This document is uncontrolled once printed. Please check on the CCG s Intranet site for the most up to date version HEALTH AND SAFETY POLICY
DOCUMENT CONTROL Type of Document Document Title Description: Location: Published version no. Policy Health and Safety Policy This policy sets out the principles by which Lambeth Clinical Commissioning Group (Lambeth CCG) will develop, manage and review the management of health and safety across the organisation File Location: S:/Lambeth Share/Lam/CCG/Governance and Development/Governance/Policy/ 1.0 Publication date December 2013 Review date December 2014 Author name, job title and contact details Consultation Body / Persons Geraldine Hennighan, Governance Manager ghennighan@nhs.net 0203 049 4090 Integrated Governance Committee Members / CCG Directors / CCG Assistant Directors / CCG Business Support Manager / NHS Property Services Director / SLCSU HR Business Partner Consultation date November 2013 Approval Body Health and Safety Group Approval date 3 December 2013 Ratification date (IGC) Readership / Audience: Information Governance Class (Restricted or unrestricted) 18 December 2013 Governing Body members, sub-committee members and all staff working for, and on behalf of, the CCG Unrestricted Governance and NHS Lambeth CCG This document supersedes all pre-existing Health and Safety policies and protocols. This Policy applies to all staff of NHS Lambeth Clinical Commissioning Group. Details of the Equality & Equity Impact Assessment Checklist can be found in Appendix 2
Version / Change History Version Date Author Approving Committee / Group Reason 0.1 October 2013 Geraldine Hennighan N/A Initial draft version 0.2 November 2013 Geraldine Hennighan N/A Updated draft version, following consultation feedback 1.0 December 2013 Geraldine Hennighan Health & Safety Group Approved policy, ratified by Integrated Governance Committee Consultation History Consultation Body / Persons Integrated Governance Committee Area of expertise Date sent Comments / Changes made Corporate Governance 4/11/13 4/11/13: Dr Raj Mitra No amendments Executive Directors Corporate 4/11/13 No amendments received Assistant Directors Operational 4/11/13 4/11/13: Jennifer Burgess addition of fire training requirements section 4.7 Business Support Manager Operational 4/11/13 29/11/13: Niymeti Ramadan No amendments NHS Property Services Director Health and Safety / premises overview in line with NHS Property Services policies and guidelines 4/11/13 No amendments received
Consultation Body / Persons SLCSU HR Business Partner Area of expertise Date sent Comments / Changes made HR / Training 4/11/13 No amendments received
CONTENTS 1. Introduction... 7 1.1 Document Statement and Aim... 7 1.2 Objectives... 7 2. Scope of Document... 8 3. Equality and Human Rights Statement... 8 4. Roles and Responsibilities... 8 4.1 CCG Governing Body... 9 4.2 Governing Body Member responsible for Health and Safety / Chief Officer... 9 4.3 Accountable Officer for Health and Safety / Director of Governance and Development... 10 4.4 Appointed Competent Person for Health and Safety / Assistant Director Governance and Quality... 10 4.5 Directors and Assistant Directors... 11 4.6 Managers... 12 4.7 Governance Manager... 13 4.8 All staff... 13 5. Arrangements for Health and Safety... 14 5.1 Risk Assessments... 14 5.2 The Workplace... 15 5.3 Personal Security... 15 5.4 Equipment and Facilities... 16 5.41 Portable Appliances and Electrical Safety... 16 5.42 Heating and Air Conditioning... 16 5.5 Contact with Hazard Substances... 17 5.6 First Aid... 17 5.7 Fire Safety... 18 5.8 Manual Handling... 18 5.9 Health and Safety Executive... 18 Document Status: DRAFT, FOLLOWING CONSULTATION Review date: December 2014
6. Health and Safety Group... 19 7. Policy Audit and Monitoring Compliance... 19 7.1 Policy Review... 19 7.2 Policy Monitoring and Audit... 20 8. Statement of evidence / references... 21 9. Implementation and dissemination of document... 21 10. Associated Documents... 21 11. Appendices... 21 Appendix 1 Health & Safety Group Terms of Reference... 22 Appendix 2 Equality & Equity Impact Assessment Checklist... 24 Document Status: DRAFT, FOLLOWING CONSULTATION Review date: December 2014
