Apologies had been received as noted above.

Enclosure A Health and Safety Committee Minutes of the Meeting Held on 2 May 2013 held in the Abbey and Swithland Rooms, Evington Centre, Leicester General Hospital Site A University Teaching Trust PRESENT Bernadette Keavney BK Head of Trust Health & Safety Compliance (Chair) Helen Perfect HP Chair, FYPCS Divisional Group Liam Whitelaw LW RCN Steward Lorraine Austen LA Chair, CHS Divisional Group Samantha Roost SR Health and Safety Advisor Amanda Howell AH Senior Nurse Advisor - Infection Control Sue Deakin SD Moving and Handling Advisor Steve Walls SWa Local Security Management Specialist Mark Deardon MD Training and Quality Assurance Lead Paul Dickens PD Fire Safety Assurance Officer Mark Spencer MS Health and Safety Advisor Manjit Dharam MD Senior Finance Advisor Carolyn Jones CJ RCN Steward Kevin Robotham KR Emergency Planning Manager Glyn Lambley GL Statutory Compliance Manager, LLR FMC IN ATTENDANCE Maureen Bailey MB Health and Safety Administrator APOLOGIES Paul Miller PM Chief Operating Officer Julie Glover JG Chair, AMHLD Divisional Group Wendy Bath WB Corporate Services Manager (HIS) Neil Loach NL Occupational Health Nurse Kathryn Burt KB Head of Operational Human Resources 01/05/13 Present and Apologies Apologies had been received as noted above. BK welcomed all to the meeting and advised that Paul Miller had been appointed to the position of Chief Operating Officer and would be the Chair for future meetings. 19/05/13 Health and Safety Committee Terms of Reference and Attendance Sheet Enclosure O and O1 BK requested the committee review and agree if appropriate the revised terms of reference presented to the committee and advised the proposed changes had been highlighted. BK advised the significant changes to be are to support the Emergency Preparedness Resilience and Response (EPRR) Strategy and Page 1 of 12

Framework and to reduce the number of Staff Side Representatives (SSR) required to be deemed quorate. LW and CJ advised that given the current difficulties within the SSR service at this time agreed to this amendment however, recommended further agreement be sought from the wider SSR group as both LW and CJ represented RCN members. CJ to confirm with SSR group and inform the next committee of their decision. HP confirmed that only one SSR attends the FYPCS divisional group. It was also agreed that quoracy from the group should include representation from each Division and or Directorate to ensure information is received and shared in a timely manner. It was noted the Terms of Reference for the Divisional Groups would need to be reviewed to reflect the agreed changes BK advised that attendance to the committee has also been reviewed and thanked all for their continued support in achieving the required 75% attendance rate. MD asked what action had been taken to address those staff showing 0% attendance. BK advised the matter had been raised with Richard Apps, Trust Lead for Corporate Risk Assurance and attendance at this committee was being agreed at the Quality Directorate Senior Team Meeting scheduled for 7 May 2013. Members of the Health and Safety Committee agreed the changes to the terms of reference subject to further SSR approval. 02/05/13 Minutes of the meeting held 7 March 2013 Enclosure A Minutes of the meeting held 7 March 2013 were accepted as a true and accurate record. CJ 03/05/13/ 04/05/13 Matters Arising / Sheet - Enclosure B 22/01/13 Wheelchair Safety and Standardisation SD advised that she had spoken to Procurement about the standardisation of wheelchairs within the Trust however, was advised that Divisions are not restricted to what they could purchase and that current controls in place were minimal. BK suggested that a Task and Finish Group led by a Clinical Lead to take this matter forward within the Trust. LA suggested this should be Linda Wood, Service Manager for Occupational Therapy & Physiotherapy. The group would also need to review contracts for maintenance and would require full support from each division. SD to contact to progress and report back to the next committee. SD Page 2 of 12

