AGENDA ITEM 4.2 HEALTH AND SAFETY PRIORITY ACTION PLAN /13 Executive Lead: Deputy Chief Executive Author: Head of Health and Safety Contact Details for further information: Charles Dalton 02920 743751 SITUATION The Health Board has initiated a Health & Safety Priority Action Plan to monitor its progress on key health & safety strategic areas. The /13 Priority Action Plan was submitted to the October Health and Safety Committee, which was then updated at the January 2013 Committee. BACKGROUND These are monitored at each Operational Health & Safety Group meeting and each Division has in turn produced its own Priority Action Plan based on these strategic areas. The prioritised approach continues to identify seven strategic areas for action, these being: 1. Structural and Health & Safety Management (including incident reporting) 2. Violence & Aggression Management 3. Manual Handling 4. Health Issues 5. Environment Safety and Health & Safety Patient Issues 6. Fire Safety Management 7. Health and Safety Estates Management. The Divisions and Estates Management Risk Registers include identified risks within this Health and Safety Action Plan, whilst centrally managed risks are included within the Corporate Management Risk Register. The Action Plan was considered as part of the shared services audit of Health & Safety during the period. HSE Priority Action Plan /13 Page 1 of 18 Health and Safety Committee
Reviewed /13 Plan TABLE 1 Total no of requirements Green Amber Red H&S Policy Management and Organisational Arrangement 10 4 4 2 Violence & Aggression (inc Lone worker) 10 3 4 3 Manual Handling 4 0 4 0 Health Issues 6 4 2 0 Patient & Environment H&S 8 2 4 2 Fire Safety Management 5 2 2 1 Estate H&S Management 6 2 3 1 Total 49 17 23 9 Total Improved areas during period Table 1 demonstrates of the revised total of 49 requirements, 17 have been resolved and 9 remain as high priority and non compliant, these are detailed below. A further 23 are identified as Amber, thus meaning that the risk has been reduced as a result of action taken but further control measures are required. AREAS OF SIGNIFICANT PROGRESS The following areas have been of noticeable change during the period. 1.0 Health & Safety Policy Management and Organisational Arrangement 1.4 Health & Safety Risks - risks are now being considered within the Risk Registers and Priority Action Plan at both Corporate and Divisional level. Red to Amber 1.9 Delays in entering incident forms New Area The Recent audit undertaken by Shared Services identified a significant delay from date of event to receipt of incident form within the Health & Safety Department. Red 1.10 Policy Schedule New Area Health & Safety to expand policy schedule to include Health & Safety related policies which are approved by the other Committees. Amber 2.0 Violence and Aggression 2.2 Case Management - Case Management Officer now appointed and in post. Amber to Green HSE Priority Action Plan /13 Page 2 of 18 Health and Safety Committee
2.3 All Wales Violence & Aggression Passport Scheme a review of refresher training requirements have been undertaken. Red to Amber 3.0 Manual Handling 3.2 Addressing NPSA requirement for moving patients after falls - the equipment purchases have been completed, however protocols on the use of scoops are yet to be finalised. Remains Amber 3.3 Bariatric hoisting - enhanced plans for the centralised distribution of a Bariatric Patient Kit has been established through the bed management contract. Remains Amber 4.0 Health Issues 4.2 Environmental Monitoring monitoring has been undertaken in all of the identified priority areas. Amber to Green 4.4 Needle stick Injuries a programme for implementing safety cannulas in clinical areas is underway. Amber to Green 5.0 Environment Safety and Health & Safety Patient Issues 5.8 Waste Controls New Area A recent audit identified poor controls in relation to the disposal of used sharps and medication. All Divisions have now been made aware of these shortcomings. Red 6.0 Fire Safety Management 6.2 Nomination Officer Fire Training- during the period training has been given to NOFs. Amber to Green 6.3 Programme for Fire Risk Assessments - these have been completed for all areas. Amber to Green 7.0 Estates Health & Safety Management 7.1 Contractor Control policy has been approved and implemented. Amber to Green HSE Priority Action Plan /13 Page 3 of 18 Health and Safety Committee
ASSESSMENT The Priority Action Plan continues be an important document in the improvement of health and safety within the Health Board. The action plan (Appendix 1) has identified significant areas of progress since submission to the October Health & Safety Committee meeting. The plan is monitored as a substantive item on the Operational Health & Safety Group and by the Divisional Safety Groups. The report identifies areas that have met the required standards and also where enhanced performance is planned and necessary. The Priority Action Plan is a live document and as such the following additional priority areas for action were identified during the period. These being: 1.9 Incident Forms Delay 1.10 Policy Status Reviews 5.8 Utilisation of Appropriate Waste Route The Health and Safety Action Plan builds upon the significant progress made in the improvement of staff and patient health and safety risks. The report identifies areas where enhanced performance is planned and necessary, and