1. INTRODUCTION 1.1 DOCUMENT STATEMENT AND AIM This policy sets out the principles by which Lambeth Clinical Commissioning Group (Lambeth CCG) will develop, manage and review the management of health and safety across the organisation 1.2 OBJECTIVES The objective of this policy is to clarify the ways that Lambeth CCG will: Provide a healthy and safe environment for all staff, patients, contractors, volunteers and members of the public through the adoption of the CCG Health and Safety Policy Ensure that that the CCG complies with all relevant health and safety legislation Operate a system where the CCG is able to demonstrate, open and effectively, the development and achievement of optimum health and safety standards The Governing Body of Lambeth CCG recognise the need for the development of effective Health and Safety Management. The CCG policy is to comply with relevant legislation as a minimum, and exceed this wherever possible to improve the health, safety and wellbeing of any person (staff, visitor, agency worker or contractor) who may be affected by the CCGs activities. Systems will be put in place which will allow the CCG to maintain, monitor and, where necessary, improve its safety performance. A robust health and safety culture and operational system will be maintained by ensuring that, in so far as is reasonably practicable: Adequate resources (financial and physical) to maintain health and safety, are provided Activities are risk assessed and those assessments are reviewed as necessary All systems of work are safe and without unnecessary risks to health and safety Systems of work for the safe use, handling, storage and transportation of articles and substances are provided and maintained Suitable and sufficient information, instruction, training and supervision are provided for all staff, to ensure their competence A safe working environment is provided, along with adequate welfare arrangements and facilities Contractors undertaking work on behalf of the CCG are competent to do so Advice, support and guidance will be available across the CCG Page 7
This policy will be brought to the attention of all employees and contractors, via the CCG intranet. The policy will be reviewed annually and following any changes in legislation. 2. SCOPE OF DOCUMENT This policy is applicable without exception to all staff working within Lambeth CCG at the areas occupied by the CCG at the premises at Lower Marsh, Lambeth, whether directly or indirectly employed, and is related to providing a healthy and safe environment for all staff, patients, contractors, volunteers and members of the public or the CCG at these premises. 3. EQUALITY AND HUMAN RIGHTS STATEMENT Promoting equality, eliminating unfairness and unlawful discrimination, and treating colleagues, partners and the public with dignity and respect, are fundamental to successful performance by all staff in the CCG, including the Governing Body, who are all expected to actively promote equality and human rights and challenge racism, homophobia and other forms of discrimination through their activities, and support others to do the same. All staff are expected to work with others on effective approaches to ensure strategies, policies and activities promote and demonstrate equality and human rights. Equality Impact Assessment and Equality Analysis are to be used as part of developing and monitoring proposals and projects for their impact on equality and equity. All staff of Lambeth CCG, including the Governing Body are required to abide by all equality and human rights legislation and good practice, and will receive appropriate training and support to do so. 4. ROLES AND RESPONSIBILITIES The corporate responsibility for Health & Safety risk management sits with the Senior Management (Director) team who are charged with managing business affairs. The Health and Safety at Work etc Act 1974 states that the ultimate responsibility for all health and safety rests with the Accountable Officer as employing officer. The day-to-day responsibility for discharging these duties devolves through the Directors, Assistant Directors and the Management team to each employee as detailed in the following sections. The Accountable Officer for Health and Safety is the Director of Governance and Development. Page 8
The operational responsibility for Health and Safety sits with the Assistant Director for Governance and Quality. 4.1 CCG GOVERNING BODY The CCG Governing Body is responsible for the overall management of health and safety within the organisation. It is responsible for providing health and safety leadership, ensuring all CCG decisions reflect the intentions laid down in this policy; and for monitoring the implementation of this policy, Each Executive Director of the Governing Body has responsibilities with regards to implementing the policy in their own Directorate. These responsibilities are noted in the following sections. In addition, individual Executive Directors have strategic health and safety responsibilities, which are also described on the following pages. 