Slips, Trips and Falls policy (Non-patient) Type: Policy Register No: 17020 Status: Public Developed in response to: Trust requirements Best Practice Contributes to CQC Outcome number: 15 Consulted With Post/Committee/Group Date Helen Clarke Head of Governance August 2017 Julie Shepard Claims Manager August 2017 Stella Smith Senior Manual Handling Advisor August 2017 Jim Turner Head of Health & Safety and Fire August 2017 (BTUH) Carrie Type Falls Prevention Nurse August 2017 Phil Robson Head of Maintenance August 2017 Phil Kitchener Interim Head of Hotel Services August 2017 Health & Safety Group September 2017 Professionally Approved By Carin Charlton, Chief Director of EFM September 2017 Version Number 1.0 Issuing Directorate Estates & Facilities Directorate Ratified by: DRAG Chairmans Action Ratified on: 29 th October 2017 Executive Management Board Sign Off November 2017 Date Implementation Date 6 th November 2017 Next Review Date October 2020 Author/Contact for Information Jo Mitchell, Head of Assurance & Compliance (EFM) Policy to be followed by (target staff) Distribution Method Intranet and Website Related Trust Policies (to be read in Health and Safety Policy conjunction with) Risk Management Strategy and Policy Incident Policy Serious Incident Requiring Investigation Policy Learning from experience policy Mandatory Training Policy Moving and Handling Policy Supporting for Staff Involved in an Incident Complaint or Claim Complaints Handling Policy First Aid Policy Document Review History Version No Brief Reason for Change Authored/Reviewed by Active date 1.0 Jo Mitchell, Head of Assurance & Compliance 6 Nov 2017
INDEX 1. Purpose 2. Background 3. Scope 4. Definitions 5. Staffing and Management Responsibilities 6. Staff Training 7. Risk Assessment for the Management of Slips, Trips and Falls - Staff Equality & Others 8. Incident Reporting Serious Incident Reporting 9. Staff Responsibilities for Management of Falls Incidents 10. Support for Staff following an Event 11. Equality and Diversity 12. Audit and Monitoring 13. Review 14. Communication & Implementation 15. References and Further Reading 2
1.0 Purpose 1.1 The purpose of this policy is to provide information and guidance to staff to ensure a consistent and safe approach across Mid Essex Hospital Services Trust (henceforth known as the Trust) to the prevention and management of slips, trips and falls in, staff and others, including falls from a height. 1.2 The policy aims to raise awareness amongst staff about the risk of slips, trips and falls and the appropriate management of these risks including the risk assessment process and incident reporting and to facilitate the implementation of best practice. 1.3 Specifically the policy provides guidance on: The actions staff should take to minimising the risk of falls The actions that staff should take to ensure the appropriate and timely care of patients / staff / volunteers / visitors following a slip, trip or fall; 1.4 Where slips, trips or falls do occur the contributory factors within the hospital should be examined and adequately controlled. 1.5 The Trust aims to take all reasonable steps to ensure the safety and independence of its patients and to respect the rights of patients to make their own decisions about their care. 2.0 Background 2.1 Slips, trips and falls are the most common cause of major injury in all UK Workplaces, with the NHS sector reporting a high annual incidence 2.2 Slips and trips resulting in falls are a common cause of injuries to staff within the Trust. These accidents can be cut dramatically through planning and pro-active management together with good housekeeping. 2.3 The Trust has a duty under the Health and Safety at Work Act 1974 Section 2 and Section 3 to ensure their employees and anyone else who could be affected by their work (such as visitors, members of the public, patients etc), are kept safe from harm and that their health is not affected. This means slips and trips risks must be controlled to minimise the risk of a slip, trip or fall. 2.4 The Management of Health and Safety at work Regulations 1999 Section 3 places a duty on employers to assess risks including slips, trips, falls risks and where necessary take action to safeguard health & safety. 3.0 Scope 3.1 All staff working within the Trust are expected to adhere to this policy. 4.0 Definitions FALL An unexpected event in which a person comes to the ground or other lower level with or without loss of consciousness 3
