NHS WORCESTERSHIRE Health and Safety Policy To be read in conjunction with associated health and safety guidance documents Version: Final Ratified by: Quality & Patient Safety Assurance Date ratified: 20/09/11 Name of originator/author: Tracy Owen Name of responsible committee/individual: Quality & Patient Safety Assurance Date issued: October 2011 Review date: March 2013 Target audience: All staff EIA Completed: January 2010
Contents Paragraph Page 1 Introduction 3 2 Purpose / Statement 3 3 Duties 4 4 Arrangements 6 5 Planning and Implementation 8 6 Audit and Review 8 7 Standards/key Performance Indicators 8 8 References 9
1 Introduction This document is intended to reflect the views of the organisation and sets out the Health and Safety Policy Statement, as well as details of the organisation and arrangements that have been implemented, in order to comply with the Health and Safety at Work Act. The policy is supported by a number of documents that offer guidance about specific health and safety issues. This Policy will be communicated to all staff during their Induction phase and a copy will be available via the internet. The policy applies to all individuals on NHS premises and therefore reflects the organisation s equality and diversity arrangements. 2 Purpose / Statement The organisation aims to provide all staff, visitors and service users with a safe environment, in which to be able to work or visit, without suffering any personal injury or ill health. It recognises the need to identify the significant workplace hazards on all of its sites and implement any necessary measures, in order to eliminate or reduce any associated risks of harm, damage or loss. The organisation aims to prevent, or reduce the nature and severity of, all workplace accidents, the spread of infectious diseases and any dangerous occurrences in line with the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations. All employees are expected to co-operate with the organisation to ensure it complies with any statutory duties under Health and Safety legislation. Management and staff will work proactively together to ensure that all plans, procedures and systems of work are designed to take full account of health and safety issues. This will include arrangements for a safe place of work, maintenance of equipment, safe handling of substances and articles, the assessment of any risks, and sufficient information, instruction and training for staff to ensure they comply with their individual statutory duties. The Chief Executive accepts overall responsibility for health and safety in the organisation. However, day to day responsibility for health, safety and welfare is delegated to Executive Directors and Heads of Service. They have responsibilities for the well being of all staff, service users and visitors within their respective work areas. In line with the Management of Health and Safety at Work Regulations, the organisation also employs a competent person to assist in complying with its statutory health and safety duties. The policy is reviewed annually, and if necessary, revised in the light of legislative or organisational changes. Signed:... Date:... Chief Executive NHS Worcestershire 3
3 Duties The organisation s Board of Management and its Directors fully accept their responsibility for health and safety in the workplace and will discharge this through their organisational responsibilities. Duties within the Organisation 3.1 Management Responsibilities 3.1.1 Chief Executive The overall and final responsibility for health and safety in the organisation rests with the Chief Executive. The Chief Executive is responsible for: The provision of sufficient resources to implement the Health and Safety Policy Ensuring that all employees are fully aware of their statutory responsibilities and that these responsibilities are fulfilled Ensuring that the organisation complies with all statutory health and safety requirements Ensuring that the arrangements for health and safety and the Health and Safety Policy are fully implemented by the inclusion of health and safety within all Managers' performance reviews Monitoring the effectiveness of the Health and Safety Policy and its revision where necessary Ensuring health and safety matters are reported to the Board and appropriate safety committees in accordance with S.2 of the Health and Safety at Work Act. 3.1.2 Directors Must ensure: The implementation of the Health and Safety Policy, corporately and within their areas of control Effective delegation of safety responsibilities within their areas of responsibility Effective support for their senior managers decisions and recommendations in terms of the provision of appropriate resources for health and safety A Director appointed as H&S lead at Board level to ensure considered decision making at a strategic level The promotion of a positive health and safety culture which enables all employees to fulfil their statutory duties That staff have adequate experience and training to safely undertake their work That risk assessments, which identify significant risks to health and safety are undertaken and the results of those assessments communicated to employees before they are exposed to such risks The purchase of appropriate equipment and facilities that are safely used and properly maintained That all accidents are investigated and that the necessary reporting and recording procedures are implemented That arrangements are made for consultation with Union accredited H&S representatives and all employees in the workplace Detailed analysis of all accident statistics and the development of strategies for the reduction of injury, loss or damage to equipment and risk to persons Adherence of contractors to the prescribed health and safety standards 4
