Oct-15 As above CK/JG. Aug/Sep TU Reps

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Action Log Recommendations in Order of Priority for Remedial Action 1 A1 It is recommended that the Health and Safety Policy be reviewed. 1a A1 The Health and Safety Policy should be dated and signed by the Chief Executive. RF Sep-15 Draft policy prepared 20/08/2015? Final draft produced and with Policy Team for comment before approval by Resources Committee CE Oct-15 Final draft to be approved by Resources Committee (remotely) by end of October 1b A1 The Health and \safety Policy should be made available to all employees on the intranet. 1c A1 The Health and Safety Policy should be displayed in all offices. 1d A1 The revised Health and Safety Policy and any future updates should be brought to the attention of all 2 A1 In reviewing the Health and Safety Policy it is recommended that consideration the workforce and their representatives are actively engaged in the review. 2a A1 In reviewing the Health and Safety Policy advice should be obtained from a competent person 3 A1 In reviewing the Health and Safety Policy it is recommended that consideration should be given to document hierarchy and structure. /JG/ TU Reps /RF /JG Aug/Sep 2015 Oct-15 As above Oct-15 Will be posted on intranet when approved. Oct-15 As above Draft provided to for review by Policy Team prior to policy review group and Partnership Forum consultation. Aug-15 External Health & Safety Consultant (RF) has developed draft policy and forwarded to. Sep-15 Review document hierarchy, ensure policy and associated procedures aligns with system. 4 A1 When developing plans, policy and structure for managing for health and safety it is recommended that the level of competence necessary to comply with the law is considered. 6 A1 Once identified in the structure it is recommended that information be provided to all 7 A1 It is recommended that training is provided to employees with supervisory/managerial roles. /RF Jul-15 RF engaged to act as competent person and work closely with and others to develop HSMS. Training needs identified and procured. Page 1 of 7

9 A1 It is recommended that appropriate training should be given members of the Board and Executive Management Team, who are pivotal in the process. 11 A1 To improve engagement it is recommended that the Care Inspectorate formally constitute a health and safety committee with a clear remit for both function and membership. 12 A1 It is recommended that health and safety performance is included within business performance indicators. 16 A1 It is recommended that specific risk assessments should be undertaken when required. / RF Sep-15 Safety for Senior Executives procurement in progress. Sep-15 Existing committee structure to be reviewed to reflect the needs of the organisation and its structure. Proposed ToR and membership with. Next meeting to consider new Role and Membership on 29th September. The new policy takes the HSG65 approach to set indicators and monitor and review performance. The Indicators will be agreed and monitored at high level by the H&S Committee. A review of existing risk assessments will be carried out to produce a set of generic assessments that can be adapted and amended to suit local and individual circumstances in progress. 17 A1 It is recommended that all persons undertaking risk assessments should have appropriate training in risk assessment. 18 A1 It is recommended that a central register of risk assessments should be put in place. 19 A1 It is recommended that all generic risk assessments should be approved by chair of the health and safety forum following an agreed consultation process. 2015-16 Managing Safely training for all line management staff procured. 20 A1 It is recommended that specific/local risk assessments should be approved by local manager. 22 A1 It is recommended that a /JG system of document hierarchy should be put in place as part of the ongoing review of documents. 23 A1 It is recommended that a OD version control is incorporated into documents. Complete. There is a register already in place that is managed by the Health and Safety team. Sep-15 The remit of the National Health, Safety and Environment Forum is being revised to include the approval of all H&S policies, guidance and generic risk assessments. Completed. All generic risk assessments are completed and review by local managers and added to the risk register. Dec-15 Already underway. Jan-16 Accepted and will put in place from 2016. Page 2 of 7

24 A1 It is recommended that health and safety documents on the intranet are current and positioned in an area where information can be easily found. 25 A1 It is recommended that with the risk profile of the organisation the competent person should be a Safety Practitioner (Adviser) at Chartered Member of the Institution of Occupational Safety and Health. 27 A1 It is recommended that conflict resolution training is provided for those who have a public interface. 28 A1 When reviewing the Driving Guidance document it is recommended that a replacement document be prepared on the Management of Occupational Road Risk. 29 A1 It is recommended that as a priority, systems should be developed in addressing stress through the use of the HSE Stress Management Standards. 30 A1 It is recommended that employees and their representatives are fully engaged in developing systems to manage stress. 31 A1 It is recommended that when undertaking a review of documents and fire risk assessment processes sector specific guidance for offices on the Scottish Government website is used for reference and recognises that further external advice may be required. RF Nov-15 Schedule time with Comms and Policy Team to ensure all current docs are available. Jun-15 Complete. CMIOSH consultant in place from 1st August. CFHSAd in place from June 2015. Diploma in Progress. Unit B passed July 2015 Selection of appropriate training in progress. Train the trainer for the CFHSA to be investigated. Oct-15 Review of Driving Guidance to Handbook and Risk Assessment in progress. Dec-15 Working with Health Working Lives to implement their Work Positive Standards and system for managing work related stress. Sep-15 National Health, Safety and Environment remit and membership to be strategic and inclusive for staff representation. Jun-15 Completed. 32 A1 It is recommended that procedures be put in place to exchange information with other occupants and view master fire assessment for shared premises. PH Dec-15 Already in place prior to report but formal procedure to be written. Page 3 of 7

