Item 8.2 Meeting: Trust Board Public Meeting Date: 7 October 2015 Title of Paper: Quarterly Trust Health and Safety Report April to June 2015. Key Issues: Two RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations) reportable incidents for the Trust in the April to June 2015 period. Average overall Unit/Ward Safety Matrix score of 723, down from 775 in the previous quarter. 16 of the 19 Unit/wards saw their Health & Safety Performance Matrix score decrease quarter on quarter. 20 properties audited with respect to fire safety. Number of unwanted fire signals totalled 12. Links to Strategic Objectives: Deliver high quality, safe and effective services. Risk Issues: Two RIDDOR reportable incidents for the Trust in the April to June 2015 period. 16 of the 19 Unit/wards saw their Health & Safety Performance Matrix score decrease quarter on quarter. 12 unwanted fire signals. Recommendations: The Board is asked to note the report and actions being taken. Author of Report: Paul Duggleby, Health and Safety Manager
1 INTRODUCTION This report is based on the work currently being undertaken on Health and Safety and Fire Safety within the Trust. 2 WORKPLACE/ACTIVITY SAFETY MANAGEMENT REVIEWS 2.1 Health and Safety risk assessment reviews As part of the Trust Health and Safety management review scheme, reviews of Health and Safety risk assessments have taken place in the reporting period. The reviews focused on: Workplace/activity risk assessments. Control of Substances Hazardous to Health (COSHH) assessments for compliance with the Substances Hazardous to Health Policy. Display Screen Equipment (DSE) assessments for compliance with the DSE Policy. Driving at Work assessments for compliance with the Driving at Work Policy. Moving and Handling assessments for compliance with the Moving and Handling Policy. The following Teams have been reviewed in the reporting period: East Riding Single Point of Contact Team- Community Beverley Learning Disabilities Team (Hull Pediatrics) Hedon Community Nurses Team (Community Holderness) Derwent Ward Humber Centre Swale Ward Humber Centre Hawthorne Court In-Patient Unit Mill View Court In-Patient Unit 2.2 Findings from the safety management reviews Key themes: Unit/Team East Riding Single Point of Contact Team- Community Beverley Main Findings The review identified that the required assessments were in place and in date. Hedon Community Nurses Team (Community Holderness) The review identified that the required assessments were in place and in date. Page 2
Unit/Team Main Findings Derwent Ward Humber Centre The review identified that a small number of additional assessments were required in addition to the existing assessments. The additional assessments are now in place. Swale Ward Humber Centre The review identified the required assessments were in place and in date. Ouse Ward Humber Centre The review identified that a small number of additional assessments were required in addition to the existing assessments. The additional assessments are now in place. Hawthorne Court In-Patient Unit The review identified that a small number of additional assessments were required in addition to the existing assessments. The additional assessments are now in place. Mill View Court In-Patient Unit The review identified that a significant number of assessments needed to be reviewed and updated. Following the review the Unit Management Team fully reviewed and updated the assessments and put in place procedures to ensure that regular assessment reviews are now undertaken. 3 HEALTH AND SAFETY PERFORMANCE MATRIX SYSTEM The Health and Safety Performance Matrix System is designed to measure pro-active actions taken to prevent incidents, rather than the traditional way of focusing on and measuring reactive events (e.g. focusing solely on measuring incident statistics). Page 3
Unit / Team 3.1 Safety Matrix Quarterly Key Performance Indicator (KPI) Scores The Units/Wards have achieved the following quarterly safety KPI scores: 2014 Jan - Mar 2014 Apr - Jun 2014 Jul - Sep 2014 Oct - Dec 2105 Jan - Mar 2015 Apr - Jun Avondale Unit 740 710 830 870 775 790 Townend Court 850 840 840 820 790 775 Greentrees Unit 860 860 860 860 840 780 PICU Unit 760 785 725 840 840 685 Hawthorne Court Unit 920 920 920 920 920 900 St Andrews Place Unit 760 820 800 880 920 900 Maister Lodge Unit 775 795 860 860 750 705 Mill View Court Unit 775 815 765 820 660 610 Mill View Lodge Unit 670 830 870 810 755 730 Newbridges Unit 880 860 860 815 735 690 Westlands Unit 515 635 840 730 800 650 Swale Ward - Humber Ctr 755 860 860 815 785 770 Ullswater Ward - Humber Ctr 580 740 740 690 685 Derwent Ward - Humber Ctr 565 780 860 840 765 685 Darley House - Humber Ctr 525 770 850 790 770 615 Ouse Ward - Humber Ctr 455 650 640 690 635 680 East Riding Community Hospital Ward 770 770 810 655 595 Macmilland Wold Community Hospital Ward 880 755 855 855 755 Withernsea Community Hospital Ward 800 820 820 795 695 Average Overall Score 712 796 814 818 775 723 Key Baseline score 300 Goal score 700 Highest possible score 1000 Blank - Unit not partcipating during the quarter Score above the goal score Score below the goal score 3.2 Themes arising from the quarterly matrix 3.2.1 Scoring During 2015, the average Unit/Ward overall safety KPI (key performance indicator) performance score has declined over the first two quarters. This is largely as a result of a decline in the Unit/Ward safety checks compliance rates and the safety related training compliance rates. Page 4
