NHS Highland Board 5 April 2016 Item 3.4 DRAFT ASSURANCE REPORT of MEETING of the HEALTH and SAFETY COMMITTEE Board Room, Assynt House Assynt House Beechwood Park Inverness IV2 3BW Tel: 01463 717123 Fax: 01463 235189 Textphone users can contact us via Typetalk: Tel 0800 959598 www.nhshighland.scot.nhs.uk 11 February, 2016 10.00 am Present In attendance Apologies Ms Elspeth Caithness, Joint Chair and RCN Health & Safety Representative Mrs Elaine Wilkinson-Crane, Joint Chair Mr Stephen Don, UNITE Mrs Anne Gent, Director of Human Resources (from 11.00am) Ms Tracy Ligema, Deputy Director of Operations, North and West Mrs Katherine Sutton, Deputy Director of Operations, Raigmore Division, Inner Moray Firth Unit (from 10.30am) Mrs Rosie Brunton, Health & Safety Manager, Raigmore Hospital Mr John Burnside, Environmental Sustainability Manager (from 11.10am) Ms Fiona Campbell, Clinical Governance Manager, Argyll & Bute CHP (by videoconference) Ms Diane Fraser, Violence and Aggression Prevention Manager Mr Eric Green Head of Estates (by videoconference) Mr Andy Knox, Fire Safety Advisor Ms Debbie Miller, Occupational Health Business Manager Ms Fiona Miller, Health & Safety Manager (by videoconference) Mr B Mitchell, Committee Administrator Ms Alison Moore, Health & Safety Manager Ms L Rawlinson, Occupational Health Nurse Manager Mrs Catherine Stokoe, Infection Control Manager Mr Bob Summers, Head of Health & Safety Ms Karen-Anne Wilson, Health & Safety Manager (by videoconference) Fraser Brunton, Ian Duff, Carl Hope, Mirian Morrison, Bob Silverwood and Christina West.
1) DECLARATIONS OF INTEREST There were no declarations of interest. The Committee agreed to consider the Agenda Items in the following order in the meeting. 2) TOPIC: HEALTH AND SAFETY POLICY AND PROCEDURES FIRE SAFETY POLICY What is position in relation to development of Fire Safety Policy? E Green spoke to the circulated Fire Safety Policy, which had been presented for ratification following an extensive consultation exercise. Members welcomed the Policy. Agreed to ratify Policy E Green 3) TOPIC: HEALTH & SAFETY IMPROVEMENT PLAN CORPORATE PLAN UPDATE Issues/Risks/Outcome Expected Assurance Actions Fire Safety Training There had been circulated Training Needs Analyses for generic fire training, fire extinguisher training, fire marshall/warden training, workplace specific fire safety & evacuation training and Highland fire safety e- learning. BS stated that accurate recording of attendance data in OLM still problematic. EG advised illustrated range of activity underway. Issue relating to number of staff attending organised training events. AG advised RPIW to look at a range of training aspects including in relation to fire safety training. To include issues around identification of individual training needs and attendance recording. EG urged manager engagement in identifying actual training needs and attending training. Noted attendance issue not restricted to fire safety training. Chair 2
welcomed activity and stated data relating to Statutory training compliance would enable focussed activity. Await outcome of RPIW on Statutory and Mandatory Training Fire Safety Evacuation Training Window Restrictors Update Building Water Safety EG advised series of successful training events had been undertaken. AK added number of Adult Social Care premises staff had been involved, with examples of positive activity evidenced. He added quality and variety of training had improved, this being tailored to individual locations as appropriate. Overall the position was much improved. The Chair welcomed the update and assurance provided. EG advised assessment and installation activity ongoing, with relevant financial resource appropriately identified and set aside. EG advised the next meeting of the Water Safety Group was to consider all relevant Risk Registers. Overall, good progress was being made, with relevant matters being taken forward as appropriate. The Chair welcomed the progress reported. Estates to establish PPM maintenance schedules for installed window restrictors E Green Agreed Window Restrictor Procedure to be submitted to May 2016 meeting E Green Mr E Green and Mr A Knox left the meeting at 10.25am. 4) TOPIC: ASSURANCE REPORT 5 NOVEMBER 2015 Any issues relating to accuracy of Assurance Report? No matters raised. Noted Assurance Report had been considered by NHS Board. Rolling Action Plan to be regularly updated Committee Administrator 3