10/03/13 Use of Lone Worker Devices HP advised that a date had been arranged but unfortunately this had had to be cancelled. BK advised that she has information on alternative devices available which she will forward and requested an update at the next meeting. HP/SW 18/03/13 HSE Visits HP and LA confirmed this had been discussed at Divisional Meetings. Confirmation awaited from AMHLD. MB to chase. MB 23/03/13 Police Intervention Report SW advised this information had been shared with the Divisions and that he is currently working on an end of year report with the Police advising the Trust of the work undertaken, prosecutions brought and the outcomes. BK requested this report be available by 17 May for inclusion in the Annual Report. SW 24/03/13 Estates and Facilities Alert EFA/ 2013/002 Window Restrictors It was confirmed this had been an agenda item on the Divisional Groups agenda and actions will be confirmed at the next Divisional Group meeting. Update to be provided to the next Health and Safety Committee. LA/JG/HP 18/03/13 External Visits - Health and Safety Executive (HSE) Investigation Bradgate Unit BK advised that following the HSE investigation at the Bradgate Unit confirmation had been received by the Trust that no further action would be taken on this occasion. BK acknowledged the support given by all staff involved and thanked them all for their assistance in this matter. 05/05/13 Health and Safety Policy Schedule Enclosure C SR presented to the committee a schedule of all health and safety policies currently identified and advised that there were a number due for review this year which the committee would be expected to consult on. Page 3 of 12

Members of the committee acknowledged the list and confirmed its support to the consultation period. 06/05/13 Ligature Policy BK advised the committee that the Ligature Policy had been presented and ownership formally transferred to the Patient Safety and Experience Group (PSEG) who agreed the policy subject to minor amendments on the 10 April 2013. Vicky McDonnell, Trust Lead - Quality and Patient Safety would be taking this policy forward within the Trust. 07/05/13 Emergency Preparedness, Resilience and Response Policy Enclosure D KR advised this policy had been distributed to members of the committee for onward dissemination and consultation. The consultation closes on 31 May 2013 and the final policy will be presented to the July committee for agreement. BK advised that Divisional Directors may want to review this document and requested Divisional Leads include their Senior Management Teams in the consultation process. All KR confirmed the policy outlines the standards, regulations and obligations of the Trust and outlines the Trusts framework, responsibilities and Key Performance Indicators (KPIs). BK also advised that the Clinical Commissioning Groups (CCGs) may also ask to review and test our arrangements in place. 08/05/13 Prevention of Arson Guidance Enclosure E PD presented to the committee the final version of the Prevention of Arson Guidance and advised that following consultation a number of amendments were received and included where appropriate. The guidance is therefore being presented to the committee for agreement. Members of the committee agreed the guidance. PD advised the final document would be available shortly and a copy of this should be placed in each Fire Log Book. 09/05/13 Health and Safety Training Enclosure F MD presented to the committee the Mandatory Training Report and advised there had been an increase in previous periods with some areas receiving an 85% compliance rate in some topics. MD advised The Academy had worked with the divisions to prioritise the topics pertinent to their service to ensure targets are met by the revised deadline of 30 June 2013. MD advised that divisions are Page 4 of 12

now receiving an update report every two weeks in an attempt to increase Trust compliance. BK informed the committee that staff attending Health and Safety Training had been an issue on the recent Staff Opinion Survey (SOS) and urged committee members to ensure that staff understood what constitutes Health and Safety Training. BK advised that the IOSH Management Refresher training is available for all staff who have either attended the IOSH four day course or would like an overview of health and safety. The course is also open to all new managers within the Trust. Dates for this course are included in Enclosure K. HP advised that the FYPCS Division are sharing the SOS Plan at the divisional meeting to ensure ownership. BK suggested this may be replicated in the other Divisions/Services. LA asked if it would be possible to know how many staff from each division have completed the IOSH Managing Safely Course. MD to forward this information to Divisional Leads and SR. All LA/JG/HP MD 10/05/13 LLR FMC Statutory Compliance Report GL advised that it was hoped a written report would be presented to this committee however, there had been a number of issues preventing this. BK asked for assurance that a written report would be received at the next meeting. GL advised that he hoped that it would however, the reporting structure had only just been agreed which indicates the assurance report would need to be presented to the LLR FMC Board prior to being presented to the committee. GL asked permission for Andy Powell, Deputy Director of Facilities to attend the July meeting. Members of the committee agreed this to be in order. GL to invite. BK and GL to meet to agree timeline in accordance with the agreed reporting structure. GL BK/GL GL advised that due to the technical issues experienced since 1 March 2013 it was difficult to provide accurate figures however, highlighted a number of areas where non-compliance had been raised these included inductions to LPT be completed within two working days, statutory and non-statutory inspections and emergency requests receiving adequate response time. GL advised that 95% of statutory and 90% of non-statutory inspections had been undertaken, the compliance rate for this KPI is 100%. Statutory inspections include Planned Preventative Maintenance (PPM) for items such as lifting equipment, pressure and boiler systems. Examples of non-statutory compliance include guttering and electric doors. Page 5 of 12