In regards to the Unit/Ward safety checks compliance rates, declines in the compliance rate have coincided where there has been significant changes to the Unit Management, e.g. Newbridges In-patient Unit, in the reference period. The decline in the safety related training compliance rates has coincided with the changes to the availability on certain face to face training courses in the January to March 2015 period. Unit/Ward Management have expressed concerns about the availability of certain courses, particularly the Immediate and Basic Life Support and the Management of Actual or Potential Aggression (MAPA) courses. These concerns have been relayed to the relevant Line Management and the Organisational Development Team. The additional availability of the above courses would have a significant impact on the safety related training compliance scores. 3.2.2 Townend Court The decrease in the overall safety KPI score was due to the safety related training compliance rate decreasing from 68% to 63%. It was also noted that the Basic Life Support training compliance rate for the Healthcare Assistants was low at 24%. The above information was given to the Unit Management and their Line Management. 3.2.3 PICU Unit The decrease in the overall safety KPI score was due to the following: A decrease in the Estates/Hotel Services safety related compliance check rate from 100% to 86%. A decrease in the Unit Safety related checks compliance rate from 100% to 81%. This was due to Weekly Audit of Medical Equipment checks not being carried out for each of the reference months. A decrease in the safety related training compliance rate from 55% to 51%. The above information was given to the Unit Management, their Line Management and to Estates. 3.2.4 Mill View Court In-patient Unit The decrease in the overall safety KPI score was due to the following: A decrease in the Unit Safety related checks compliance rate from Page 5
70% to 65%. The low score was due to incomplete monthly safety inspection records; the June 2015 Defibrillator check being missing and only one week of the Weekly Audit of Medical Equipment checks completed for the April to June 2015 period. A drop in the safety related training compliance rate from 75% to 69%. Due to the significant decline in the quarterly overall safety KPI scores during 2015, the Health and Safety Manager has spent some time with the Unit Management reviewing the above issues. The Unit Management have put actions in place to address the issues highlighted by the Matrix and subsequent reviews will measure the progress made. 3.2.5 Westlands In-patient Unit The decrease in the overall safety KPI score was due to the following: A decrease in the Unit Safety related checks compliance rate from 100% to 44%. A decrease in the safety related training compliance rate from 62% to 59%. Due to the significant decline in the quarterly overall safety KPI scores during 2015, the Health and Safety Manager has spent some time with the Unit Management reviewing the above issues. The Unit Management have put actions in place to address the issues highlighted by the Matrix and subsequent reviews will measure the progress made in addressing the issues. 3.2.6 Humber Centre Wards The Ullswater Ward review is scheduled to take place in late September 2015, as previous scheduled review meetings have been cancelled due to lack of Ward management availability. The remaining 4 Humber Centre Wards saw a decrease in their overall safety KPI scores. This was largely due to a drop in the Estates/Hotel Services safety related compliance check rate for the Humber Centre building from 100% to 78%. Estates have been informed about the above. Darley House saw a significant drop in their score due to: A decrease in the Unit Safety related checks compliance rate from 100% to 90%. A decrease in the safety related training compliance rate from 68% to 59%. Page 6
3.2.7 Community Wards East Riding Community Ward saw a decrease in the overall safety KPI score due to the following: A Unit Safety related checks compliance rate of 60%. A decrease in the Estates/Hotel Services safety related compliance check rate from 100% to 89%. A low stress assessment score of 92 out of 175. Due to the significant decline in the quarterly overall safety KPI scores during 2015, the Health and Safety Manager has spent some time with the Ward Management reviewing the above issues. The Ward Management have put actions in place to address the issues highlighted by the Matrix and subsequent reviews will measure the progress made in addressing the issues. 4 INCIDENT REPORTING 4.1 Reporting of Injuries, Diseases and Dangerous Occurrences (RIDDOR) reportable incidents Comparison of all RIDDOR reportable incidents for 2013, 2014 and 2015 Year 2013 2014 2015 1 January to 30 June 4 6 4 1 April to 30 June 1 3 2 Page 7