5) TOPIC: RPIW REPORT OUT IMPROVING ACCESS TO OCCUPATIONAL HEALTH NURISNG SERVICES What are the outcomes to date from RPIW activity in relation to improving OH access? L Rawlinson and D Miller gave a 90 day Report Out presentation to members, following initial identification of issues including DNA rates, referral quality, initial appointment waiting times and management of existing cases. It was reported that recent recruitment activity had been successful and following appropriate training would have a positive impact on service delivery. DM took members through the RPIW process and advised this had led to identification of some 53 waste areas and generated 40 improvement ideas. Areas identified for improvement had included alignment with relevant Key Performance Indicators (KPIs), form completion, ehealth aspects, reducing inappropriate referrals, a reduction in the DNA rate (was 13%) and a removal of some administrative activity undertaken by OH Professionals. Activity undertaken since the 60 Day Report Out had included completion of 56 out of 72 actions identified in the previous RPIW Newspaper. This included commencement of training activity for managers across Operational Unit areas, scheduling improvements, and implementation of case management triage processes. Other activity included the purchase of dictation equipment for OH Professional staff and the introduction of a weekly meeting with admin staff to ensure standardised working. Work was in progress in relation to ehealth and communications aspects, including text reminders and investigation of options for managers to book pre-referral discussions. LR stated future challenges related to sustaining the progress made to date through a continuous 4
6) TOPIC: REVISED HEALTH AND SAFETY POLICY testing regime, fulfilling the ambitious improvement plan, and increased introduction of dictation activity for nursing staff. The Chair welcomed the update, congratulating those involved in the successful activity to date, and recognising the educational element for managers making referrals. Ms D Miller left the meeting at 10.50am. What is the position in relation to the revised Health and Safety Policy? BS gave a presentation to members, introducing the recently revised Policy. The Policy, required by Statute, had been revised due to a number of reorganizational and structural changes over recent years and had been no longer fit for purpose. He outlined the key Policy principles which were to; underpin and enable HQA and our objectives, support an integrated, joined-up culture and approach to safety, taking a risk based approach to statutory compliance, promoting sensible risk management, build and maintain competence and facilitating mangers to own and control their risks. BS outlined the relevant accountabilities and responsibilities for managers and staff, the governance arrangements along with the appropriate document control and structure. Implementing the Policy required a safety management system based on a Plan-Do- Check-Act approach and NHSH subscribed to the HSEs HSG65 Managing for Health & Safety model. The Policy itself was a one page document and was underpinned by a documented suite of management 5
What should the NHS Board be seeking to achieve, avoid and be mindful of? How should the revised Policy be taken forward? arrangements (eg governance & assurance, risk assessment, accountabilities & responsibilities, competence, consultation, monitoring etc), and hazard based procedures (eg COSHH, Violence and Aggression, Moving & Handling, Fire Safety, Occupational Road Risk, Lone Working) In summary, successful Policy implementation would rely on good visible leadership, effective risk management, control, communication and staff consultation by managers and staff. BS highlighted a range of day to day activity areas that should ideally be commenced or continued, with a degree of focus on leadership, culture, investigation and reporting. There was a role for senior managers in taking staff along the Health & Safety journey. He emphasised the importance of prioritising and discussing difficult issues whilst making the best use of available resource, the importance of being able to consider upstream elements, developing appropriately designed systems and being mindful of the potential impact of decisions being taken at a high level. In thanking Mr Summers for the development of a comprehensive and easy to read document it was stated this should be presented at NHS Board level. There was general agreement that a communications plan, based on the Statement of Intent was required. It was suggested that to emphasise the links between Health & Safety and patient safety that activity be undertaken in a single hospital ward to test the approach at front line level. The Committee otherwise agreed to endorse the circulated revised draft Health and Safety Policy subject to the Statement of Intent being updated to reflect discussion in relation to links to patient safety. 6 Agreed to circulate a web link to video on leading staff Committee Administrator Agreed dissemination of the Policy be planned in association with Communications Team B Summers Agreed to consider how best to develop a communication plan. Suggested this could be tested within in a single ward in Raigmore Hospital B Summers Agreed the Statement of Intent be amended to reflect discussion on patient safety links B Summers