4.2 GOVERNING BODY MEMBER RESPONSIBLE FOR HEALTH AND SAFETY / CHIEF OFFICER The Chief Officer is the member of the Governing Body responsible for the overall coordination and monitoring of the implementation of the policy in the CCG. Particular responsibilities include ensuring that: The CCG Health and Safety Policy reflects current priorities and is monitored, reviewed and revised as necessary There are clearly defined responsibilities and arrangements for implementing the policy The CCG Governing Body members and CCG managers are provided with competent health, safety and welfare advice to assist with the provision of protective and preventative measure and the implementation of health and safety legislation There is a CCG Health and Safety Group Systems are in place for identifying competencies to manage Health and Safety and meeting any competency requirements Arrangements are in place for monitoring the implementation of the Health and Safety Policy The effective co-ordination of health, safety and welfare both within and between directorates and/or departments and other organisations, including the CSU and NHS Property Services is consistent with the ethos of the Governing Body Significant Health and Safety issues which cannot be resolved are raised with the Accountable Officer Page 9
4.3 ACCOUNTABLE OFFICER FOR HEALTH AND SAFETY / DIRECTOR OF GOVERNANCE AND DEVELOPMENT The Accountable Officer for Health and Safety has overall responsibility for ensuring that the CCG complies with the Health and Safety at Work etc Act 1974, the Management of Health and Safety at Work Regulations 1999 and all other responsibilities. The Accountable Officer for Health & Safety for Lambeth CCG is the Director of Governance and Development. The Accountable Officer for Health and Safety also has responsibility for: Ensuring that adequate resources are available to implement the Health and Safety Policy Ensuring that Health and Safety performance is regularly reviewed Monitoring the effectiveness of the Health and Safety Policy Ensuring that the Policy is reviewed at least annually Ensuring that the Health and Safety Group is appropriately chaired and represented. 4.4 APPOINTED COMPETENT PERSON FOR HEALTH AND SAFETY / ASSISTANT DIRECTOR GOVERNANCE AND QUALITY The Assistant Director Governance and Quality is the appointed Competent Person in relation to Health and Safety for the CCG and will provide professional advice, support and guidance to Directors, Assistant Directors, Managers and staff. The responsibility for the ongoing operational management, delivery, management and monitoring of the Health and Safety Policy and health, safety and welfare arrangement sits with the Assistant Director of Governance and Quality. The appointed Competent Person is responsible for: Ensuring the effective implementation and monitoring of the Health and Safety Policy, and other directly associated policies Ensuring that all requirements detailed in Section 4 of this policy (Health and Safety Arrangements) are met on a day-to-day basis, in conjunction with NHS Property Services and South London Commissioning Support Unit as necessary Ensuring so far as is reasonably practicable that the CCG complies with current Health and Safety legislation Ensuring the provision of advice, support and guidance to CCG staff on Health and Safety matters Liaising with the CSU HR and Training Team in ensuring that all training is organised for implementation of this policy Page 10
Liaising with the CSU HR and Training Team to ensure that training records for Health and Safety are maintained for CCG staff and that training needs are identified Providing expert advice and information on Health and Safety issues Completing COSHH assessments for the Lower Marsh areas occupied by CCG staff Liaising with the CSU Human Resources and Training Team to ensure that Health and Training is provided for new staff at Induction Escalate uncontrolled or significant Health and Safety issues, including ensuring they are considered for inclusion on departmental and the corporate risk registers. Acting as the Responsible Person for the CCG under RIDDOR legislation for reportable accidents. Ensuring that regular safety inspections are carried out in areas occupied by the CCG, in conjunction with NHS Property Services, at least once per year Developing and maintaining the Health and Safety Risk Register Provision of 6-monthly Health and Safety reports via the Health and Safety Group to the Integrated Governance Committee on Health and Safety Performance, on the following indicators: Percentage attendance of staff at Health and Safety training events / sessions Percentage of attendees at induction training within 2 months of appointment Percentage of