Breakdown of categories of RIDDOR reported incidents January to June 2015 Type Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Total V&A - Injured 1 1 Slips/Trips/Falls (employees) 1 1 Slips/Trips/Falls (patients/other) Moving & Handling 1 1 Struck/Trapped/Collided with Burns/Scalds Contact with Harm/Bio Subs Working at Height Exposure to Infection Play/therapeutic activity All Other 1 1 Totals 1 1 0 0 1 1 4 4.2 Description of RIDDOR Incidents for the April to June 2015 period 4.2.1 Report of Occupational Disease May 2015 The individual suffered a skin reaction after wearing latex gloves which she had found in the Team store cupboard. The Occupational Health Team was informed, the causation of the skin reaction was quickly identified and the latex gloves were removed from the store cupboard. The staff member was placed under health surveillance with the Occupational Health Team and continued her work duties. The incident investigation identified the following: The staff member was made aware of potential issues with using rubber (latex) based products by her General Practitioner in 2012. A review of the ordering of clinical gloves across the Trust, for the previous 12 months prior to the incident, identified a number of Teams and Units had purchased latex gloves without authorisation. To prevent unauthorised purchasing of latex gloves, the latex gloves on the NHS Supplies website should have been masked by the Supplies Team. It appears that the latex gloves had been unmasked on the NHS Supplies website in early 2014 to allow for a one-off authorised purchase of latex gloves, but had not then been re-masked in error, thus allowing Teams to order latex gloves. Page 8
The following remedial actions were implemented: Teams and Units who had ordered latex gloves and were unauthorised to do so, were contacted and requested to remove all latex gloves from their supplies. The NHS Supplies website has been checked to ensure all latex gloves were masked to prevent unauthorised ordering. Staff, who are authorised to use latex gloves by Occupational Health, are required to keep their supplies secure and separate. The Supplies Team now require authorisation from Occupational Health to order latex gloves for any staff member not already on the authorised latex supply list. A reminder about the use of latex gloves was placed in a weekly global email. 4.2.2 Moving and Handling Incident June 2015 The staff member bent down to lift a medical records box in order to stack it with the others. However, whilst attempting to lift the box, the staff member felt a sharp pain in his lower back. The staff member was subsequently off work for more than 7 days before returning to work. The following remedial actions were implemented: A lift trolley purchased to mechanise the lifting operation. The introduction of monitoring of the weights of the medical record boxes to prevent overfilling. Page 9
4.3 Trust Employee incidents which resulted in injury and treatment January to June 2015 Type Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 2015 Comparison Totals 2014 Comparison Totals 2013 Comparison Totals Violence & Aggression Phsyical 12 5 10 8 11 2 48 53 37 Violence & Aggression Verbal 3 2 4 2 0 1 12 2 1 Burns/scalds 0 0 0 0 0 1 1 3 0 Exposed to Hazardous substance 0 0 0 0 0 0 0 0 0 Exposed to Infection 1 0 0 0 0 0 1 0 0 Slips/Trips/Falls 3 2 0 0 0 3 8 7 16 Moving & Handling 2 0 0 1 2 2 7 4 7 Needlestick/Sharps 1 1 1 1 1 0 5 8 11 Road Traffic Accident 0 1 0 0 0 0 1 1 1 Sexual Behaviour 0 1 1 0 1 0 3 4 0 Struck/Trapped/Collided with 0 1 1 2 1 2 7 5 11 Unwell/Illness 0 0 0 2 0 0 2 1 1 Totals 22 13 17 16 16 11 95 88 85
4.3.1 Themes arising from the Violence and Aggression Physical Incidents A breakdown of the 21 incidents in the April to June 2015 period identified incidents that occurred in the following Units: Avondale 1 incident. Maister Lodge 2 incidents. Psychiatric Intensive Care Unit (Miranda House) 5 incidents. Townend Court Lilac Ward 2 incidents. Townend Court Willow Ward 4 incidents. Ullswater Ward, Humber Centre 2 incidents. 4.3.2 Psychiatric Intensive Care Unit (Miranda House) 5 Incidents Four of the 5 incidents involved same client. The Health and Safety Manager has reviewed the incidents with the Ward Charge Nurse and found appropriate protocols had been followed during and after the incidents. 4.3.3 Townend Court Lilac Ward 4 incidents Two of the 4 incidents involved the same client. The Health and Safety Manager has reviewed the incidents with the Ward Charge Nurse and found appropriate protocols had been followed during and after the incidents. 4.3.4 Summary on Violence and Aggression Physical Incidents A review of the violence and aggression incidents for the review period has not identified any clear indication of a theme developing. The numbers and types of incidents vary depending on the client profile within the service at any one time. It was noted during the reviews that the client profile at Townend Court was particularly challenging for staff during this period and some of the clients have subsequently been moved to more suitable facilities. 4.3.5 Themes arising from the Violence and Aggression Verbal Incidents A review of the 12 incidents in the January to June 2015 period did not identify any trends or themes as the location and nature of the incidents varied. Staff have been encouraged to report cases of verbal aggressions and the increase in the number of incidents during 2014 and into 2015 indicates that a more representative number of incidents are being reported than previously. 4.3.6 Themes arising from the Moving and Handling Incidents A review of the 5 incidents in the April to June 2015 period identified that 2 of the 5 incidents involved staff being injured whilst preventing clients from falling.