7) TOPIC: HEALTH & SAFETY IMPROVEMENT PLAN CORPORATE PLAN UPDATE Issues/Risks/Outcome Expected Assurance Actions Redevelopment of Health and Safety Intranet Site BS advised discussion held with ehealth, including in relation to review and redesign of H&S Intranet site and accessibility of material. Concern that Intranet nugget for Health and Safety no longer on front page and message this sends to staff. AG suggested this be rebadged Safety to reinforce overall message. Agreed Intranet element be re-badged Safety B Summers Progress on Sharps LearnPro Training Uptake Audit the Implementation of VA Individualised Risk Assessment and Management plans in Care Homes, Community and Ward Areas There had been circulated a report indicating the performance against the training uptake targets to October 2015. This showed that Dental Services had achieved 100%, Argyll and Bute 75%, North and West 70%, Raigmore 40% and South & Mid 50 (approx figures). Challenges in collating data were noted. Stated using sharps safely is reinforced by adopting safe behaviours/practice and could only be underpinned through training and supervision. Operational Units were strongly encouraged to promote and drive forward improvements in uptake before end March 2016 in order to secure safe practice and patient care. FM requested quarterly updates to Operational Units and the Chair requested a further update also be provided to the November 2016 meeting. Ms Fraser advised progress was being made. Dates were in place to visit and audit Care Homes and this would include electronic survey activity. Assessments would consider other aspects in addition to Violence and Aggression. AG suggested consideration be given to streamlining the assessment process. 7 Agreed consideration be given to provision of quarterly updates to Operational Units where behind trajectory B Summers Agreed further update be submitted to November 2016 meeting B Summers
Review Extent of Physical Restraint across NHS Highland BS and DF advised were investigating extent of use across general settings, this to include sedation activity etc. Relevant issues were being discussed with senior staff members. Agreed further update be submitted to August 2016 meeting B Summers Review the Incidence and Learning Associated with Patient Related Slips and Trips The Chair requested, and the Committee agreed that an update be provided to the August 2016 meeting. Agreed further update be submitted to August 2016 meeting B Summers 8) TOPIC: WASTE MANAGEMENT Issues/Risks/Outcome Expected Assurance Actions How is Waste Management within NHS Highland addressed? JB spoke to the Committee, advising as Environmental Sustainability Manager he and his team, as part of the Estates Service, had responsibility for policy implementation across NHSH with activity recorded on the emart system. Annual spend was in the region of 820k per annum. He was Chair of the North Waste Consortium, meeting quarterly and comprising seven NHS Boards. There was a National Waste Management Steering Group that reported to a National Sustainability Group. In Highland, the contract for non-clinical waste was held by MITIE, this having been extended to September 2016. Having outlined relevant technical aspects, including in relation to the circulated CEL14(2013) Scottish Government letter and Waste Management Action Plan 2013-2016, JB advised the Scottish Government Zero Waste plan set challenging targets for all NHS Boards, with Waste (Scotland) Regulations having been introduced in 2012. This impacted on areas such as recycling, food and bio-degradable waste. In Highland, following a previous audit of activity, areas of non-compliance had been addressed, 8
there was close liaison with the local SEPA Officer, and a Highland Waste Management Group established. The Group had developed an Action Plan, segregation chart; was in the process of developing an appropriate policy document, associated procedures and risk assessment for community based staff. Other actions had included savings identification and development of a Sustainable Development Action Plan. A contract for food waste management was out to tender. A system (Warp-It), funded by Health Facilities Scotland, for re-use of equipment, furniture and other resources had been established and this was generating a range of cash and carbon savings. Consideration was being given to extending the scheme to Highland Council and perhaps University of Highlands and Islands. A Dangerous Goods Safety Advisor had been engaged. There were now four waste audits per year, the most recent of which had related to clinical waste storage areas. Current activity included the introduction of reusable sharps boxes in all areas and the removal of plaster casts and dental moulds from clinical waste. Why was the emart system introduced in NHS Highland? JB advised this allowed for more efficient reporting, especially from relevant contractors. It would also assist in the production of future sustainability reports. What are the arrangements in Argyll and Bute? JB advised he maintained overall responsibility and that Mr J Dempsey managed the local arrangements in that area. The Committee thanked Mr Burnside for the comprehensive update provided and requested that an annual update on the Waste Management Group Action Plan be submitted to the Committee. 9 Agreed Integrated Joint Board be reminded as to Policy adherence and assurance requirements J Burnside Agreed to receive annual progress report on the Waste Management Group Action Plan J Burnside