staff attending manual handling training Number of Directors trained in Health and Safety Number and detail of staff incidents reported Number and detail of claims involving health and safety Number of HSE reportable incidents including expression as a percentage of total incidents reported Number and detail of health and safety risks on the risk register Further indicators will be adopted as the Health and Safety management system and processes mature and develop within the CCG 4.5 DIRECTORS AND ASSISTANT DIRECTORS Directors and Assistant Directors will support the Accountable Officer for Health and Safety and carry direct responsibility for the implementation of the Health and Safety Policy. They will do all that is reasonably practicable to establish and maintain high standards of health, safety and welfare in their areas of control. Directors and Assistant Directors will: Page 11
Monitor and evaluate the health and safety performance in areas under their control, paying particular attention to any safety inspections, training, accident / incident reporting and action plans developed in conjunction with the Assistant Director of Governance and Quality Promote and support the CCG Health and Safety Policy and procedures, ensuring communication an implementation through line management Provide adequate resources and training arrangements to enable staff to discharge their Health and Safety responsibilities and ensure that all policy objectives and legal requirements are met as so far as is reasonably practicable Ensure that employees are aware of Health and Safety Policies and other safety rules or procedures Ensure that any relevant Health and Safety assessments or inspections that are the responsibility of the CCG are carried out, e.g. workplace assessments for nominated workspaces and hot desks. There is a clear responsibility to communicate with relevant staff / teams about any actions necessary. It is equally important that appropriate feedback and consultation is undertaken when specific actions are not going to be taken, along with a clear rationale for the decision. Ensure that all staff levels report safety related incidents and near misses via the CCG incident reporting system (QUIC) Bring to the attention of the CCG Health and Safety Group and Governing Body significant or uncontrolled Health and Safety issues Notify the Assistant Director Governance and Quality of areas of significant or uncontrolled Health and Safety issues Provide feedback to the Assistant Director Governance and Quality on the progress of Health and Safety compliance or non-compliance to enable issues to be raised and discussed and on behalf of their area of control at the Health and Safety Group. 4.6 MANAGERS Managers will be responsible and accountable to their Director for the safety performance of their areas of activity. As part of the implementation process, the role of Managers will be key to the day-to-day management of Health and Safety and they will receive Health and Safety Management training. Specifically, Managers are responsible for: Ensuring that the Health and Safety Policy, relevant risk assessments and procedures are communicated to their staff. Page 12
Promoting and supporting the CCG Health and Safety Policy, ensuring that employees under their control are aware of the policy and able to carry out their work in a safe manner and in a safe environment Motivating staff by stimulating interest in Health and Safety matters, allocating relevant time and importance to relevant Health and Safety issues to departmental / team meetings Implementing and monitoring the compliance with this policy Undertaking and reviewing risk assessments Ensuring that any incident, accident, near-miss, dangerous occurrence, damage to property or other untoward occurrence is correctly reported on the CCG QUIC incident reporting system to allow investigation by the appropriate individual. Team or organisation Keeping and maintain statutory records and other legal documents related to Health and Safety as relevant Notifying Occupational Health of any staff requiting health surveillance and referring any employee where signs of health problems arise which may be considered to be as a result of an occupational health and safety issue Ensuring that direct reports objectives reflect the range of health and safety risks that the individual might reasonably be expected to come across, and the action that needs to be taken to control those risks 4.7 GOVERNANCE MANAGER The Governance Manager is responsible for: Developing, providing and maintaining an incident reporting system for use by all staff Liaising with Assistant Director of Governance and Quality around RIDDOR reports Being a member of Health and Safety Group 4.8 ALL STAFF All CCG employees have duties and responsibilities under the Health and Safety at Work etc. Act 1974. These duties and responsibilities are to: Take responsibility for their own health and safety and for that of others who may be affected by their acts or omissions Co-operate with their employers to enable them to fulfil their statutory duties under the Health and Safety at Work etc. Act 1974 Page 13