these will be monitored through the Health and Safety Committee and its subgroups and will be managed via the Priority Action Plan. RECOMMENDATION The Health and Safety Committee is asked to: NOTE and CONSIDER the Report Financial Impact Quality, Safety and Experience Standards for Health Services Risks and Assurance The report has no direct financial consequences This report is fundamental to the safety and quality of both staff and patients This report provides assurance against Healthcare Standard 22: Managing Risk and Health and Safety The Report supports the Risk Register by ensuring that all actions are appropriately recorded with local and Central Risk Registers. It also gives assurance that actions identified are being progressed HSE Priority Action Plan /13 Page 4 of 18 Health and Safety Committee
Equality and diversity An Equality Impact Assessment has been undertaken and identifies there is no obvious evidence of any equality concerns relating to the Priority Action Plan HSE Priority Action Plan /13 Page 5 of 18 Health and Safety Committee
Requirement Status April Progress Action required Accountable Lead 1.1 Programme of review of All Health and Safety Polices required 1.2 Health and Safety Committee and Staff Confirm H&S Group arrangements All Policies have been reviewed except the Latex Allergy Policy. All H&S Groups formed with the exception of Executives Services Policy Approved at July H&S Committee The Executive Departments Health and Safety Group has been deferred whilst rearrangement of management responsibilities are underway. Action Completed Review of membership of group in light of restraints. Chief Executive/ Status Priority Time Scale for Completion Green High Completed July Amber Mod August 2013 1.3 A comprehensive programme of risk assessments to be completed with identified control measures implemented Risk Assessment Procedure expanding the requirement so that assessments greater than 10 are validated and monitored Review of risk assessment approach via E-Datix project. Audit of local risk assessment to be initiated. Chairs of Divisional Safety Group Red High July 2013 1.4 Ensure All H&S Risks are considered within the UHB Risk Register Requirement with above procedure Risk Assessments considered within Risk Register. Divisional Leads, Health and Safety and Clinical are meeting to incorporate all Health and Safety risks within their relevant registers. Agenda on each Operational Group Meeting. Progress report to be given as agenda item at Operational Group Meeting. Chairs of Divisional Safety Group Amber Mod Ongoing 1.5 Incident Reporting - NHS Organisations are required to utilise E DATIX Project group formed to progress the corporate implementation of E Datix Project Lead to be reestablished Implement E Datix. Amber Mod 2013 HSE Priority Action Plan /13 Page 6 of 18 Health and Safety Committee
1.6 Latex - UHB to agree a unified Latex Policy with regards to both patient & staff risks Policy being progressed by Quality and Safety Committee with H&S input Approved policy requirements are now included in Divisional Action Plans. Action Completed Chief Executive/ Green Mod Completed July 1.7 Improved communication with Patient Safety & others 1.8 Action Plan Monitoring and Audit 1.9 Incident forms to be entered on to system within 48hrs. 1.10 Health & Safety Committee are kept aware of status of all H&S related policies. Divisional H&S Groups established with joint membership. Monitoring arrangements established as part of Divisional H&S Group Recent analysis on Datix system identified significant delays, from date of event to date of entry. Policy schedule submitted to committee relates only to those documents approved. Integrated Meeting established All Divisional H&S Groups prepared and submitted actions plans to Operational H&S Group Divisional Leads alerted to delays relating to latent time between ward raising and posting to H&S. All forms entered within 48hrs of receipt. Identified as part of Shared Services Audit as a requirement. Action Completed Action completed but on going requirement E-Datix project will facilitate instant reporting. Policy schedule to include the relevant policy and approval committee for information of any out of date. Divisional H&S Group Chairs Head of Health & Safety Green Mod Completed June Green Mod On going Red High On going Amber Mod Completed April 2013 2 Violence and Aggression Requirement Status April Progress Further Action required Accountable Lead 2.1 V&A Steering group with Independent lead to report to the HB on progress 2.2 The role of Case Manager to be further developed. Implementation group of WAG Action met to progress requirements- WAG plan closed The role of Case Manager has proved very successful in reducing the number Independent Lead and Executive lead considered at April meeting it timely to review steering group membership and function The role of the Case Management Officer has now been appointed and commenced post Executive Lead to determine group reestablishment. Action completed Deputy Chief Executive Status Priority Time Scale for Completion Red High January 2013 Green Mod Completed October HSE Priority Action Plan /13 Page 7 of 18 Health and Safety Committee