SLIP A slip is to slide accidentally causing the individual to lose their balance, this is either corrected or causes an individual to fall. May occur when something has been spilt or when the sole of the footwear and floor are unsuited. TRIP - A trip is to stumble accidentally often over an obstacle or uneven surfaces causing the individual to lose their balance, this is either corrected or causes an individual to fall. Fall from height a place is at height if a person could be injured falling from it. A height is classed as standing on or above 1 metre from the floor Assisted fall- Lowered to the floor or bed with assistance from staff. Restraint - the intentional restriction of a person s voluntary movement or behaviour Risk - the term risk is determined to mean the likelihood of harm or injury arising from a hazard Near miss an event not causing harm, but has the potential to cause injury or ill health 5.0 Staffing and Management Responsibilities (Staff responsibilities following an incident can be found in section 11.) 5.1 Chief Estates & Facilities Director 5.1.1 The Chief Estates & Facilities Director is the nominated Executive Director with responsibility for Health and Safety of persons on premises and will act on behalf of the Chief Executive to ensure processes are in place to manage the risks associated with slips, trips and falls including implementing and monitoring this policy. 5.2 Senior Health and Safety Advisor 5.2.1 The Senior Health and Safety Advisor will review, monitor and escalate identified high level risk relating the slips, trips and falls. 5.2.2 A copy of all department risk assessments must be sent to the Senior Health and Safety Advisor to review and monitor any implemented actions. Any residual risks will be included in the relevant Directorate and Health & Safety Risk Assurance Frameworks. 5.3 Heads of Nursing, Lead Nurses, Clinical Operational Managers (COM), Ward Sisters and other Supervisors 5.3.1 To ensure that steps are taken to implement the requirements of Trust policies and management guidelines. 5.3.2 Identify hazards and ensure the process of risk assessment and risk reduction is implemented within their area of responsibility. They may nominate competent staff to assist in this process. 4
5.3.3 To ensure all staff receive training in slips, trips and falls prevention in accordance with the Trust s Training Needs Analysis and in the use of any equipment required to comply with this policy. Additional information is available in the Mandatory Training Policy and the Moving and Handling Policy. 5.3.4 To provide suitable equipment and encourage the use of relevant equipment where provided, ensuring that there is a procedure in place for cleaning, servicing and maintaining all floor coverings, grounds and pathways. 5.3.5 To follow up all accidents, incidents and near misses associated with slips, trips and falls to identify their cause and review the control measures in place. Significant events will be reported to the Health & Safety Executive (HSE) under the Reporting of Injuries Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR). 5.4 All Employees 5.4.1 All Employees have an individual responsibility and accountability for the provision of safe and competent practice and are expected to adhere to Trust policies and follow the guidelines to prevent risks to themselves and others. 5.4.2 Co-operate with their managers to assess and control the risk of slips, trips and falls. 5.4.3 Report any unsafe conditions that may result in a slip, trip or fall incident. 5.4.4 Report any incidents or near misses relating to slips, trips or falls in accordance with the Incident Policy. 5.4.5 All healthcare providers must ensure that there are systems in place to protect the safety and wellbeing of patients in their care. 5.5 Health & Safety Group 5.5.1 Health & Safety Group is responsible for providing oversight and assurance that the risks associated with non-patient falls are identified and mitigated. 6.0 Staff Training 6.1 Slips, trips and falls awareness training is included in the Health and Safety training provided on commencement of employment as part of the Trust Induction Programme and within the Mandatory training sessions delivered in accordance with the Trust Training Needs Analysis (Mandatory Training Policy). 6.2 In addition to the training provided, the following basic guidance must be followed by all staff in their workplace: Use your initiative If you see a spillage i.e. water, food etc. clear it up. Suggest ways of preventing contamination (spillages, waste etc.) from getting onto the floor Respond promptly to any reports of spillages and ensure appropriate signage is used to highlight wet floors. Make sure the floor is clean and dry Clear up spillages immediately with the appropriate provisions 5