Not knowingly interfere with or misuse any article provided in the interests of health, safety or welfare Comply with CCG procedures and health and safety rules Identify and report defects and other health and safety concerns to either their line manager or the Assistant Director Governance and Quality Attend Occupational Health as requested Report all accidents, incidents or near misses promptly on the QUIC reporting system Ensure all vaccinations and other job related health precaution measures are up to date (as applicable) Book and attend any relevant training courses, in conjunction with their line managers 5. ARRANGEMENTS FOR HEALTH AND SAFETY 5.1 RISK ASSESSMENTS The Management of Health and Safety at Work Regulations 1999 make more explicit the general duties placed on the CCG under the Health and Safety at Work etc. Act 1974. In order to meet the regulatory requirements, the CCG will ensure that: Risk assessments are carried out in order to evaluate and adequately control hazards, so as to ensure the health, safety and welfare of employees and others who could be affected by work activities of the CCG. Risk assessments are recorded in writing on the appropriate form, in accordance with the CCG Risk Assessment Policy Arrangements are in place for putting into practice the preventative and protective measure that follow from risk assessments, including entry on relevant risk registers Business Continuity Plans and emergency plans, including the Major Incident Plan are established and kept updated and followed in the event of serious or imminent danger or risk. The outcomes of risk assessments will be readily available and communicated to staff. Staff. Staff will receive instructions and/or training associated with the level of risk identified and the control measures taken to prevent or control risks. Risk assessments relating to Health and Safety issues must be forward to the Assistant Director Governance and Quality and populated on the Health and Safety Risk Register and, where relevant and necessary, also included on the Corporate Risk Register. Page 14
Safety training and guidance will be provided in safe systems of work, which will include dealing with challenging or aggressive behaviour, manual handling, lone working, working with display screen equipment (DSE) etc. 5.2 THE WORKPLACE The CCG is committed to providing a safe and healthy working environment and this extends to the premises occupied by CCG staff at Lower Marsh. In conjunction with NHS Property Services the CCG will ensure that: Access to, and egress from each workplace remains safe for all premises users Suitable and sufficient heating, ventilation and lighting is provided and maintained. Adequate welfare facilities are provided Premises are inspected and kept in good order and well maintained Emergency procedures and business continuity plans are in place and communicated to all concerned With no direct management control over the premises (e.g. Lower Marsh) the CCG Governing Body will to ensure there are suitable and sufficient processes in place to assure themselves regarding the safety of the working environment and building that CCG staff occupy. This will require seeking such assurance as are necessary from NHS Property Services and other tenants of the Lower Marsh building. 5.3 PERSONAL SECURITY All employees should help to create a secure environment for themselves and other by: Limiting the amount of personal property brought to, and left at, work, including cash, credit cards etc. Locking all personal property away wherever possible Locking away all CCG equipment / property wherever possible Wearing their ID badge Challenging (politely and courteously) any person not wearing an ID badge whose ID is not known Reporting any untoward activities or suspicious characters immediately Completing a QUIC incident report for any security breaches or hazards Page 15
