Occupational Health & Safety Policy N.B. Staff should be discouraged from printing this document. This is to avoid the risk of out of date printed versions of the document. The Intranet should be referred to for the current version of the document. Policy Number:
Contents: 1 INTRODUCTION... 3 2 POLICY STATEMENT... 4 3 ORGANISATION / RESPONSIBILITIES... 5 3.1 THE BOARD / DIRECTORS... 5 3.2 HEALTH AND SAFETY MANAGER... 5 3.3 HEALTH, SAFETY AND FIRE DEVELOPMENT OFFICERS... 7 3.4 HEALTH, SAFETY & FIRE DEVELOPMENT ASSISTANTS... 7 3.5 CLINICAL DIRECTORS AND SENIOR MANAGERS... 7 3.6 LINE MANAGERS AND CLINICIANS... 8 3.7 SAFETY REPRESENTATIVES... 9 3.8 SAFETY COORDINATORS (COMPETENT PERSONS)... 9 3.9 SAFETY SUPERVISORS (SPECIALIST DEPARTMENTS)... 10 3.10 OCCUPATIONAL HEALTH PHYSICIAN... 10 3.11 EMPLOYEES... 10 4 OCCUPATIONAL HEALTH SERVICE... 11 4.1 OCCUPATIONAL HEALTH WILL PROVIDE THE FOLLOWING SERVICES:... 11 4.1.1 PRE-EMPLOYMENT HEALTH ASSESSMENT... 11 4.1.2 HEALTH ASSESSMENT IN EMPLOYMENT... 11 4.1.3 HEALTH SURVEILLANCE... 11 4.1.4 IMMUNISATION... 12 4.1.5 LIAISON WITH HEALTH AND SAFETY... 12 4.1.6 IDENTIFICATION OF OCCUPATIONAL HAZARDS AND RISKS.. 12 4.1.7 STAFF SUPPORT AND ADVICE... 12 5 RISK MANAGEMENT... 12 6 RIDDOR (1995)... 12 7 ARRANGEMENTS FOR IMPLEMENTING POLICY... 13 8 TRAINING... 13 9 AUDIT... 14 10 INFORMATION... 14 11 RISK ASSESSMENT... 15 12 WORK INSPECTIONS... 15 13 WORK EQUIPMENT... 15 14 PERSONAL PROTECTIVE EQUIPMENT... 16 15 CONTRACTORS AND CONTRACTED SERVICES... 17 16 DRIVING AT WORK... 17 17 CONSULTATION... 18 18 SUPPORTING POLICIES... 18 Page 2 of 19
1 INTRODUCTION Every year 2.2 million people suffer ill health caused or made worse by work. (HSE IND (G)62L). The Health and Safety at Work etc Act 1974 was introduced to protect people whilst at work and also to protect others affected by our workplace activities. This includes patients, visitors, contractors and volunteers. European Directives were introduced in 1992 to support the Health & Safety at Work Act and introduce the principle of Risk Assessment. The management of Health & Safety at Work regulations places specific emphasis on making risk assessment a legal requirement which is the focus around the management of Health & Safety. Senior Managers and clinicians in each Division / Directorate / Locality are responsible for implementing this policy and ensuring their managers, in turn, make adequate arrangements to comply with this policy and health and safety legislation. This policy is applicable to all Health & Safety Legislation. Where separate policies exist these have been cross referenced in this policy and should be read in conjunction with this policy. All policies are available on the Intranet. Page 3 of 19
2 POLICY STATEMENT 2.1 It is the policy of Aneurin Bevan Health Board to do more than just prevent work related harm. The Board will promote better working environments with initiatives to motivate staff and encourage pro-active management. 2.2 The Chief Executive of Aneurin Bevan Health Board has a legal and moral duty to secure the health and safety of employees, patients, visitors and others. In order to achieve this Aneurin Bevan Health Board will promote a strong safety culture. 2.3 Aneurin Bevan Health Board will continue to strive to achieve standards of best practice. 2.4 To complement the Welsh Assembly Government s vision for a competitive, knowledge driven economy, Aneurin Bevan Health Board will have a workforce that understands its responsibility in relation to health and safety and the benefits of a culture which promotes health and safety for individuals and Aneurin Bevan Health Board as a whole. 2.5 Occupational Health is a crucial part of Aneurin Bevan Health Board s safety strategy, working along side health & safety to secure continuous improvement in employee and organisational safety and well being. 2.6 In order to maintain the highest standards of care for patients, all staff must play a part in the implementation of the Policy in practice. 2.7 This Policy is applicable to all premises either owned, leased, rented or managed for the business purpose of Aneurin Bevan Health Board where staff are expected to work from or visit during their employment. Signed Date Andrew Goodall Chief Executive Page 4 of 19