Dispose of waste materials (in accordance with the Trust waste disposal policy) Avoid causing any obstructions and avoid causing trailing cables Store goods safely Keep workstations clear of obstacles Report where you feel there is inadequate lighting Wear sensible footwear (in accordance with the Trust Dresscode Policy and local PPE protocol where applicable) Think about visitors coming to your workplace - what do they need to know and should do we need to do more to protect them? 6.3 As need arises publications of national and local initiatives will take place. 7.0 Risk Assessment for the Management of Slips, Trips and Falls Staff and Others 7.1 The Workplace (Health, Safety & Welfare) Regulations 1992 Regulation 13 (1) So far as reasonably practicable, suitable and effective measures shall be taken to prevent any event of a person falling a distance likely to cause personal injury. The legislation includes the need for effective planning, control measures and a continuous monitoring and review process that evaluates the measures adopted to reduce the risks. 7.2.1 Managers or a nominated competent person of each department or area are required to undertake a risk assessment of the environment on annual basis (appendix G). This should be reviewed periodically throughout the year or following an incident, policy change, staff change, location change, any significant change or based on the needs of individual staff who would be deemed at risk under the Disability Discrimination Act 2005. 7.2.2 The risk assessment will identify potential slip, trip and fall hazards relating to activities carried out within their areas of responsibility and the precautions and control measures to be taken, through the risk assessment process to reduce the risk of incidents to Staff, volunteers, visitors and patients. 7.2.3 All Risk Assessments for the staff and environment must be stored electronically, with a copy sent to the Health and Safety Manger and in paper format stored in the Red Risk Folder located in each clinical area. Any residual risks will be included on the Directorate and Health and Safety Risk Assurance Framework. 7.2.4 Managers of each department or area should ensure cleaning regimes are adequately risk assessed, and sufficient safety equipment is provided for staff so they may comply with the preventative and protective measures designed to reduce slips trips and falls. 7.2.5 Trust staff and associated contractors on Trust premises should be vigilant in the identification of potential slips, trips and falls hazards. Where appropriate these hazards should be removed, or if this is not possible then ensure the appropriate department who can take the necessary action is notified and ensure this action is documented. 6
7.2.6 Staff must ensure their work areas are kept clear, free from obstructions and spillages that may be hazardous or increase the risk of slips, trips or falls. Position any equipment with cables with care to avoid cables crossing pedestrian routes. 7.2.7 Ensure that spillages are identified as soon as possible and cleared immediately. Use appropriate signage or staff to alert persons of the potential slip risk in the area. 7.2.8 The cleaning of departments must be undertaken in a safe manner, identifying the area to be cleaned and ensuring that segregation of wet and dry areas take place with signage put in place. Staff working in these areas must ensure staff, patients and members of the public are aware of cleaning being undertaken in the area. 7.2.9 Monthly environmental inspections are undertaken of all unoccupied areas by the Estates and Facilities directorate including grounds and gardens, car parks, public corridors, main receptions and public toilets. All hazards are reported at the time of inspections. 8.0 Incident Reporting Serious Incident Reporting 8.1 Where a slip, trip or fall occurs, the incident must be reported in accordance with the Incident Policy. 8.2 If the fall results in a significant injury. The Governance Team and the Senior Health and Safety Advisor must be alerted and the incident discussed at the daily Serious Incident Management Group. Further details are available in the Serious Incidents Policy. Root cause analysis will be undertaken in accordance with the required timescales and the learning points identified and acted upon. Out of Hours, the Clinical Operations Managers must also be informed. For guidance on risk ratings please see: http://meht-intranet/clinical-pages/incidents-and-risks/ and open risk rating guidance. 