2.3 Have in place an action plan to ensure full and ongoing compliance with requirements of the All Wales V&A Passport Scheme. and duration of days lost due to a V&A event. The number of lost days being reduced. The HB has been accepted as National best practise Lack of ability to release staff for training has also reduced compliance. A number of specialist programmes for training have been initiated. It has subsequently reviewed its prioritisation of training. Review of refresher requirements for module A & B undertaken. Divisional Leads to confirm TNA. Head Health Safety of & Amber High December 2.4 Review of Security Arrangements to enhance protection against assaults The UHB has committed to establish a separate Security Team Separation of Security completed. Transfers of staff to offer best support arrangements being progressed. Complete staff transfers Head of H&S Amber Mod July 2013 2. 5 2. 6 Hospitals to ensure that patient movement is controlled with appropriate monitoring. Safety Environment audit CCTV coverage is able to monitor and record all areas of risk to staff from violence within limits of agreed dignity protocols Security Strategy Group reviewing requests for access and egress controls and CCTV monitoring. Report on deficiencies will be submitted to V&A group CCTV coverage within Hospital sites is incomplete and of insufficient standard to allow for effective detection and The re-establishment of the Security Strategy Group has been initiated to ensure appropriate coverage. A review of these areas not covered by CCTV or where CCTV is non operational has been initiated with a view to inform those effected areas of enhanced Group to meet prior to next committee. Complete CCTV survey and inform all relevant managers. Chair of Security Strategy Group Chair of Security Strategy Group Red Mod July 2013 Red September 2013 HSE Priority Action Plan /13 Page 8 of 18 Health and Safety Committee
2. 7 2. 8 Sufficient Trained Staff to respond to personal attacks and safely restrain Improve case management links with Primary Care and Safe Haven prosecution. Business Case has been prepared and implemented by Security Manager to replace faulty and upgrade cameras Security Team not trained to required standard. Security team required to be of suitable size and deployed to respond to events. The Case Manager has started to extend the service offered to the Health Board staff into the Primary Care sector and GP s surgeries risk. Review of security team which has increased security presence, where evidence supports need has been completed. Additional Case Manager Officer appointed. Case Manager has met with Primary Care, resulting in improved relationship. Enhanced training for the reviewed team to be progressed. Head of Security Services Amber July 2013 Head of H&S Green December 2. 9 2. 10 Lone Worker The analysis of data of Lone Worker Alert devices illustrates that staff have a poor utilisation rate Lone Worker Alert System Contract review due in June 2013. Investigation into suitable alternatives to enhance usage Each Division is given data of individual usage to pursue improvement. National Group progressing unified approach to improving usage National Loneworker Group formed to evaluate performance Personal messages sent to each user. Status Report submitted to H&S Committee and Workforce & OD Committee. Alternative device and approval to be progressed. A User Worker Group has been formed to look at options of devices and systems. Complete review in readiness for new contract. Complete contract review. V&A Group / Divisional H&S Chairs Amber Mod On going Green Mod June 2013 HSE Priority Action Plan /13 Page 9 of 18 Health and Safety Committee
3 Manual Handling Requirement Status April Progress Further Action required Accountable Lead 3. 1 All staff involved in manual handling tasks require training to required standard and refreshed at the agreed intervals Training Working Group formed led by OD Training frequency assessment (TFA) commenced Progress Report considered by Workforce & OD Committee Manual Handling compliance to be added to dash board of departments. Greater usage of TFA to be progressed Ast Director of OD Head of Health and Safety Status Priorit y Time Scale for Completion Amber High April 2013 3. 2 3. 3 Addressing the NHS National Patient Safety Agency Report Essential care after an in patient fall Treating an increasing number of bariatric patients Hover Jacks purchased Additional equipment identified Expansion of Bariatric beds Revised arrangements required. Scoops Protocol has been progressed by Nurse education. Group to be formed to consider additional equipment needs including weighing devices for bariatric patients. Arrangements for transfer of bariatric kit have been established with Hill ROM to ensure timely ward availability. Purchase of Scoops Protocol of usage needs to be agreed Adequate stock of ancillary equipment, provision of specialist equipment outside normal working hours. Head of H&S Therapies Amber High October January 2013 Amber High Completed Sept 2011 3. 4 The lack of flat glide sheets which are essential Manual Handling equipment Special Sheets were purchased but stock has diminished. Risks identified in the use of single use glide sheet Issues raised with regards to glide sheet availability and management. A meeting with Procurement identified that the new contract commencing April 2013 will improve glide Manual Handling Advisers/ Laundry Manager Amber Mod December HSE Priority Action Plan /13 Page 10 of 18 Health and Safety Committee