3 ORGANISATION / RESPONSIBILITIES 3.1 THE BOARD / DIRECTORS 3.1.1 The Chairman and Directors of the Board have an overall legal responsibility for Occupational Health and Safety. 3.1.2 The Chief Executive is given ultimate responsibility by the Board for ensuring the day-to-day implementation of this policy. 3.1.3 The Director of Therapies and Health Science has the responsibility for the strategic management of Occupational Health & Safety on behalf of the Board. 3.1.4 It is the responsibility of all managers within Aneurin Bevan Health Board to ensure: 3.1.4.1 Safe places of work and safe access to places of work 3.1.4.2 Safe systems of work for all staff and contractors 3.1.4.3 Protection of staff, patients and visitors from unnecessary risk or injury 3.1.4.4 The law imposes a duty on Aneurin Bevan Health Board as an employer, to ensure so far is reasonably practicable, the health, safety and welfare at work of all its employees. 3.2 HEALTH AND SAFETY MANAGER 3.2.1 The Health and Safety Manager reports to the Director of Therapies and Health Science and will ensure: 3.2.1.1 A clear organisational strategy for health and safety is developed and implemented. 3.2.1.2 That health and safety advice is available to all staff, contractors and others as appropriate. 3.2.1.3 That health and safety systems are effectively monitored and reviewed. Page 5 of 19
3.2.1.4 That Aneurin Bevan Health Board has an effective accident/incident reporting process. 3.2.1.5 That health and safety related training is planned implemented and monitored effectively. 3.2.1.6 That the appropriate advice is given to managers and clinicians on new legislation together with supporting information. 3.2.1.7 Direct and lead the Health and Safety Team (including manual handling, fire safety, personal safety) to ensure best practice is achieved throughout Aneurin Bevan Health Board. 3.2.1.8 Identify the major organisational skills in relation to health and safety and notify the relevant committees of potential risk areas. 3.2.1.9 Provide advice and guidance to anyone who may require it. 3.2.1.10 Advise on the introduction and adoption of new safety legislation and the provision of supporting information. 3.2.1.11 Monitor and advise on the effectiveness of the new initiatives. 3.2.1.12 Implement an education framework that develops the necessary skills of all Aneurin Bevan Health Board employees. 3.2.1.13 To monitor the uptake of training compliance ensuring Aneurin Bevan Health Board meets its statutory requirements and identify where remedial action plans may be necessary to address noncompliance. 3.2.1.14 Provide the Aneurin Bevan Health Board with an annual report of Health & Safety issues and achievements. Page 6 of 19
3.3 HEALTH, SAFETY AND FIRE DEVELOPMENT OFFICERS 3.3.1 The Health, Safety and Fire Development Officers report to the Health and Safety Manager and are responsible for the delivery of the service within Divisions on a day to day basis. The Health, Safety and Fire Development Officers will: 3.3.1.1 Audit compliance with Health & Safety Policy and current Safety Legislation, and assist Managers with further development where necessary. 3.3.1.2 Advise on and monitor effective safety training. 3.3.1.3 Assist competent persons with the development of risk assessment. 3.3.1.4 Offer advice and guidance on any aspect of health and safety to any person that may require it. 3.3.1.5 Utilize health and safety incident reports and develop action plans with departmental managers to address key health and safety risks and incidents. 3.3.1.6 Manage the Health, Safety and Fire Development Assistants. 3.4 HEALTH, SAFETY & FIRE DEVELOPMENT ASSISTANTS 3.4.1 The Health, Safety and Fire Development Assistants report to the Health, Safety and Fire Development Officers. The main function of these posts is to support the Health, Safety and Fire Development Officers by carrying out routine audits, training and inspections. 3.5 CLINICAL DIRECTORS AND SENIOR MANAGERS 3.5.1 Clinical Directors and Senior Managers are accountable to the Chief Executive for ensuring all staff within their management responsibility fully implement Aneurin Bevan Health Board Health and Safety Policy and develop Health and Safety Local Policy. They will ensure, so far as is reasonably practicable that: 3.5.1.1 There are adequate resources available to meet health and safety requirements Page 7 of 19