GL reiterated however that issues with the CAFM system meant a delay in information being recorded and this compliance rate is expected to change once all of the information has been entered. BK requested that future reporting include details of what has not been completed in order that gaps in compliance are highlighted, rather than what has been completed to provide the Trust with an early warning mechanism for risks, trends or themes. GL advised that with regards to emergency response times guidance is being developed on what is termed an emergency, as at present this is based on an individuals perception of a situation. This guidance once developed will be shared with the committee and may alleviate some of the issues presently being experienced. It was noted that response times would need to be agreed by the Trust as these are dependent on the area and the service provided and what may be acceptable for one area may not in another due to the patient group. LA advised that the On-Call Manager and Directors receive a number of calls from staff who have been advised by the Interserve Help Desk to contact their On-Call Manager, which is not the correct or appropriate action. GL advised that he had been asked to advise that Interserve do feel well supported by the Trust and that it is hoped initial issues raised will be ironed out as part of the bedding period of three months. GL advised that there are financial penalties linked to the KPIs which come into full force from July 2013. MD advised that assurance will need to be provided that the training staff receive is appropriate to the tasks they are undertaking and they areas in which they are working eg MAPA for inpatient mental health areas. If this is not in the contract then this is a risk and will need monitoring accordingly. GL agreed to provide this information to MD. KR asked about business continuity and EPRR in identified critical activities and agreed to undertake a benchmarking exercise with GL. KR advised there had been an issue recently with generator testing. GL advised there were specific ways in which a generator can and must be tested and all parties need to have an understanding on this is undertaken and the impact of testing on services. GL KR/GL It was raised that there had been an issue raised with the spillage kits in use being changed. AH advised that she was not aware of any changes to the kits used and would take up outside of the meeting. BK advised that at the request of the Divisional Directors the Health Page 6 of 12

and Safety Compliance Team will be maintaining a register of issues arising from the new contract with Interserve, however, these issues need to be first logged with the interserve help desk and if they are then not dealt with in a timely manner then they can be recorded as an issue. Whereby an issue is raised that is not a maintenance issue e.g. contractual changes in arrangements then these can also be logged. GL advised that a further issues experienced was a number of staff on the Interserve structure were in interim positions. These positions are now being filled with permanent staff. Neil Mitchell has been appointed to the post of Director of Operations. It was hoped all appointments would be made imminently and agreed to forward the final Interserve and LLR FMC structures to the committee in July. GL 11/05/13 Update on LPT Compliance against EU Sharps Directive Enclosure G AH presented to the committee Enclosure G and apologised for the lateness and the paper being tabled at the meeting. AH advised the delay had occurred to ensure the most accurate and up to date information has been received and reported on. AH advised that following a review of the directive by herself and MS, the overarching risk assessment had been reviewed and was now recorded within the Safeguard risk register. Each Division via the Divisional Lead Nurse have been asked to look at their own areas and undertake a local risk assessment to identify main risks for each division with a view to safer sharps working and to ensure that all staff are captured. AH advised that the risk assessment and current work book in place for training are compliant with the directive however, this would need to be reviewed should the training package delivery change in the future. AH was asked to confirm if there were any concerns from the information provided? AH advised the committee that she is confident the Trust are compliant with the overarching elements of the directive however, was not so confident of divisional compliance and that the Divisional Lead Nurses have been asked to produce action plans for monitoring. AH advised that systems are in place within the CHS division and actions have been put in place for higher risk areas. Podiatry Services have transferred to single use injections, a change that was cost neutral to the service. AMHLD had undertaken a lot of work especially around the use of Page 7 of 12

