Title Reference Slips Trips and Falls Policy (Staff and Others) HS/POL/076 Description of document The purpose of this policy is to ensure all Norfolk Community Health & Care NHS Trust staff are aware of the relevant hazards in the workplace relating to slips, trips and falls and how to prevent and manage the associated risks involving staff and others. Scope Author and designation Equality impact assessment (EIA) Associated documents This policy applies to all NCH&C staff and contracted staff. Carl Ward, Health & Safety Manager, NCH&C. An EIA was carried out on 03.07.17 and was found to have no negative impact NCH&C Health and Safety Policies; NCH&C Manual Handling Policy. Supporting references Health and Safety at Work Act 1974; Management of Health and Safety at Work Regulations 1999; Work at Height Regulations; Workplace (Health, Safety and Welfare) Regulations. CQC domain Consultation or development process Safe and Well Led. Health and Safety. Training implications See section 10. Process for monitoring compliance Duties, accountability and responsibility Dissemination See section 11. See sections 6 & 7. This procedural document is published on NCH&Cs Intranet and is accessible via the Internet. Staff are informed of publication and any changes or updates via the Monthly Briefing Exchange, Weekly Messages or equivalent. Is there any reason why any part of this document should not be available on the public web site? Yes No This policy replaces the previous version of NCH&C Slips, Trips and Falls (Staff and Others) Policy V2 published March 2015. Approval process Clinical Policies Group on 07.09.17 Ratification process Quality and Risk Assurance on 18.09.17 Review arrangements September 2021, or sooner should changes to legislation or guidance require it. (Staff and Others) NCH&C Page 1 of 11
Date of issue September 2017. Archiving arrangements This document will be archived in line with the policy for procedural documents. (Staff and Others) NCH&C Page 2 of 11
Slips, Trips and Falls Policy (Staff and Others) Contents Section Page Document Control 4 1 Introduction 5 2 Purpose 5 3 Scope 6 4 Definitions 6 5. Legal and Statutory Requirements 6 6 Individual/Departmental Duties, Accountability and Responsibility 7 7 Duties, Accountability and Responsibility 9 8 Factors known to contribute to the risk of falls 9 9 Reporting trends and sharing learning 10 10 Training 11 11 Monitoring 11 Appendices Appendix A Appendix B Causative factors and slip risk controls (taken from HSE information sheet No2 Slips and trips in the health services) Wet surface warning poster (Staff and Others) NCH&C Page 3 of 11
Document Control Version number Date Name and title of author or committee Document approval status Description of change to document or status 1.0 14.03.12 Quality and Risk Assurance 1.1 14.01.15 Brenda Stolworthy/Gillian Stansfield 2.0 03.02.15 Clinical Policies Group Ratified Draft Approved Minor formatting amendments made. 2.0 16.02.15 QRAC Ratified 2.1 25.05.17 Carl Ward Draft Minor formatting amendments made. Addition of appendix C Added 6.5.8 Amended 6.5 to include maintenance 2.2 03.08.17 Health and Safety 2.3 07.09.17 Clinical Policies Group Draft Approved For information and agreement Approved subject to changes / queries addressed re: wet surface poster, monitoring, RA and Incident management section to be removed and make ref to policy, to add training to monitoring table. 2.4 12.09.17 Karen Pope Approved Amended policy to meet NCH&C standards for procedural documents: Amended associated documents, Amended supporting references, standardised formatting, removed risk assessment section and replaced with 8.3 Added section 7 Added training to monitoring table 3.0 18.09.17 Quality and Risk Assurance Ratified (Staff and Others) NCH&C Page 4 of 11
1. Introduction 1.1 The management of Health and Safety at Work Regulations 1999 in line with the Health and Safety at Work Act 1974 includes duties for people in control of workplaces to assess risks (including slips, trips and falls). They require appropriate arrangements for planning, organisation, control, monitoring and review of any measures to safeguard health and safety identified by risk assessment. Similar requirements for falls from height are included in the Work at Height Regulations 2005. The policy requirements below therefore apply to work carried out on a level surface and where there is potential for a fall of any height. 