3.5.1.2 All managers are competent to discharge their health and safety responsibilities in line with health & safety legislation and the knowledge and skills framework. 3.5.1.3 The effectiveness of the policy and arrangements for implementing the policy are regularly monitored / reviewed and Divisional / Directorate / Locality Health & Safety Policies are devised and implemented. 3.5.1.4 Their levels of personal competence and knowledge are regularly reviewed and updated in line with health & safety legislation. 3.6 LINE MANAGERS AND CLINICIANS 3.6.1 All line managers and clinicians are responsible for: 3.6.1.1 Ensuring that all statutory obligations and requirements within the sphere of health and safety are met in their departments. 3.6.1.2 Implementing both Aneurin Bevan Health Board & local health and safety policy within their area of responsibility. 3.6.1.3 Developing safe systems of work to maximize protection of staff and drawing up clearly defined safe operating procedures and instructions in conjunction with these systems. 3.6.1.4 Ensuring that all their staff have knowledge of and understand the health and safety policy and supporting procedures in line with health and safety legislation and the knowledge and skills framework. 3.6.1.5 Effectively notifying staff of hazards relating to their job and arranging training in safe methods of working. 3.6.1.6 Ensuring safety equipment and personal protective equipment is available for staff and that they are used correctly when required. 3.6.1.7 Investigating accidents and near misses with the assistance of the Health and Safety Team as necessary. 3.6.1.8 Ensuring regular inspection and maintenance of equipment in conjunction with Works and Estates. 3.6.1.9 Ensuring regular monitoring to enable activities to be reviewed and performance improved. Page 8 of 19
3.7 SAFETY REPRESENTATIVES 3.7.1 The appointment of Safety Representatives will be supported to represent employee interests on health and safety matters. The Safety Representative will: 3.7.1.1 Notify the Health & Safety Manager when they have been accredited by respective Trade Union organization. 3.7.1.2 Support and co-operate with managers and staff in health and safety bringing matters to Aneurin Bevan Health Board s attention. 3.7.1.3 Carry out safety inspections, investigate health and safety queries including accidents as appropriate in line with Aneurin Bevan Health Board Policy. 3.7.1.4 Link with the relevant Aneurin Bevan Health Board health and safety committees. 3.7.1.5 Be entitled to appropriate time off with pay for training and to enable them to carry out their duties. 3.7.1.6 Work collaboratively with the Health and Safety Team in delivering local and national strategy and policy. 3.7.1.7 Ensure that evidence and records of personal updating and training arranged by Trade Unions in relation to health and safety are maintained and shared with the health and safety department. 3.8 SAFETY COORDINATORS (COMPETENT PERSONS) 3.8.1 Each Department / Specialty / Locality Manager will co-ordinate all safety measures within their areas of responsibility or appoint a safety co-ordinator (Competent Person) to carry out this role on their behalf. 3.8.2 Accountability for health and safety remains with that manager. 3.8.3 Safety coordinator(s) where appointed shall be nominated from within the department /specialty / locality on the basis of their experience or knowledge of the activities undertaken. Training to the agreed Aneurin Bevan Health Board level will be provided for these persons by the Health & Safety Team. Page 9 of 19