sheet availability. 4 Health Issues - Requirement Status April Progress Further Action required Accountabl e Lead 4. 1 Latex Allergy The Latex Policy has been approved Latex Allergy Improvement in the management of Latex continued. Action completed Chair of each Divisional H&S Group Status Priority Time Scale for Completion Green High Completed 4. 2 4. 3 4. 4 The organisation is required to undertake environmental monitoring to ensure staff and patients are not put at risk Biological risks and face masks. All staff required to wear protection masks must be given a mask fit test. Enhanced protection for staff against needlestick injuries and implement requirements of the EU Directive There is a current backlog of monitoring to meet the UHB licencing and Statutory obligation Face mask testing undertaken and completed by Infection Control. Improvements in protocols and safer sharp boxes noted in annual report. Progress reports submitted to H&S Committee Alternative programme has been commenced and all priority areas will be completed. Paper submitted and agreed Contract issued. Programme of transfer to safety cannula commenced. Review of resource available to consider if more monitoring can be undertaken Developing a local training approach whereby each Directorate is able to undertake fit mask testing as required. Review of other safety devices. Head of H&S Head of Infection Control Head of H&S Green High April 2013 Amber December Green December 4. 5 Reassurance is required that staff working in Asbestos containing buildings are not at risk Enhanced Asbestos control has been implemented A review of asbestos arrangements within the Dental Hospital has reassured staff. Feedback sessions to be completed to the identified staff. 1:1 sessions being progressed. Occ Health Consultant Green May 2013 HSE Priority Action Plan /13 Page 11 of 18 Health and Safety Committee
4. 6 Hazard Substances The Organisation is required to maintain a database of Risk Assessments associated with hazardous substances. Version 7 of Sypol COSHH management system has been implemented and cascaded throughout UHB. Annual report identifies areas where COSHH assessments have not been completed, this need to be resolved. COSHH procedure approved by Operational H&S Group December 2011. Gap analysis of COSHH coordinators Monitored through local H&S meetings Head of Health & Safety/ Chairs of Divisional H&S Groups Amber April 2013 5. Health &Safety Patient and Environment Safety Requirement Status April Progress Further Action required Accountable Lead 5.1 Ultra Low Beds A need for ultra low beds has been identified for those at risk. The number of ultra low beds within the organisation has been expanded to 115, this reflects the current demand for these beds. Arrangements are also in place to hire in additional beds as required based off risk assessment. A patient falls group has been formed and an Executive Lead identified to progress the reduction of patient falls 5.2 Window Closures Not all windows above the Ground floor are fitted with 100mm restrictors. A Assurance given through both Quality & Safety and Health and Safety Committees. An additional working group which includes H&S to be established to progress improvement in the design and use of these beds. Survey and risk assessment of all windows above the ground floor has been completed. Action has Ongoing commitment required to expand stock Further Work on anti tamper screws to be initiated to meet hazard alert guidance. Therapies and Health Sciences Status Priority Time Scale for Completion Green On going Amber Mod /13 HSE Priority Action Plan /13 Page 12 of 18 Health and Safety Committee
programme of work has been undertaken to replace all high risk areas. Medium and lower risk areas are still required for action. A programme of work is required to fit anti tamper devices to the in place ligature closures. been taken to rectify those windows which failed to meet the required standard. 5.3 Flooring Risk Assessment - HSE identified a minimum standard of slippage risk. HSE published a document on Investigation of slip resistance and the hygienic cleaning of floors in hospital settings. This was based on a joint research project between Cardiff and Vale UHB and the Health and Safety Executive Laboratories Work undertaken has identified that general vinyl flooring within hospital settings has a significant slip risk when contaminated. The introduction of additional controls including greater use of micro mopping and replacement of existing flooring as justified with flooring of higher micro roughness without compromising cleaning/infection requirements. Estates have circulated the Research findings. This will now be included as design brief for new and refurbished floors. Amber High December Ongoing 5.4 Walkways WOLF Reforms Best practice guidance identifies the need for regular monitoring of designated walkways for defects. The current organisation Walk way monitoring introduced within UHW Further audit of systems to be made by H&S Amber High /13 HSE Priority Action Plan /13 Page 13 of 18 Health and Safety Committee