One of the incidents involved the staff member receiving an impact injury from the object being carried. 4.4 Comparison of reported contractor incidents for 2013, 2014 and 2015 Year 2013 2014 2015 1 January to 30 June 1 0 0 4.4.1 Contractor Incidents No contractor incidents were reported in the April to June 2015 quarter. 5. Health and Safety Visual Inspection of Trust Properties A visual walk around Health and Safety inspection of the following Trust Properties was undertaken in the reference period: Bridlington Trust Buildings Coltman Street Clinic East Riding Community Hospital Hawthorne Court Highlands Health Centre Newbridges Pocklington Health Centre Skidby House Westlands Withernsea Where non-conformities were identified, these were passed on to the relevant Unit/Team Management and/or the Estates Team to be rectified. 6. Fire Safety Report April June 2015 Detailed below are the premises within Humber NHS Foundation Trust organisational area which have had recent Fire Risk Assessments and other matters appertaining to fire safety. 6.1 Properties Audited Townend Court (LD) Humber Centre Victoria House Brough Medical Centre Bridlington Medical Centre Technology Centre Page 12
Greentrees South West Lodge 74 Lairgate Sunshine House Rosedale Community Centre College House Skidby House Four Winds Becca House Miranda House Coltman Avenue Clinic Alfred Bean Hospital 6.2 General Comments The fire risk assessments completed have shown that the issues found have been of a minor nature and, on the whole, have been down to general maintenance requirements. Records regarding fire safety measures and testing regimes, kept within the premises fire folders, were found to be completed to a high standard and would provide a full audit trail should they be required. Fire doors within the unit accommodation areas have been surveyed and a schedule of replacement and remedial works has been discussed with the Estates Department, with works set to commence July 2015. Once works have commenced, this will have the effect of reducing the risk rating given to this matter, which has been placed on the corporate risk register. 6.3 Training At the time of compiling this report, fire training compliance stands at 68.6% for HFT staff. Fire warden courses continued to be delivered during this period and the compliment of fire wardens globally continues to rise. Team managers have asked if fire training can be delivered at site to facilitate both mandatory training requirements and work streams. A new approach to onsite training has commenced, whereby the fire manager is attending sites to ensure compliance is achieved and that a more bespoke approach to this training is delivered to staff. 6.4 Firecode Advice has been given regarding compliance with the fire safety requirements of Firecode, the Department of Health s policy which provides guidance and advice over and above that required by the Building Regulations. 6.5 Fire, False Alarms and Unwanted Fire Signals Within this reporting period the organisation has had the following incidents: Fires 0 False Alarm Activations 3 Unwanted Fire Signals 12 Page 13
The amount of unwanted and false alarm fire signals since the last reporting period continues to reduce; 3 fire alarm activations with the attendance of the fire service still remaining low. Over this reporting period, the organisation has had 12 unwanted fire signals and 3 false alarm incidences with the fire service attending on 2 occasions only. The 3 false alarms were as a result of 2 incidences of food left unattended (toast in ADL areas) and 1 fire phenomena caused by contractors. Staff and management have been informed as to the reason for the fire alarm activations from their premises and to take appropriate action to reduce the alarm incidences. Contractors responsibilities whilst carrying out works within HFT premises, are being more vigorously policed via the Estates Development team at progress meetings and site visits. This measure has had a noticeable effect on fire alarm activations by contractors. 6.6 Fire Doors/Risk Register Fire doors within life risk buildings have become, due to heavy use by clients, noncompliant and a full risk survey has been completed for all residential type premises. This issue has been given a risk rating of 16 on the risk register. This will reduce significantly as the replacement programme gathers momentum. At the time of compiling this report the risk has not changed. 6.7 Fire & Fire Alarm Zone Plans A programme of updating the existing fire plans has commenced to ensure up to date information is available for staff. The fire alarm zone plan is now overlaid onto the existing fire plan, which incorporates the main utility isolation points for the gas, electric and water supplies. This approach will reduce the amount of plans staff have to consult in the event of an incident; in essence one plan will deliver all fire related information for use by HFT staff or the emergency/utility services that may attend. 6.8 Summary The organisation continues to achieve compliance with the RRFSO 2005 and from evidence obtained, managers are policing their areas of responsibility in a more systematic approach and more importantly communicating findings between staff/teams. Management teams have been advised of their responsibilities when occupying new premises during the recent movement of personnel. The hard work of staff across services in achieving this level of compliance should be noted. Paul Dent Fire & Security Manager Page 14