5.4 EQUIPMENT AND FACILITIES In conjunction with NHS Property Services and South London Commissioning Support Unit (SLCSU) as appropriate, the CCG will ensure all equipment, including work equipment, kitchen/cooking facilities and IT equipment safe to use and ensure that the correct equipment is provided and used. All staff are responsible for their own safety, ensuring that the correct operating and safety instructions are followed at all times. If an item of equipment is suspected of being defective and/or unsafe, this must be reported immediately and it should not be used until it has been thoroughly checked and approved for use by a competent person. As part of its health and safety management process the CCG must satisfy itself that arrangements are in place to allow the following areas to be adhered to: 5.41 PORTABLE APPLIANCES AND ELECTRICAL SAFETY All portable electrical appliances will be tested in accordance with the requirements and frequency as determined by legislation. All portable electrical equipment should be given a visual inspection for damage to the casing and wiring before being used. Any defects should be reported immediately, the equipment taken out of use and a CCG incident report completed. Staff should not bring their own portable electrical equipment (such as heaters, fans, coffee machines, kettles etc) as these will not be tested and therefore pose a potential risk to other staff and property. Testing and examination of the electrical installation system in accordance with the Institute of Electrical Engineers (IEE) standards and/or Department of Health publications is the responsibility of NHS Property Services as the building landlord and they will need to provide the necessary assurances to the CCG Governing Body. 5.42 HEATING AND AIR CONDITIONING Maintenance and testing of the heating and air conditioning systems within premises is the responsibility of NHS Property Services as the building landlord and they will need to provide the necessary assurances to the CCG Governing Body that all maintenance and testing is carried out in accordance with regulations and maintenance schedules. Page 16
5.5 CONTACT WITH HAZARD SUBSTANCES Hazardous substances are identified as substances that may be harmful to health, e.g. liquids/chemicals that may be toxic, harmful, corrosive or irritant; dusts; fumes; gases and biological agents (bacteria and micro-organisms) The CCG is based in a low risk office environment with few hazardous substances present. The Assistant Director Governance and Quality will undertake a review of substance used within the CCG and complete a Control of Substances Hazardous to Health (COSHH) assessment accordingly. Guidance on COSHH and copies of COSHH risk assessments will be held by the Assistant Director Governance and Quality and made available to staff if required. 5.6 FIRST AID The CCG is based within a low risk office environment, however adequate first aid trained members of staff will be trained and in place to minimise the consequence of injury or ill health in the workplace by treating minor injuries and where necessary giving help until professional assistance can be obtained. As a tenant, the CCG is required to: nominate and provide staff to be trained as First Aiders [First Aid Training is provided via NHS Property Services] under the guidance of the Assistant Director Governance and Quality, carry out assessments to determine the extent of first aid provision required within the area for which the CCG First Aiders are responsible As the building landlord NHS Property Services are required to: provide / arrange First Aid training for nominated First Aiders provide adequately stocked and accessible first aid boxes at identified locations Any staff identified as being suitable to administer first aid will be required to attend a Health and Safety Executive (HSE) approved training course. Consideration should also be given to interim training during the intervening three years between training courses. It is acknowledged by the HSE that registered Doctors and Nurses who may not have attended a first aid training course, may, if present at an incident at work, act in an emergency First Aider capacity if they feel competent to do so, Page 17
5.7 FIRE SAFETY It is the duty of NHS Property Services as the building landlord to co-ordinate the arrangements for fire safety within the building. This includes: the provision of safe access and egress the provision of emergency fire safety equipment including extinguishers, signage, emergency lighting and alarm system maintenance of emergency fire safety equipment the provision of evacuation procedures for the building. the provision of Fire Marshall training for nominated Fire Marshalls As a tenant, the CCG is required to: co-operate with NHS Property Services (and other tenants in the building) in the execution of their statutory duties, develop evacuation procedures (if necessary) for areas occupied by CCG staff ensure that staff are aware of the importance of fire prevention in the workplace nominate and provide staff to be trained as Fire Marshalls [Fire Marshall Training is provided via NHS Property Services] ensure that all staff complete fire training The CCG Governing Body will seek to assure itself that NHS Property Services as the building landlord has implemented suitable process and controls to ensure the safety of staff and that these are maintained in accordance with legislation and guidance. 