34 A1 It is recommended that when reviewing the guidance and training for first aiders, reference is made to HSE website to obtain current information on requirements. Dec-15 Complete 5 A2 It is recommended that job descriptions be reviewed to ensure the inclusion of health and safety responsibilities linked to the health and safety policy. 8 A2 It is recommended that training is provided to those with specialist roles eg risk assessors, fire wardens. 13 A2 It is recommended that all existing risk assessments should be reviewed to ensure that they are suitable and sufficient and that control measures are proportionate to the risk. 14 A2 It is recommended that a system should be put in place to facilitate access to risk assessments for all 15 A2 It is recommended that a system should be put in place to facilitate the exchange of information relating to risk assessments to ensure consistency of control measures and avoid duplication. 26 A2 It is recommended that the system for recording and retrieval of information (PMS) be reviewed to assist in the management of risk. OD HR / RF Oct-2015 and 2015-16 Apr-16 To be discussed with as part of the larger organisational review and restructure. Completion of training for all fire wardens. Already procured and scheduled. Risk assessment as part of Managing Safely training. Nov-15 In progress. Dec-15 The H&S pages on the intranet are being updated to include all current content and approved risk assessments as they become active. Covered by previous actions. 33 A2 It is recommended that training, including refresher training be put in place for fire wardens. 36 A2 When reviewing and updating DSE and laptop guidance it is recommended that the documents are merged into a single document. / OD Team Nov-15 Completion of training for all fire wardens. Already procured and scheduled. Dec-15 In progress. Draft Guidance on both. Page 4 of 7

37 A2 When reviewing the documents it is recommended that consideration should be given to the most cost effective measure for undertaking and recording DSE risk assessments. 43 A2 It is recommended that when reviewing documentation a manual handling assessment form is also developed for use and appropriate training be put in place. Mar-15 In progress. Currently have dse e- learning in place. New tender to be developed with escalation process. Use SG OH Assist framework or Posturite tender. RF Dec-15 47 A2 It is recommended that when reviewing and updating the document systems for monitoring return of inspection reports and any action required are addressed in the guidance. 10 A2 It is recommended that a training matrix be developed to embrace health and safety training requirements for all 35 A2 Depending on any previous threat it would be prudent to consider the inclusion of procedures to address bomb threat and white powder incidents. It is recommended that other threats be considered when reviewing emergency procedures. / On-going Included as part of the business continuity plan. No history or incidents reported in the last 13 years. Will be kept under review. 38 A2 In addition it is recommended that a management system be put in place to manage any DSE issues that arise and this should be supported with training for relevant In progress. Currently have dse e- learning in place. New tender to be developed with escalation process. Use SG OH Assist framework or Posturite tender. All internal DSE Assessors re-trained this year. 39 A2 It is also recommended that in developing a system to manage referrals, referral to a Health and Safety or Occupational Health Advisor should be the last stage. Dec-15 Working with OD team to revised procedures. Page 5 of 7

40 A2 It is recommended that the supply of chairs and other DSE equipment be reviewed to ensure appropriate provision for individuals. 41 A2 It is recommended that when reviewing and updating guidance recognition is taken on technology changes where phone chargers may be more common in offices and due to transient nature may not be PAT tested. In progress. New tender to be developed with escalation process. Use SG OH Assist framework or Posturite tender. All internal DSE Assessors re-trained this year. PAT completed every year in excess of guidance. (Completed October 2014 and scheduled for October 2015) 42 A2 It is recommended that a system of monitoring compliance with guidance on standards is put in place unless such a system is already in place to ensure electrical safety and help reduce fire risk. 44 A2 It is recommended that consideration be considered for relevant employees to receive presentation on use of current moving and handling devices a movement of people 45 A2 It is recommended that a system be put in place to ensure that H & S inspections undertaken are logged and where issues are identified follow up action is taken. PAT regime and Fixed Wiring Testing in place. Reviewing Manual Handling risk assessment and roll out of training. In future, will be covered at induction. Premises inspection regime already in place. 46 A2 It is also recommended that when inspection reports are not completed or returned on time there should also be follow up action to identify the reason. 48 A2 It is recommended that consideration be given to developing guidance on accident investigation. 49 A2 It is recommended that consideration be given to reviewing the capacity tool for calculation of caseload. Premises inspection regime already in place. To be discussed with the Inspection Planning Team. Page 6 of 7

50 A3 It is recommended that any reduction in office space be monitored to ensure that adequate space provision is met for the health, safety and wellbeing of all employees regardless of Agency. 51 A3 It is recommended that a 3 year health and safety strategy be developed to assist in forward planning to help identify future requirements and help monitor actions arising from the health and safety review undertaken by consultants. Page 7 of 7