3.9 SAFETY SUPERVISORS (Specialist Departments) 3.9.1 Safety Supervisors required by legislation or approved Codes of Practice shall be appointed in addition to the safety co-ordinator(s), or assume both roles. 3.9.2 The following regulations and codes of practice require safety Supervisors: 3.9.2.1 Radiology the Ionizing Radiation Regulations 1999. The administration of radioactive substances advisory committee regulations. 3.9.2.2 Pathology approved code of practice HSE guidance note Safe working and prevention of infection in clinical laboratories. 3.9.2.3 Theatres & Physiotherapy Welsh Office, scientific advisory committee Laser safety in hospitals 1982. 3.10 OCCUPATIONAL HEALTH PHYSICIAN 3.10.1 The consultant Occupational Health Physician is accountable to the Chief Executive and reports to the Medical Director. This person is responsible for the clinical and associate services of the department. 3.11 EMPLOYEES 3.11.1 Whilst at work all employees have a duty: 3.11.1.1 To take reasonable care of their own health and safety at work and of other persons who may be affected by their acts or omissions. 3.11.1.2 To co-operate with their managers in meeting any requirements of the law. 3.11.1.3 To not interfere with or misuse any equipment provided to protect their health, safety and welfare in compliance with law. 3.11.1.4 To report any defects or hazards in the workplace. Page 10 of 19
3.11.1.5 To participate in health and safety training and ensure knowledge and skills are regularly updated in line with legislation and knowledge & skills framework. 3.11.1.6 To use equipment in the way they have been trained. 4 OCCUPATIONAL HEALTH SERVICE Occupational Health and Health & Safety work in collaboration to reduce the level of ill health and accidents caused by work. The Occupational Health Service will ensure: The fitness of individual workers for specific jobs are assessed. Potential cases of Occupational Injuries and illness are assessed. 4.1 OCCUPATIONAL HEALTH WILL PROVIDE THE FOLLOWING SERVICES: 4.1.1 PRE-EMPLOYMENT HEALTH ASSESSMENT Are carried out, in accordance with relevant legislation, to ensure that employees are fit to undertake their jobs without risk to themselves, their colleagues, patients or visitors. 4.1.2 HEALTH ASSESSMENT IN EMPLOYMENT Are undertaken in connection with fitness to work e.g. following sickness absence, for work related ill health issues or for ill health retirement purposes. To ensure that employees are fit to undertake their usual occupation and / or advise management and respective staff on rehabilitation, suitable alternative work adjustments or retirement, as appropriate. 4.1.3 HEALTH SURVEILLANCE Health surveillance of workers exposed to specific hazards is carried out. The law requires an annual enquiry for dermatitis and asthma resulting from Latex Allergies. This should be addressed by Managers during annual appraisal. Refer to Latex Policy for further clarification. Page 11 of 19
4.1.4 IMMUNISATION To offer appropriate immunisation, where occupationally relevant, to staff at risk of infection from direct patient contact, potentially infected specimens or instruments/work equipment. 4.1.5 LIAISON WITH HEALTH AND SAFETY Active contribution to the development of policies and practices that promote and maintain the physical, mental and social well being of all workers. 4.1.6 IDENTIFICATION OF OCCUPATIONAL HAZARDS AND RISKS In conjunction with the appropriate managers and Health and Safety Team, Occupational Health will identify hazards and risks to the health of employees and identify the organisation of any action necessary. 4.1.7 STAFF SUPPORT AND ADVICE To provide support and advice to employees and managers in relation to health and safety matters. 5 RISK MANAGEMENT 5.1 The Health and Safety Manager will manage the Risk Management Support Team to ensure consistency and avoid duplication. 5.2 The Risk Management Support Team will be responsible for maintaining the datix incident reporting database, enabling Divisional & Corporate personnel to produce incident reports for interpretation, analysis and appropriate action. 6 REPORTING OF INJURIES, DISEASES AND DANGEROUS OCCURRENCES REGULATIONS (1995) 6.1 Aneurin Bevan Health Board has a legal duty to report certain accidents and ill health at work occurrences to the Health and Safety Executive under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR). Reporting will be carried out via the Risk Management Support Team or the locality Health & Safety nominated person, but the Health & Safety Team will determine what is to be reported under RIDDOR. It is imperative that any incidents which fall Page 12 of 19