arm protectors however, work is still ongoing to raise staff awareness of their necessity rather than preference. AH advised that difficulties had been experienced in receiving information from the FYPCS division however, some assurance has been received but a number of gaps are still requiring addressing. AH will be working with the division to ensure compliance is achieved. AH advised the committee that more devices considered safer are becoming available however, Divisions / services need to ensure the device whilst considered safer for some is the most appropriate for the service delivered and that the appropriate training is available and delivered to staff prior to use. Any new devices would need to be trialled and decisions evidence based on those trials. AH asked GL to provide assurance to the next committee that Interserve were compliant with this directive as part of the Statutory Compliance Report. GL CJ asked what would happen if a member of staff sustains a sharps injury after 11 May 2013 on a traditional device? AH advised the Trust are able to evidence that we are working towards and that each incident is reviewed as it is not always the better option or it could be the safest device but a training need has been identified. For example, it was identified within the Podiatry Service that a particular single use item had posed a high risk as the device was snapping. This device was not changed. AH advised that an update would be provided to the Infection Prevention and Control (IPCC) and Health and Safety Committee of any trials currently taking place within the Trust. BK requested the overarching risk assessment be reviewed to include the HSE regulations which came into form in May 2013. AH/MS LW asked for clarification regarding Item 34 of the checklist. AH advised that this did not appear to be an issue with the Trust but was a national indicator. 12/05/13 Use of Lone Worker Devices Enclosure H MB presented to the committee a report identifying the work undertaken by the Health and Safety Compliance Team in the allocation of the Reliance Lone Worker Devices. MB advised that following the risk assessment last year services had been asked to review the usage of the devices and the enhancement to the lone working systems they provided. As a result of this the committee were advised that whilst the number of devices within the Trust had not decreased to those Page 8 of 12

previously expected, a number of devices were being redeployed to services where their use had been identified as an enhancement. LA asked if usage would be monitored to ensure they are used to their maximum benefit. SW advised that monthly user reports are available and would be forwarded to service managers for monitoring. This information is also included in Local Security Management Service Quarterly report. MB/SW/BL 13/05/13 Fire Authority Audits Enclosure I PD presented to the committee a brief guide on the process undertaken and the potential outcomes following Fire Authority Audit visits and advised that inpatient areas are audited every three years using a central government audit tool to assess. PD advised that he hopes to attend all audit visits and will be visiting all high risk sites prior to audit to assist and advise staff on the expectations of them. PD advised that there had been some confusion over the title Responsible Person and clarified that with regards to fire any person in a position to make a difference or influence a decision are considered a Responsible Person by the Fire Authority. PD advised that he is meeting with the local Fire Authority to confirm how the Trust is advised of any visits and requested that staff are informed to advise him immediately should they receive notification directly of an audit visits. All visits by the Fire Authority are to be managed via the Management of External Visitors Policy. PD advised that a Fire Authority audit at Mill Lodge in April 2013 achieved Broadly Compliant which is the highest compliance rate to be achieved from the audit. 14/05/13 Fire Warden / Co-ordinator Training Enclosure J PD advised that an issue that has been identified within the Trust relating to fire is the lack of appropriately trained Fire Wardens / Coordinators. To address this issue the current training package is being revised and developed in associate with Interserve who deliver the training and sessions are available for staff to attend as detailed in Enclosure J. PD asked for Divisional Leads to check with services the Fire Warden / Co-ordinator allocations and to identify appropriate staff to fulfil this role within each site. LA/JG/HP 15/05/13 Health and Safety Refresh Training Enclosure K See item 09/05/13. 16/05/13 On-call Director Alerting Flowchart Enclosure L Page 9 of 12