Mr J Burnside and Ms D Fraser left the meeting at 12.10pm. 9) TOPIC: OPERATIONAL UNIT PLANS Operational Units had been requested in addition to usual reporting arrangements to provide updates, based on current Plans, in relation to Bedrails, Window Restrictors, Sharps Training in Clinical Nursing areas, Face Fit Testing and Medical Gases External Storage. Inner Moray Firth - Raigmore Division Bed Rails Window Restrictors Sharps Training Target Face Fit Testing Medical Gases Training South and Mid Division Bed Rails Window Restrictors Sharps Training Face Fit Testing North and West Bed Rails Confirmed Policy now available and applied. Audit now complete and schedule for fitting being developed. An uplift in training being evidenced at this time. No uplift in training since last reported position, and consideration being given as to how to improve testing provision. Audit now complete in all hospitals. Reports are also now issued to all Directors of Operations. Confirmed Policy now available and applied. Most audits now complete. New Craigs subject to technical restrictions given aspects relating to ligature point risk. Overall, activity ongoing. Issue raised at all relevant meetings. 92% of relevant staff have now completed training, with remainder of training having now been scheduled. Policy being applied and relevant training being 10 Raigmore Health and Safety Manager to provide ongoing support R Brunton
developed. Activity was being maintained and strong progress evidenced. Window Restrictors Sharps Training Face Fit Testing Argyll and Bute Bed Rails Window Restrictors Face Fit Testing Sharps Training Medical Gases Activity within most facilities now complete, with only couple of locations remaining outstanding. 70% of relevant staff completed training, activity ongoing and continued improvement expected over next two months. Training activity ongoing, with particular issue in Skye area, where target of 90% completion has been set for end March 2016. Overall, 69% completion at this time. New Policy and Risk Assessment documentation disseminated. Implementation to be monitored via Nursing cohort. Activity for new staff now in place. All assessments now complete. Training activity challenging due to staffing resource capacity issues. Operational Unit Health & Safety Group considered report on training of new testers and this also considered by Infection Control Improvement Group. BS advised that training of Health & Safety Managers as testers would be of benefit. 75% of staff training complete. COSHH audits to be conducted in March 2016. Audit of all relevant sites, with exception of Lorn & Isles and Mull now complete. 11
10) TOPIC: REPORT BY HEALTH & SAFETY REPRESENTATIVES What is the position in relation to Health and Safety representatives? EC re-emphasised reduction in number of representatives, including loss of community representative, had impacted on capacity and presented a challenge at this time. Engagement with representatives could be improved and Operational Groups should consider how best to utilise this resource. Further training for representatives should also be considered. BS emphasised the important role played by representatives, especially at ward level. The Committee noted the position. 11) TOPIC: ADVISER S REPORTS 11.1) Clinical Governance and Risk Management Performance What is the current position in relation to activity? 11.2) RIDDOR reporting What is the latest position in relation to RIDDOR reporting in NHSH? AG advised that further consideration was being given in relation to improvement activity, including dissemination of appropriate information and ensuring appropriate actions were taken. BS spoke to the circulated report outlining RIDDOR events and the status of possible investigation activity. He provided further information in relation to two specific events. With regard to the storage and transport of formaldehyde, FM advised a number of recommendations had been identified and a formal action plan requested. BS stated activity ongoing in relation to consideration of aspects relating to wandering patients, the detail of which was required to be shared with HSE. The 12 Agreed action plan be submitted to next meeting F Campbell Update on progress to August 2016 meeting B Summers