1.2 Slips, trips and falls can affect all individuals (staff, volunteers, contractors and member of the public) whilst carrying out their roles or whilst visiting our premises. Norfolk Community Health and Care (NCH&C) provide services in many different venues Health Centres, Out Patient Clinics, inpatient areas, patients own homes, etc. 1.3 Slip, trip or fall incidents can be serious and costly. Nearly 50% of all major accidents in the health services reported to the Health and Safety Executive (HSE) are caused by slips trips and falls. 1.4 Norfolk Community Health and Care NHS Trust (NCH&C) recognises its responsibilities under health and safety legislation and the importance of providing a working environment that is safe and healthy for all employees, contractors, visitors, volunteers and members of the public. 1.5 NCH&C has a statutory duty to comply with regulations relevant to the management of risks of slips, trips and falls. These include: 1.5.1 Health and Safety at Work Act 1974; 1.5.2 Management of Health and Safety at Work Regulations 1999; 1.5.3 Work at Height Regulations; 1.5.4 Workplace (Health, Safety and Welfare) Regulations. 1.6 The Trust will endeavour to protect staff and other persons, to whom it has third party liability at law, from the effects of slips, trips and falls hazards by good management and risk assessment. 2. Purpose 2.1. The purpose of this policy is to ensure all Norfolk Community Health &Care (NCH&C) staff, are aware of the relevant hazards in the workplace relating to slips, trips and falls and how to prevent and manage the associated risks involving patients, staff and others. 2.2. To have clear standards and documentation which describes the process for managing the risks associated with slips, trips and falls involving staff and others. 2.3. To ensure all staff maintain a safe environment which reduces the risk of slips, (Staff and Others) NCH&C Page 5 of 11
trips and falls. 2.4. To examine the contributing factors across the Trust and to ensure robust systems are in place to address concerns and minimise risks. 3. Scope 3.1. This policy applies to all staff employed or contracted to work in NCH&C. These staff will work within a variety of settings, including NCH&C premises, patients own homes, or care settings owned by other agencies. 4. Definitions of a slip, trip or fall 4.1. Slip: A slip is to slide accidentally, causing the person to lose their balance. This is either corrected or causes the person to fall. 4.2. Trip: A trip is to stumble accidentally, often over an obstacle causing the person to lose their balance. This is either corrected or causes the person to fall. 4.3. Fall: A fall is an event that results in a person, or a body part of that person, coming to rest inadvertently on the ground or surface lower than the person, whether or not an injury is sustained. 4.4. Almost all slips happen when floors are wet or dirty (e.g. contaminated with water, body fluids, oil, food debris, talcum powder etc.). If the floor has a smooth surface (e.g. surface of standard vinyl, varnished wood or ceramic tiles) even a small amount of contaminating can prove a slip hazard. 4.5. Trips and falls usually occur on damaged, uneven and badly repaired floors or because obstacles have been left where people do not expect to find them. 5. Legal and Statutory Requirements 5.1 Although previous Health and Safety legislation has always required action against slips, trips and falls risks, recent regulations have emphasised the importance of these measures and demonstrated how to implement them. 5.2 The Management of Health and Safety at Work Regulations 1992 (amended in 1999) specifies the legal requirements for risk assessments to be carried out and for effective risk control measures to be implemented and enforced. 5.3 RIDDOR requires the reporting of death or serious injury to both employees and non-employees. 5.4 The NHS Litigation Authority (NHS LA) recognises slips, trips and falls as a risk to organisations and to their resources. It has therefore introduced a set of standards around falls prevention which includes such issues as the requirement (Staff and Others) NCH&C Page 6 of 11