5.8 MANUAL HANDLING All CCG staff are required to complete manual handling training, appropriate to their job role. 5.9 HEALTH AND SAFETY EXECUTIVE The Health and Safety Executive (HSE) are the enforcing authority for Health and Safety within a range of sectors including NHS / healthcare organisations. Their role is to protect people s health and safety by ensuring risk in the changing workplace is properly controlled. In the main this is done by guidance or support, however they have the power to bring prosecutions for failing where deemed appropriate. The HSE can make unannounced visits to any work premises. The inspector will make their presence known to the senior person on site at the time and expect full cop-operation. Page 18
6. HEALTH AND SAFETY GROUP The Terms of Reference for this Group are included in this Policy as Appendix 1. The Group is chaired by the CCG s Accountable Officer for Health and Safety 7. POLICY AUDIT AND MONITORING COMPLIANCE 7.1 POLICY REVIEW The Health and Safety Policy will be reviewed annually, and following any significant changes in Health and Safety legislation or guidance. Page 19
7.2 POLICY MONITORING AND AUDIT MONITORING / AUDIT REQUIREMENT Area in document for monitoring e.g. processes Note specifically any monitoring needed to assure equality and equity of delivery MONITORING / AUDIT METHOD (e.g. statistics, report) MONITORING REPORT / AUDIT PREPARED BY (job titles) MONITORING REPORT / AUDIT PRESENTED TO (name of Committee / group) FREQUENCY OF MONITORING REPORT / AUDIT (e.g. annually, sixmonthly) Training record for CCG staff for Health and Safety (Section 3.4) Training records / action plan Assistant Director Governance and Quality Health and Safety Group Annually Ensuring that regular safety inspections are carried out in areas occupied by the CCG, in conjunction with NHS Property Services (Section 3.4) Developing and maintaining the Health and Safety Risk Register (Section 3.4) Inspection record / risk assessment Health and Safety Risk Register Assistant Director Governance and Quality Assistant Director Governance and Quality Health and Safety Group Health and Safety Group At least annually Annually Provision of 6-monthly Health and Safety reports via the Health and Safety Group to the Integrated Governance Committee on Health and Safety Performance, on the noted indicators (Section 3.4) Reports and minutes of meetings to confirm receipt Assistant Director Governance and Quality Health and Safety Group Annually COSHH Assessment (section 4.5) Risk Assessment Assistant Director Governance and Quality Health and Safety Group Annually Page 20
8. STATEMENT OF EVIDENCE / REFERENCES The Health and Safety at Work etc Act 1974 9. IMPLEMENTATION AND DISSEMINATION OF DOCUMENT Following ratification, the Health and Safety Policy will be uploaded onto the CCG intranet and the document location confirmed to all CCG staff launched at a Lower Marsh staff briefing shared with NHS Property Services for information included in all new staff induction packs In addition, all CCG staff will be required to confirm that they have seen and read the policy 10. ASSOCIATED DOCUMENTS Lambeth CCG Risk Assessment Guidance NHS Property Services Fire Safety Policy NHS Property Services Health and Safety Policy SLCSU Lone Worker Policy [to be completed by 31 March 2014] SLCSU Health and Safety Policy 11. APPENDICES Appendix 1 Appendix 2 Health and Safety Group Terms of Reference Equality and Equity Impact Assessment Page 21