KR advised that he had met with a number of Directors to provide On-call training and that further training sessions will be held in due course. KR also advised that he would be reviewing the On-call pack to ensure all information is correct and advised the flow chart had been developed to clarify the Director On-call process. 17/05/13 LPTIA/2013/003/Q&I NHSLA Certificate Enclosure M BK advised the Committee the above alert has been distributed by the Risk Department and requested Divisional Leads ensure this alert has been actioned as requested. LA/JG/HP 18/05/13 RIDDOR Reporting Flowchart Enclosure N SR advised the flowchart had been developed to advise members of the committee of the internal process undertaken by the Health and Safety Compliance Team following a RIDDOR incident. SR confirmed that each RIDDOR incident is fully investigated by a member of the team and the findings and recommendations are shared with the service and the division. Members of the Health and Safety Committee noted and supported the internal investigation process. 20/05/13 Emergency Preparedness, Resilience and Response (EPRR) Enclosure P KR advised the committee that the new NHS England Core Standards for EPRR outline the minimum standards for preparedness for emergencies and business continuity that the Trust needs to show assurance of compliance to the CCGs. KR advised that it had been noted the current Emergency Plan is out of date and advised it is currently being reviewed and that a gap analysis would be undertaken to establish where the Trust is achieving compliance. This will determine the workplan for the Emergency Planning Manager to ensure compliance across the whole Trust. KR advised that some incidents are being reported via the Safeguard system and that incidents of telephone lines and confirmed he would be working with the Risk Assurance Team to ensure incidents are reported when appropriate To support this process KR requested that anybody identifying a potential business continuity or emergency planning issue contact him to discuss an appropriate course of action. Confirmation was sought as to whether telephone lines not being available should be reported as an incident? KR advised that a standard of reportable incidents would need to be agreed, reported LA/JG/HP/ Page 10 of 12

and monitored through the divisional action groups. KR 21/05/13 Sling and Hoist Inspection Flow Chart and verbal update from Moving and Handling Steering Group Enclosure Q SD advised the committee that an internal alert had been issued through the Central Alert System (CAS) regarding illegible labels on slings. An audit form was also issued along with the alert. SD confirmed this audit only applied to slings owned by the Trust and did not include those owned by the community equipment store. The alert is due to close on 31 May however, an update from the Risk Assurance has confirmed that the audit has taken place within CHS and actions are underway within the other Divisions. SD advised that the flow charts has been developed to advise the Divisions of the process undertaken when inspecting a sling or hoist and advised that insurance inspectors are currently undertaking inspections and changing inspection tags, the colour of which will be green from April 2013. SD confirmed these flowcharts would be included in the Code of Practice for Using Hoists to Move Clients. SD confirmed a formal report would be presented to the Health and Safety Committee in July to advise of the outcome of the audit, the recommendations made and the actions taken. SD 22/05/13 Staff Side Issues BK confirmed that no issues had been raised by SSR prior to the meeting. CJ and LW confirmed there were no issues to raise at this time. 23/05/13 24/05/13 25/05/13 Minutes of the Divisional Health, Safety and Security Groups AMHLD 17 January 2013 Enclosure R CHS 21 February 2013 Enclosure S FYPCS 6 February 2013 Enclosure T 26/05/13 Minutes of the Healthy Organisation Group (HOG) Enclosure U 18 February 2013 CJ asked whether it would be possible for SSR of the Health and Safety Committee to receive minutes of the HOG directly for information. BK to make request for KB. BK 27/05/13 Minutes of the Infection Prevention and Control Committee 8 January 2013 Enclosure V 28/05/13 JSCNC Minutes Enclosure W 17 January 2013 Page 11 of 12

29/05/13 PSEG Minutes Enclosure X 13 February 2013 and 13 March 2013 30/05/13 Missing Persons and Violence Reduction Group Minutes Enclosure Y 15 February 2013 and 15 March 2013 Members of the committee received and noted the above enclosures without issue. 31/05/13 Missing Persons and Violence Reduction Group Terms of Reference Enclosure Z 32/05/13 NHS Protect Circular re: Future Guidance Enclosure AA 33/05/13 Any other business 33/05/13.1 Plans for Heatwave and Pandemic Flu KR asked if members of the committee were aware if there were such documents within the Trust. It was felt that there was and LA advised that John Mallon and Tim Davis may be able to assist. KR advised that NHS England will be looking for them and task and finish groups to support their development would need to be formed with the support of the Divisions. 34/05/13.2 Property Security SW advised that a member of the local group known as the Coventry Falcons who have been working across the Midlands has successfully been prosecuted. However NHS Protect and the Police have advised that this group appear now to be targeting smaller sites and staff should be extra vigilant in ensuring buildings and property are kept secure. SW advised that an article will be placed in the weekly newsletter to support this. SW/BL 33/05/13 Date and Time of Next Meeting Thursday 4 July 2013 10.00 am 12.30 pm Abbey / Swithland Room, Evington Centre, Leicester Agenda items and enclosure to be received by Friday 19 April 2013 BK thanked all for their attendance. The meeting closed at 12.20 pm Page 12 of 12