to undertake risk assessments, falls prevention, staff training and monitoring compliance with policy. 5.5 The Workplace (Health, Safety and Welfare) Regulations 1992 require the floor surface to be suitable for purpose and kept free from hazard or obstruction which may cause a person to slip, trip or fall. Particular attention should be paid to: 5.5.1 Holes, bumps and uneven areas; 5.5.2 Snow and ice on external walkways; 5.5.3 Drainage systems where appropriate; 5.5.4 Arrangements for dealing with spillages; 5.5.5 Health Centre/building entrances; 5.5.6 Obstructions to walkways; 5.5.7 Lighting and resulting visual effects; 5.5.8 Irregularities on stairs/ steps; 5.5.9 Loose or lack of handrails; 5.5.10 Height of furniture. 6. Duties, Accountability and Responsibility 6.1. Chief Executive The Chief Executive and members of the Trust Board are accountable for the administration of the Slips, Trips and Falls Policy. The Chief Executive and Trust Board have overall responsibility for the implementation of this and for monitoring its effectiveness and have the ultimate responsibility for ensuring the implementation of the Slips, Trips and Falls Policy. The day-to-day responsibility for the prevention and management of slips, trips and falls is delegated as below in paragraphs 6.2 to 6.5 inclusive. 6.2. Directors/Assistant Directors The Directors are responsible for ensuring systems are in place for the dissemination Health and Safety Policies throughout their directorate. They will ensure that: 6.2.1 Services within their area of responsibility adhere to this policy, and other policies and procedures related to Health and Safety; 6.2.2 There is an effective link in communicating slips, trips and falls and related information; 6.2.3 They respond to risk assessment reports from line managers and take appropriate remedial action to minimise the risks; 6.2.4 They identify and allocate resources, including human and financial, as far as is reasonably practicable, in order to comply with this policy. 6.3 Service/Locality Managers and Matrons (Staff and Others) NCH&C Page 7 of 11
These managers are responsible for health and safety in their area of management responsibility. These managers are expected to manage health and safety as part of their daily routine. The key function is as follows: 6.3.1 To ensure that this policy and local arrangements are understood, accepted and practised. 6.3.2 To ensure that systems are in place to report to Estates and /or Health and Safety Manager any areas of concern re floor surface, lighting etc to prevent potential incidents. 6.4 Ward Managers/Heads of Departments/Team Leaders and other Managers in Charge These managers are responsible for their ward/department s staff health and safety as well as visitors. The key functions are as follows: 6.4.1 Undertaking risk assessments and identifying and implementing methods of elimination and control to minimise risks from slips, trips and falls; 6.4.2 Ensuring all incidents and near misses are reported and recorded promptly and that appropriate action is undertaken to prevent recurrence including review of existing risk assessments or undertaking additional one; 6.4.3 Ensuring all new starters to the organisation attend the corporate induction programme and health and safety awareness in accordance with the mandatory training programme; 6.4.4 Ensuring completion and sign off of local induction training. 6.5 Employees and contractors All staff, including bank, agency staff and contractors have an obligation to follow safety instructions and comply with the information, instruction and training provided. They are responsible for their own safety and the safety of others. They should only use work equipment for the purposes it was designed for and should not modify, adapt or improvise work equipment (e.g. use a chair instead of a kick stool or steps). Work equipment will be maintained in line with manufacturer s instructions. All employees are expected to: 6.5.1 Cooperate with their managers during risk assessment; 6.5.2 Ensure that the workplace is kept free from obstruction, including trailing cables; 6.5.3 Participate in the monitoring process; 6.5.4 Clean up spillages immediately and ensure that hazard signs are in place if appropriate; 6.5.5 Wear suitable footwear; 6.5.6 Report hazards to their line manager and Datix web; 6.5.7 Ensure risk assessments regarding slips, trips and fall hazards are undertaken and kept up to date, including for patients cared for in NCH&C and non NCH&C premises; 6.5.8 Only work at height when all other options have been considered and if trained to do so. (Staff and Others) NCH&C Page 8 of 11