APPENDIX 1 HEALTH & SAFETY GROUP TERMS OF REFERENCE HEALTH & SAFETY GROUP Terms of Reference Introduction The Health & Safety Group acts as a focus for communication and consultation on Health & Safety matters. The Group s recommendations on Health & Safety matters are made as appropriate to the SE London group and the Integrated Governance Committee. The Director of Governance and Development is the Lead Director responsible for Health & Safety through to the Chief Officer and Governing Body and is the Accountable Officer for Health & Safety for NHS Lambeth CCG. Responsibilities 1. To ensure that NHS Lambeth CCG s Health & Safety policies and procedures are produced, reviewed and updated. 2. To consult with, and bring forward concerns of, staff of all grades regarding Health & Safety issues. 3. To review Health & Safety arrangements within NHS Lambeth CCG and advise management on recommendations and corrective actions with the objective of continually seeking to improve Health & Safety by eliminating or minimising risk wherever possible. 4. To study statistics and trends on accidents, incidents, near misses and notifiable diseases so that recommendations for corrective action can be made. 5. To arrange for the development of performance indicators relating to health and safety. 6. To monitor the results of audits and inspections. 7. To review the effectiveness of Health & Safety training. 8. To monitor the adequacy of Health & Safety communication. 9. To develop and promote a safety culture and raise staff awareness. 10. To maintain links with all staff within the CCG and NHS Property Services who hold responsibility for the building Health and Safety at 1 Lower Marsh. 11. To consider reports and letters from appropriate personnel involved in Health & Safety issues including Health & Safety Representatives, NHS Property Services Health and Safety Group in respect of 1 Lower Marsh, the Health and Safety Executive (HSE), local government inspectors and specialist appointed advisers. Frequency of meetings Page 22
The action group will meet 4 times per year and minutes from meetings to be reported to the Integrated Governance Committee and made widely available. Membership Director of Governance and Development / CCG Accountable Officer for Health & Safety (Chair) Assistant Director Governance and Quality / CCG Competent Person for Health & Safety (Deputy Chair) Governance Manager Business Support Manager HR Business Manager (SLCSU) A quorum is three (3) members. Review of Terms of Reference The Terms of Reference for this group will be reviewed annually (October 2014) Page 23
APPENDIX 2 EQUALITY & EQUITY IMPACT ASSESSMENT CHECKLIST The CCGs Equality and Human Rights Statement is included as Section 3 of this document. This information is also included in CCG job descriptions. This is a checklist to ensure relevant equality and equity aspects of proposals, policy or guidance have been addressed either in the main body of the document or in a separate equality & equity impact assessment (EEIA)/ equality analysis. It is not a substitute for EEIA/ equality analysis which is normally required unless it can be shown that a proposal has no capacity to influence equality. The checklist is to enable the policy lead and the relevant committee to see whether the EEIA has covered the ground and to give assurance that the proposals will not only be legal but also fair and equitable and lead to reduced health inequality. 1 2 Challenge questions Does the document set out the health care needs of the groups intended to benefit from the proposal, including any differences in need in terms of the legally protected or other characteristics (such as socioeconomic position) Does the document set out any known existing inequality in access, quality, experience and outcome of care for populations relevant to the proposal (ie as defined in 1. and in relation to the existing health or care service)? Yes / No / DK / N/A N/A N/A Comments 3 Are there any particular public concerns about equality about the policy area than need to be addressed? No 4 Has the policy described any gaps in knowledge about 1-3, and any action taken to fill gaps (or recommendations for action) N/A 5 6 7 8 9 Does the document set out risks to equity of access, quality, experience and outcomes including risk of direct or indirect discrimination, and risk to good relations between people of different groups? Does the document describe any specific opportunities to promote equality and human rights, good relations between people of different groups, to enhance participation, etc? Does the document describe how the proposal, policy etc will address the identified inequalities, and Does the document make recommendations to mitigate risks and enhance the opportunities to promote equality and equity? Does the document describe how monitoring and reporting will take place to assure equality and equity in the future including to stakeholders? [audit and monitoring table may be used] N/A N/A N/A N/A N/A * Race/ ethnicity, gender (including gender reassignment) age, religion or belief, disability, sexual orientation, marriage or civil partnership, pregnancy and maternity. This will include groups such as refugees and asylum seekers, new migrants, Gypsy and Traveller communities; and people with long term conditions, hearing or visual Page 24