has not implemented this requirement leaving it vulnerable to civil claims. Head of H&S June 2013 5.5 Legionella - Control of latent and low use water taps requires control at the patient bed Legionella Policy and Estates working group formed Water Safety / Legionella The confirmed Divisional responsibilities to those areas identified as concern. Director (Capital of & Red High December April 2013 5.6 Asbestos compliance Policy and AMP requires only controlled breach of Asbestos 5.7 Record Storage - The organisation has the requirement to safely store its mandated records for the agreed periods. 5.8 Utilisation of appropriate waste route. There is insufficient suitable storage for all records particularly in relation to archived records in the community. Audit of compliance to Environmental Permitting Regulations show some shortfalls with regards to sharps boxes. Enhanced Contractor control introduced Policy for greater use of Electronic storage being considered to alleviate problem. Paper of compliance status considered at Operational Group meeting and Divisional. Action plan to improve compliance prepared. Co-operation of all staff in not breaching barrier protection Policy to be finalised Implement Action Plan. All Green High Ongoing Chief Operations Officer Amber Mod TBC Red HSE Priority Action Plan /13 Page 14 of 18 Health and Safety Committee
6 Fire Safety Management Requirement Status April Progress Further Action required Accountable Lead 6. 1 Firecode All staff within the organisation are required to be provided with Fire Safety Training. The incumbent organisation is at approximately 50% compliance. Fire Policy Approved. Executive Director appointed as lead for Fire. E learning training developed for Fire and monitored at Health and Safety Committee. Induction training enhanced to ensure all new staff receives Fire Training within 8 weeks. Planned toolbox talks to wards by Fire Advisers to enhance local knowledge. Each Division to monitor local compliance. Director of Status Priority Time Scale for Completion Red High December 6. 2 6. 3 Each geographic location is required to have a Nominated Officer Fire (Deputy Fire Manager) who is responsible for monitoring Fire arrangements. Complete Fire Risk Assessments The new Organisation s management structures will identify Nominated Officers Fire (NOF) for each site. A programme of Risk assessments have been undertaken with a planned completion by October Training given to NOF during period. Fire Safety Group confirmed that fire risk assessments have been completed for all planned areas. Ongoing / Fire Safety Manager Green High April 2013 Green High Ongoing 6. Fire Compartmentation Programme of Enhanced fire doors being Amber High December HSE Priority Action Plan /13 Page 15 of 18 Health and Safety Committee
4 improved fire compartmentation initiated 6. 5 Implement the findings of the Fire Service Audits Priorities approach to tackling findings undertaken fitted Progress monitored at Fire Safety Group but limited by resource Report of status to be added to fire report Amber High December 7 Estates H&S Management Requirement Status April 2011 Progress Further Action required Accountable Lead 7.1 Contractor Control Contractor Briefing booklet produced for maintenance contractors. Further direct control and briefings to maintenance contractor and non CDM projects to mimic same level of control as Capital projects have been initiated. 7.2 Legionella Independent audit of Legionella system to be undertaken annually Contractor Control Policy approved and being implemented. Group formed to monitor legionella compliance and progress findings of independent audit. Pilot Study completed and usage evaluation programme for monitoring flushing in place. Monitored at Legionella Control Group formed. Assurance undertaken at Operational H&S Group. Paper prepared for the expansion of legionella resources, including increased monitoring of flushing via roll out of data base system. Status Priority Time Scale for Completion Green High December Amber High Completed April 2011 December 7.3 Asbestos Implement Asbestos Asbestos Internal review Temporary Asbestos Amber High Ongoing HSE Priority Action Plan /13 Page 16 of 18 Health and Safety Committee
Management Plan of the Asbestos Management Plan identified some shortfalls with regards to auditing arrangements. Manager contracted, Asbestos group formed, Enhanced Asbestos compliance introduced 7.4 Safe Working with Electricity Programmed inspection and testing regime in place. Training of Authorised and competent persons in place Safe working with electricity Policy approved. Secured additional funding to ensure enhanced compliance. Monitored via the Estates H&S Group Green Mod Completed 7.5 Back log maintenance of the UHB Estate Impact: Resources available to estates in line with an increasing burden of ageing physical infrastructure, bringing increased maintenance costs and increased refurbishment costs. A programme of estate rationalisation and modernisation, including major refurbishment in place across the UHB estate. Wherever possible capital projects are linked to improvement and eradication of backlog maintenance to maximise impact of investment. Regular reviews of estate condition via Estate Property Appraisals. Red Ongoing Maintenance funds are subject to a rigorous risk assessment procedure to establish prioritisation of resources. HSE Priority Action Plan /13 Page 17 of 18 Health and Safety Committee
7.6 Statutory H&S Compliance Sub group formed led by Ast Director Position of H&S Compliance Manager identified and approved Appoint Manager Compliance Director (Capital of & Amber Mod December HSE Priority Action Plan /13 Page 18 of 18 Health and Safety Committee