11.3 ) Infection Control What are the current issues in relation to Infection Control within NHSH? 11.4) Occupational Health What are the current issues relating to Occupational Health? 11.5) Radiation Protection What is the latest position in relation to Radiation Protection in NHSH? importance of taking and applying learning from events was emphasised. CS advised had evidenced a rise in Cdiff cases across NHSH, leading to breach of the relevant 2015/16 target. A range of focused activity was underway in Raigmore Hospital. Discussion was being held in relation to the potential for undertaking hydrogen peroxide fogging as a proactive measure. CS further advised there had been 58 SAB cases, against the 2015/16 target of 61, with a breach of that target now likely. Had met with HPS to appraise of the position and discuss the action being taken. Committee noted the circulated report outlining recent activity levels against Key Performance Indicators. Noted OH to be involved in RPIW activity considering how to improve the current recruitment process in March 2016. Committee further noted the proposal to develop and submit an OH service performance dashboard, based on the HQA High 5 to inform the NHS Board on issues around staff health and wellbeing. In relation to this dashboard a number of quality indicators would be reported quarterly to this Committee and others would be included within an annual report, all as indicated. There had been no significant health concerns identified through current health surveillance programmes or referrals. The Committee noted the circulated report which gave updates in relation to Radon activity, Oncology, Lasers, Radiation Protection Service and the Radiation Safety Committee. 13
12) TOPIC: Consideration of Items for Inclusion Within Internal Audit Work Plan 2016/17 Issues Assurance Actions What Health & Safety issues were discussed for inclusion? Reported that no formal feedback had yet been received in relation to previously scheduled meeting with Internal Audit representatives. Agreed to establish if meeting took place Committee Administrator 13) TOPIC: Feedback from NHS Highland Governance Review What is the position in relation to current review AG advised review being led by Jan Polley, of governance arrangements? including in relation to impact of Integrated Joint Board in Argyll and Bute from 1 April 2016. Consideration was being given to what constitutes a Governance Committee alongside issues relating to leadership/vision versus assurance and performance reporting. The relationship of Governance committees and the NHS Board would be discussed and this would include aspects relating to revision of relevant Committee Roles and Remits, including for this Committee. BS advised HSE/Institute of Directors had recommended a minimum of one Non-Executive Board member sit on NHS Health & Safety Committees, as best practice. The Chair advised initial Review outcomes, focussed on the impact of changes in Argyll and Bute, were expected by end February 2016 and these would be considered in the first instance by the NHS Board and Chair. 14) TOPIC: ANY OTHER PREVIOUSLY NOTIFIED COMPETENT BUSINESS Are there any issues for the Committee to consider? The Committee noted the circulated British Medical Journal Article titled The problem with incident reporting. 14
C Stokoe left the meeting at 12.40pm. 15.1) TOPIC: Draft Minute of Meeting of Medical Gases Committee held on 15 December 2015 Issues Assurance Actions Any issues arising from the Minute? No issues reported. Noted Minute 15.2) TOPIC: Minute of Meeting of Waste Management Steering Group held on 22 October 2015 Issues Assurance Actions Any issues arising from the Minute? No issues reported. Noted Minute 15.3) TOPIC: Argyll and Bute Health and Safety Assurance Report Issues Assurance Actions What is the position in relation to the management of Health & Safety under the Integrated Joint Board? FC spoke to the circulated report detailing activity of the Health & Safety Working Group (Health and Council) including development of outline proposals and Terms of Reference for a Health and Social Care Partnership Health & Safety Group, the first meeting of which would take place on 18 February 2016. Relevant membership had been identified. Existing arrangements would continue in the interim. There would be focus on identifying where joint arrangements were necessary for the safe and efficient operation of the Partnership, with a mapping exercise reporting to the HSCP H&S Group who would approve and monitor the longer term evolution of joint systems. FC further advised a number of staff Terms and Conditions issues to be considered when looking at responsibilities of managers. A report 15 Agreed report on future working
on future working arrangements would be presented to the next meeting. arrangements to be submitted to next meeting F Campbell What issues have the Health & Safety Working Group recently considered? Noted the October meeting had considered a First Aid mapping exercise alongside progress updates in relation to prioritised work strands including Fire Safety, RIDDOR, Incident Reporting, and the NHSH Sharps Policy. 14) DATE AND VENUE OF NEXT MEETING The next meeting of the Health and Safety Committee will be held on Thursday 12 May 2016 at 10.00am in the Board Room Assynt House. The meeting closed at 12.50pm 16