into the following categories are reported to Risk Management immediately: Death or major injury Over 3 day injury (where an employee has more than 3 days sickness absence as a result of an accident at work) Disease (this includes latex allergies, occupational asthma) Dangerous Occurrence (a dangerous occurrence does not necessarily have to result in injury. If there was potential for injury i.e. Near Miss this must still be reported under RIDDOR regulations). NB: During transition localities will continue to report RIDDOR incidents but Aneurin Bevan Health Board will work towards developing a central database to ensure all data is captured. 7 ARRANGEMENTS FOR IMPLEMENTING POLICY The Health and Safety Team will adopt a programme of work within Divisions enhancing safety performance. 8 Training 8.1 Health & Safety Awareness and Fire Safety Awareness are statutory training courses for all employees. Health & Safety Awareness must be undertaken every 2 years, and the Fire Safety must be undertaken annually. These sessions are available via on-line training. Fire training will be supplemented with walk through, talk through sessions for clinical areas. 8.2 All staff will be trained in safe working practices and procedures prior to being allocated any new role. 8.3 Training will include advice on the use and maintenance of personal protective equipment appropriate to the task concerned and the formulation of emergency contingency plans. Page 13 of 19
8.4 Training on Health & Safety matters will take place during induction for new or transferring employees. 8.5 Line managers will be responsible for identifying and ensuring that their staff receive appropriate Health & Safety training. This will include training associated with their specific duties, e.g. training in the manual handling of loads, fire safety and DSE. 9 Audit Managers need to understand local Health & Safety Performance so improvements can be made. Active monitoring will involve regular review to ensure that standards are met and management controls are working. 10 Information 10.1 Health and Safety related policies are available to all staff for reference purposes and will be communicated effectively as they are introduced or amended. All policies are available on the intranet or via line managers 10.2 Line managers and Clinicians will be responsible for informing their staff about: 10.2.1 the HAZARDS identified by risk assessment. 10.2.2 the PREVENTATIVE and PROTECTIVE measures being taken. 10.2.3 the HEALTH and SAFETY policy and supporting procedures. 10.2.4 the need to use HAZARD WARNINGS in some instances where hazards are identified. Page 14 of 19
11 RISK ASSESSMENT 11.1 Aneurin Bevan Health Board will continue to support and train the appropriate personnel in the role of competent persons to enable them to plan, implement and review programmes of risk assessment in their workplace. 11.2 The Health and Safety Team will assist in reviewing the effectiveness of this process on a regular basis. 12 WORK INSPECTIONS 12.1 Regular inspections of the workplace will be carried out by the Health and Safety Team and Safety Representatives. In addition, inspections will be conducted in the relevant areas whenever there are significant changes in the nature and/or scale of activities. 12.2 Workplace inspections will also provide an opportunity to review the continuing effectiveness of the policy and to identify areas where revision of the policy may be necessary. 13 WORK EQUIPMENT 13.1 Aneurin Bevan Health Board will endeavourer to ensure that all equipment used in the workplace is safe and suitable for the purpose for which it is used. 13.2 All staff will be provided with adequate information and training to enable them to use work equipment safely. Page 15 of 19
