% of Cheshire West & Chester Other: 0.29% of Cheshire East and 0.3% of Cheshire West & Chester None: 22.69%of Cheshire East and 22.0% of Cheshire West & Chester Not stated: 6.66% of Cheshire East and 6.5% of Cheshire West & Chester Carers: In 2011, nearly 11% (40,000) of the population in CE are unpaid carers and just over 11% (37,000) of the population in CWAC.

No 2.2 Evidence of complaints on grounds of discrimination: (Are there any complaints or concerns raised either from patients or staff (grievance) relating to the policy, procedure, proposal, strategy or service or its effects on different groups?) No 2.3 Does the information gathered from 2.1 2.3 indicate any negative impact as a result of this document? 3. Assessment of Impact Now that you have looked at the purpose, etc. of the policy, procedure, proposal, strategy or service (part 1) and looked at the data and research you have (part 2), this section asks you to assess the impact of the policy, procedure, proposal, strategy or service on each of the strands listed below. RACE: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, racial groups differently? Yes No x Explain your response: No impacts identified GENDER (INCLUDING TRANSGENDER): From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, different gender groups differently? Yes No x Explain your response: No impacts identified DISABILITY From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, disabled people differently? Yes x No Explain your response: Employees to inform their Manager of any disability which may require an individual Risk assessment and/or adjustments. AGE: From the evidence available does the policy, procedure, proposal, strategy or service, affect, or have the potential to affect, age groups differently? Yes No x Explain your response: No impacts identified LESBIAN, GAY, BISEXUAL: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, lesbian, gay or bisexual groups differently? Yes No x Explain your response: No impacts identified

RELIGION/BELIEF: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, religious belief groups differently? Yes x No Explain your response: There may be impact upon individuals who may be affected by the use of PPE. The Trusts Uniform and dress code policy must be adhered to. Within special circumstances this must be discussed with the Line Manager. CARERS: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, carers differently? Yes No x Explain your response: No impacts identified OTHER: EG Pregnant women, people in civil partnerships, human rights issues. From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect any other groups differently? Yes No x Explain your response: No impacts identified 4. Safeguarding Assessment - CHILDREN a. Is there a direct or indirect impact upon children? Yes No x b. If yes please describe the nature and level of the impact (consideration to be given to all children; children in a specific group or area, or individual children. As well as consideration of impact now or in the future; competing / conflicting impact between different groups of children and young people: c. If no please describe why there is considered to be no impact / significant impact on children 5. Relevant consultation Having identified key groups, how have you consulted with them to find out their views and that the made sure that the policy, procedure, proposal, strategy or service will affect them in the way that you intend? Have you spoken to staff groups, charities, national organisations etc? 6. Date completed: 04/12/2017 Review Date: December 2017 7. Any actions identified: Have you identified any work which you will need to do in the future to ensure that the document has no adverse impact?

Action Lead Date to be Achieved 8. Approval At this point, you should forward the template to the Trust Equality and Diversity Lead lynbailey@nhs.net Approved by Trust Equality and Diversity Lead: Date: 26.10.16 Appendix 2 Health and Safety Process Flow Chart