6.6 Health & Safety Team The Health and Safety Team will: 6.6.1 Ensure that a system is in place to monitor falls, analyse trends and respond to identified risks; 6.6.2 Ensure that reporting of all slip, trip or fall incidents that come under the Reporting of Injuries Diseases and Dangerous Occurrences Regulations (RIDDOR) to the Health and Safety Executive is complied with; 6.6.3 Review reported slips, trips and falls and provide expert advice and guidance, undertaking investigations as appropriate (See Health & Safety Policy); 6.6.4 They are responsible for providing advice guidance and training in identification of hazards and risk assessment. 7. Duties, Responsibility and Accountability 7.1 Health & Safety The Health &The Health & Safety committee is responsible for ensuring that any significant issues regarding-none patient falls are adequately controlled and that resources are available so far as is reasonably practicable. Health & Safety will report to Quality and Risk who will receive any actions requiring escalation. 7.2 Locality Health & Safety Each locality will have a dedicated health & safety meeting which will meet quarterly. All none-patient fall incidents involving harm will be discussed and escalated as required. Locality Health & Safety will report to the Health and Safety who will receive any actions requiring escalation. 7.3 Team Meetings Each team will have regular meetings using a standardised agenda which includes health and safety issues. This is an opportunity for any concerns to be raised/considered for management action and monitoring via Datix. Significant issues should be escalated and reported to Locality Health Safety. 8. Factors known to contribute to the risk of falls 8.1 The Health and Safety Executive outline 6 main contributory factors for slips, trips and falls. One or more may play a part in any situation or accident: 8.1.1 Flooring; 8.1.2 Cleaning; 8.1.3 People; 8.1.4 Environment (Snow and ice will be cleared by contractors arranged by Serco. Signage to warn the public during hazardous weather can be erected by employees as required. (See appendix B); (Staff and Others) NCH&C Page 9 of 11
8.1.5 Footwear; 8.1.6 Contamination and obstacles. 8.2. For more detailed information see Appendix A Causative factors and slip risk controls (taken from HSE information sheet No2 Slips and trips in the health services) 8.3 Any significant risk identified should be assessed in line with the Trusts risk management policy which is available on the intranet. 9. Reporting trends and sharing learning 9.1. A quarterly incident analysis is compiled for each service area local health and safety meetings, which list the slips, trip and fall s incident, these are discussed and any action and learning is shared at these meetings, this information is also taken to the general health and safety meeting. 9.2 The process for raising awareness about preventing and reducing the number of slips, trips and falls involving staff and others in NCH&C is through discussion of the issues at locality and Trust General Health and Safety Meetings. 9.3 Individual investigations of slips trips and falls incidents involving staff and others may recommend that action is required by individual staff or teams such as management or clinical supervision, and/or further training or education. 9.4 Anonymised versions of incident and trend reports of slips trips and falls incidents involving patients, staff and others should be used for training purposes. 9.5 Managers must ensure that all teams and individuals, for whom findings and recommendations are relevant, are informed of these; for example through team meetings. 10. Training 10.1. All NCH&C employees must attend the corporate induction training, which includes a session on Health and Safety. 10.2. All NCH&C staff are required to attend mandatory general health and safety training every three years as detailed in the Training Needs Analysis (TNA) which includes specific information relating to the prevention Slips, Trips and Falls involving patients, staff and others, and including falls from height 10.3. Staff are encouraged to use the Slips and Trips e-learning package (STEP) produced by the H.S.E. This is accessible at www.hse.gov.uk/slips/step/index.htm (Staff and Others) NCH&C Page 10 of 11
11. Monitoring What will be monitored Compliance with Policy Training How will the monitoring be carried out Incident reporting and investigation Health & Safety training is monitored by HR When monitoring will occur When incidents occur. Quarterly trend analysis Monthly Who will conduct the monitoring Line Managers and Health and Safety Manager HR-LEAD team Where results will be reported to Local and General Health and Safety All managers How will the resulting action plan be progressed and monitored Local and General Health and Safety HR-LEAD team Noncompliance is escalated to which Assurance Quality and Risk Assurance Quality and Risk Assurance How will learning take place Local and General Health and Safety meetings Local and General Health and Safety meetings (Staff and Others) NCH&C Page 11 of 11