The development and implementation of any emergency procedures that may be relevant to their areas of responsibility 3.1.3 Senior Management Responsibilities All senior managers, in addition to their duties as employees, must: Ensure regular inspections of the workplace and equipment are undertaken and that steps are taken to eliminate or minimise any hazards identified Undertake risk assessments as required and, where there is a significant risk to health and safety, communicate the results of those assessments to employees before they are exposed to such risks Ensure the robustness of any health and safety documents used within their teams Ensure that all staff are provided with such training and adequate supervision as is considered appropriate for them to perform their work safely Develop safe systems of work to reduce the risks of personal injury and/or damage to plant or equipment and monitor the performance of these systems Investigate and report on all accidents and incidents, and take appropriate measures to prevent recurrence Ensure that the provision of first aid in the workplace is commensurate with the level of risk associated with work activities Refer staff with work related health problems to the Occupational Health Department 3.1.4 Employee Responsibilities 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, in line with any risk assessment findings and training 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 and equipment, or potential injury, damage or loss Co-operate with, and assist, other management colleagues in implementing the Health and Safety Policy 3.1.5 Health and Safety Manager/Security Specialist The H&S Manager/LSMS is responsible for providing the organisation with professional advice, support and guidance on all health and safety matters. This will ensure the organisation is compliant with its statutory duties. The H&S Manager/LSMS or an appropriately qualified nominee will be available to attend any appropriate safety committee meetings. 3.1.6 Fire Safety Adviser The Fire Safety Adviser (FRA Associates) will be responsible for providing the organisation with advice on all aspects of fire safety including fire prevention, control and evacuation. FRA Associates are responsible for providing staff with a programme of fire safety training. They also undertake a yearly schedule of risk assessments for all organisation premises. 3.1.7 Infection Control Nurse 5
The Infection Control Nurse will be responsible for providing the organisation with advice and guidance on all infection control issues. They are responsible for providing staff with suitable training and for ensuring that adequate monitoring is provided to detect any infection control risks or problems. 3.1.8 Occupational Health Department The organisation has an external contract with the Acute Trust for the provision of Occupational Health Services. The Occupational Health Department provides a full professional occupational health service, which includes staff support and guidance, counselling, health surveillance and pre-employment screening. 3.2 Consultation and Communication with Stakeholders The organisation has a Quality and Patient Safety Assurance Committee that is directly accountable to the Board. The aim of the committee is to promote partnership working between management and staff in initiating, developing and implementing improvements to ensure effective health and safety. The Committee provides the Organisation with a forum at which managers and staff can consult about health and safety issues. It allows staff representatives to communicate with managers, in order to raise health and safety issues that may be of concern and cannot be resolved at a local level. Accredited Trade Union Safety Representatives are entitled to attend committee meetings as detailed in the Safety Representatives and Safety Committee Regulations 1977. 3.3 Development and Approval of Procedural Documents Health and safety policy and procedural documents are drafted and developed by the H&S Manager/LSMS. Key stakeholders and specialist staff are involved in the consultation process to ensure best practice e.g. infection control and estates staff. The Quality and Patient Safety Assurance Committee is responsible for approving the documentation or review of any health and safety policies. Final ratification of any health and safety policy rests with the Board. Policies will be subject to review in line with health and safety legislation or if there are changes to technology, processes or practice. The review of policies will also be based on the prioritisation of risk within the organisation and as a consequence of any serious incidents. 3.4 Dissemination Policy documents are available via the organisation s website. The principles embedded within the policy will be included in Induction Training for staff, within local inductions for new starters, as part of mandatory Minimising Risk sessions and any appropriate e-learning modules on ESR. 4 Arrangements The organisation has a number of supporting policies that offer staff further information about relevant health and safety issues. It is essential that all staff familiarise themselves with any health and safety policy documents that are applicable to their work activities. Some examples include: 6