13.3 The use of any work equipment, which could pose a risk to the well being of persons in or around the workplace, will be restricted to authorized persons. 13.4 All work equipment will be maintained in good working order and repair. 13.5 All staff will be provided with such protection as is adequate to protect them from dangers occasioned by the use of work equipment. 13.6 All work equipment will be clearly marked with health and safety warnings where appropriate. 14 PERSONAL PROTECTIVE EQUIPMENT 14.1 All staff who may be exposed to a risk to their health and safety whilst at work will be provided with suitable, properly fitting and effective personal protective equipment. 14.2 All personal protective equipment provided by Aneurin Bevan Health Board will be properly assessed by the line-manager prior to its provision. 14.3 All personal protective equipment provided by Aneurin Bevan Health Board will be maintained in good working order. 14.4 All staff provided with personal protective equipment by Aneurin Bevan Health Board will receive comprehensive training and information on the use, maintenance and purpose of the equipment. 14.5 Aneurin Bevan Health Board will endeavor to ensure that all personal protective equipment provided is used and used properly by its employees. Page 16 of 19
15 CONTRACTORS AND CONTRACTED SERVICES 15.1 Before contracts are finalised, the competency of contractors will be assessed in relation to health and safety matters. The Health and Safety Team will assist the appropriate department on this. The list of approved contractors, which encompass Health and Safety requirements will be held in the relevant departments. 15.2 Adequate information will be provided to all contractors engaged to work on Aneurin Bevan Health Board premises by the appropriate department. 15.3 All hazards on Aneurin Bevan Health Board sites that could affect contractor personnel should be clearly defined and controlled by the appropriate department. 16 DRIVING AT WORK 16.1 Aneurin Bevan Health Board is committed to identifying and minimizing those risks associated with road safety and actively encourages safe driving in order to reduce the number of accidents and to comply with its legal obligations. 16.2 All managers will have in place a process for checking driving licenses, MOT certificates, Tax and insurance documents for staff who are required to drive a vehicle as part of their working duties. 16.3 All employees are required to inform their manager of any changes relating to driving convictions or health issues which may effect their ability to drive whilst at work. Page 17 of 19
17 CONSULTATION 17.1 Aneurin Bevan Health Board identifies that communication between staff at all levels is an essential part of effective health and safety management. 17.2 Consultation will be facilitated by means of local safety committee meetings and trade union partnership forums. 17.3 Under Section 2(7) of the HSWA, safety committees have a function of keeping the measures taken to ensure the health and safety at work of employees are regularly reviewed. 17.4 In order to carry out this function local safety committees must work within agreed objectives and terms of reference. 17.5 Consultation with stakeholders will be addressed by a variety of means, but where premises have shared occupancy Health & Safety Meetings will be held for all parties to attend. The Board committee s main objectives will be to: 17.5.1 PROMOTE health and safety awareness throughout Aneurin Bevan Health Board. 17.5.2 MONITOR the effectiveness of the health and safety strategy. 17.5.3 REVIEW health and safety statistical information 18 SUPPORTING POLICIES The following policies support and underpin the Health and Safety Policy and must be referred to in conjunction with this policy: Page 18 of 19
MANUAL HANDLING OPERATIONS CONTROL OF HAZARDOUS SUBSTANCES FIRE SAFETY STRESS PERSONAL SAFETY (The policy on violence and aggression towards staff and the lone worker policy and guidelines will provide information on personal safety). FIRST AID DISPLAY SCREEN EQUIPMENT (DSE) LATEX ALLERGIES INCIDENT REPORTING & INVESTIGATION WASTE MANAGEMENT POLICY NEW AND EXPECTANT MOTHERS POLICY DRIVING AT WORK POLICY Page 19 of 19