8.3 Some significant injuries are reportable to the HSE under RIDDOR 2013. Refer to the Trust s Health and Safety Policy and Incident Policy for further information. The Senior Health and Safety Advisor must be notified at the earliest opportunity of a RIDDOR reportable event where a person experiences a slip, trip or fall on premises. Individual members of staff should not report RIDDOR events externally to the HSE: these must be reported through the Senior Health and Safety Advisor. 8.4 Examples of RIDDOR reportable events include: Sickness absence for a time greater than 7 days due to a slip, trip or fall Staff member sustaining a fracture of any bone, except fingers and toes. 8.5 Where appropriate the area should be made safe in order to prevent further incidents. 8.6 Please see Serious Incidents Policy for further information. 8.7 The Senior Health and Safety Advisor and Falls Practitioner will support the assigned investigating officer in conducting an investigation into the event and ensure recommendations are made. Implementation of actions following an incident will be monitored in accordance with the Incident Policy. Where residual risks remain these 7
should be included on the relevant Directorate and Health & Safety Risk Assurance Framework. 9.0 Staff Responsibilities for Management of Falls Incidents 9.1 Where an employee or visitor to the Trust suffers a slip, trip or fall, their immediate medical needs should be attended to and where serious injury is suspected they should be referred to A&E. Refer to the First Aid Policy for further information. Following the event, Occupational Health should be notified of any staff injury. 9.2 A Trust incident form should be completed as soon as the patient, member of staff or other person is safe. Refer to appendix I for guidance.. 9.3 Estates staff are required to respond promptly (within agreed contracts) to reports of environmental issues that may increase risk of patient, staff or the public falling e.g. damaged flooring. 9.4 Manager responsible for the area 9.4.1 Managers at all levels will be expected to empower workers to recognise risk and take action to minimise risks associated with slips, trips and falls. Managers responsible for the area should: Ensure that incidents involving slips, trips or falls are managed effectively and in accordance with the Incident Policy. Report all accidents / incidents involving slips, trips or falls using the Trust risk event report form (Datix) in accordance with the Incident Policy. Facilitate any investigation of incidents involving slips, trips or falls and develop and monitor action plans to address any findings. 10.0 Support for Staff following an Event 10.1 Any member of staff involved in a slip, trip or fall event can obtain immediate advice and support from their line manager or the Governance team. For further information on supporting staff refer to the Supporting for Staff Involved in a Traumatic Incident, Complaint and Claim Policy. 11.0 Equality and Diversity 11.1 The Trust is committed to the provision of a service that is fair, accessible and meets the needs of all individuals. 12.0 Audit and Monitoring 12.1 The completion of department environment risk assessments for staff and others will be monitored on an on-going basis by Senior Health and Safety Advisor. 12.2 Compliance will be reported to the Health and Safety Group. Where deficiencies are identified, actions with named leads and timescales will be developed and progress with implementation monitored at subsequent Health and Safety Group meetings. 8
12.3 The outcome of the monthly environmental inspections undertaken by the Estates department are reviewed by the Site Manager for Estates and Facilities as part of the directorate performance reporting process. 13.0 Review 13.1 The policy will be reviewed on a three yearly basis unless earlier revision is required as the result of any changes in legislation, the Trust s assessment processes or technological improvements. 14.0 Communication & Implementation 14.1 The policy will be made available on the Trust s intranet and website. The Health and Safety Team and Professional Development Team will be responsible for issuing copies to all Directorate Leads and Ward Sisters for dissemination within their departments. 14.2 The approved policy will be notified in the Trust s Staff Focus that is sent via e-mail to all staff. 15.0 References and Further Reading Health and Safety Executive: Health & Safety at Work Act 1974 Section 2, Section 3 and Section 7 - September 2006 Health and Safety Executive: The Management of Health & Safety at Work Regulations 1999 Section 3 - March 2008 Health and Safety Executive: The Workplace (Health, Safety & Welfare) Regulations 1992 Section 1 - January 1996 9