Incident Reporting Policy Fire Safety Policy Risk Assessment Control of Substances Hazardous to Health Manual Handling Personal Safety at Work 4.1 First Aid at Work In line with the First Aid Policy the organisation will ensure, through the risk assessment process that adequate first aid provisions are made to deal with any injuries sustained by staff whilst at work. Where it is assessed as being necessary, competent first aiders at work will be appropriately trained and supported to carry out their roles. Names and locations of specific first aiders will be prominently displayed in the workplace. The qualified first aider will be responsible for replenishing the stocks and maintaining the contents of the first aid box. External trainers will carry out first aid training. The syllabus of any course will need to meet the Health and Safety Executive's criteria and be suitable for 'First Aid at Work'. The course will qualify individuals as 'Certificated First Aiders at Work'. Individuals will need to attend a refresher course every year in order to remain competent. 4.2 Accident and Incident Reporting The organisation aims to prevent, or reduce the number of accidents and incidents to a minimum. It will monitor all accidents and incidents and implement the necessary control measures to prevent any recurrence. The organisation uses a reporting system (Sentinel) for all accidents and incidents. These will be investigated initially by the local manager/supervisor in accordance with the Incident Reporting Policy. The H&S Manager/LSMS may undertake further investigation or provide support depending on the circumstances of the incident. Where required, incidents will be reported to appropriate external stakeholders in accordance with the Incident Reporting Policy. All original documents that record accidents and incidents will be maintained in line with the Incident Reporting Policy. 4.3 Emergency Procedures The organisation will ensure, via the risk assessment process, that all emergency situations for example, spillages of hazardous substances, fire and bomb incidents etc, are taken into consideration in terms of their risk impact. Any appropriate actions will be taken and/or contingency plans developed in consultation with appropriate committees and the Emergency Planning Manager in order to reduce the risks, so far as is reasonably practicable. 4.4 Training The organisation will ensure, via its recruitment process and subsequent training programmes (both internal and external), that, during their period of employment, all members of staff have the appropriate level of competence to be able to safely carry out their role. Every Senior Manager must ensure that new members of staff attend the organisation induction training sessions. 7
Mandatory training for all staff on Minimising Risk includes information on health and safety, risk assessment, incident reporting and security management. Various health and safety e- learning packages are also available from PC s with a network connection. These packages include: health and safety, fire safety, manual handling and infection control. Some of these packages can be completed in lieu of the classroom training sessions. Local managers/supervisors must ensure that all staff are competently trained in the safe use of any equipment they may be tasked to use during the course of their employment. This will include any update training and any further training necessary as a result of any changes in the workplace arising from the introduction of new procedures and/or new equipment. Health and Safety training records for all staff will be held and maintained by line managers. 5 Planning and Implementation The Chief Executive will oversee any strategic health and safety aims and ensure that these are translated into operational objectives for Directorates and service areas. Executive Directors will ensure that health and safety planning forms an integral part of their business planning process, in order to ensure that needs are identified, prioritised, and that appropriate resources are allocated. 5.1 Proactive Monitoring The Chief Executive and Executive Directors will ensure that health and safety is monitored across the locality premises via audits and inspections. This will support the overall health and safety planning and assist in promoting a positive health and safety culture. The involvement of health and safety representatives in this process will be encouraged. Employee health and safety objectives will be set as part of the SADR process. The H&S Manager/LSMS will monitor the policy to ensure its compliance with appropriate health and safety legislation. Completed risk assessments will also be analysed to ensure effective control measures are implemented. 5.2 Reactive Monitoring Monitoring of injuries, ill health and other "loss events" will take place, as necessary, to complement active monitoring. This monitoring process will involve both managers and safety representatives. The investigation of such accidents/losses, together with analysis of incidence, will be used as a tool to identify causation, reduce future incidence and assess the effectiveness of the policy arrangements. The Chief Executive and Executive Directors, with support from the H&S Manager/LSMS will ensure that such re-active monitoring is undertaken on an organisation-wide basis. 6 Audit and Review Audit Reports will be submitted to the appropriate Director or Head of Service for action. The reports will contain any necessary recommendations and advice on shortfalls or issues of concern. The H&S Manager/LSMS with make recommendations for policy/procedure review on the basis of the audit report findings. This Policy will be reviewed annually in line with legislation. 7 Standards/Key Performance Indicators Care Quality Commission requires Trusts to achieve a required level of compliance for health and safety control. This is Outcome 10. 8
8 References Health and Safety at Work Act 1974 Management of Health and Safety at Work Regulations Reporting of Injuries, Diseases and Dangerous Occurrences Regulations The Safety Representative and Safety Committee Regulations Health and Safety (Consultation with Employees) Regulations Health and Safety (First Aid) Regulations Workplace (Health, Safety and Welfare) Regulations Provision and Use of Work Equipment Regulations Healthcare Commission Standards for Better Health Regulatory Reform (Fire Safety) Order Corporate Manslaughter and Corporate Homicide Act 9