Barnet, Enfield & Haringey Mental Health Trust Health & Safety Annual Report 2014/2015 July 2015 Page 1
Table of Contents Number Section Page 1. Introduction and Background 3 2. Fees For Interventions, Changes And New Legislation Implementation and Enforcements During 2014-15 3 3. The HSWC Annual Work Plan 2014-15 3 4. The HSWC Annual Work Plan 2015-16 11 5. Budgetary / Financial Implications 12 6. Risk Management 12 7. Equality and Diversity Implications 12 8. Consultation 12 Appendices 1. Trust and The Health Safety Executive (HSE) objectives 2014/2015 13 Page 2
1. Introduction and Background 1.1 The Health, Safety and Welfare Committee is the statutory Committee which is tasked with ensuring compliance with the Health and Safety Work etc. Act 1974 and The Management of Health and Safety at Work Regulations 1999 (as amended). 1.2 This report informs the Trust Board, and sub committees of the Board, about the activities relating to Health & Safety compliance and activities during the period of 1 April 2014 to March 31 2015 2. New Legislation Implementation and Enforcements During 2014-15 2.1 The Health and Safety Executive (HSE) began a Fee for Intervention (FFI) cost recovery scheme on the 1st of October 2012. An independent panel convened to review HSE's 'fee for intervention' (FFI) scheme and indicated that FFI has satisfied the requirement that the cost burden of enforcement is shifted away from taxpayers and towards noncompliant duty-holders (including NHS organisations). 2.2 HSE has conducted an initial review of 32 of its 52 ACOPs (codes of practice). The remaining 20 ACOPs have not been reviewed at the time of this report as they are associated with ongoing sector specific consolidations or other regulatory amendments and will be reviewed in the course of the delivery of those processes. The Trust has all their policies in line with the current guidance. 2.3 Regulations were implemented as part of a new European Union Directive, with the objective of reducing needle-stick injuries and blood borne exposures. This has been achieved by promoting preventive measures, such as the introduction of safety shields for needles and safer systems of working and it reflected in the 47% reduction of the number of needle stick injuries to staff. 2.4 There have been no health and safety related improvement or prohibition notices issued by the two inspectorate body who visited the Trust: The Fire Brigade and The Environmental Agency. 3. The Health Safety and Welfare Committee Annual Work Plan 2014-15 3.1 Background The Plan contains a combination of health and safety, fire safety, health and safety training, incident reporting, occupational health, security and risk management objectives (Appendix 1). The Trust health and safety work plan 2014-15 was devised to meet Health and Safety at Work Regulations and regulatory guidance from the relevant government bodies. The following outlines actions completed across management domains as per The Health and Safety Management System: Plan, Do, Check, Act. 3.2 Plan A. Policies Review and implement the Trust s Health, Safety and Risk Management Policies to ensure they are up to date and aligned with current legislation, contact details and good practice using the Trust Intranet Tool: Policy Development, Monitoring And Review Group Page 3
Outcome: 1. There are 34 key policies related to the management of health safety and welfare and they have been up-dated to ensure key elements are incorporated in the organisation. From the 34 policies, 18 specific policies related to Health, Safety and Fire were updated and specific intranet pages were created to support the policies appendices. B. Competence Revise health and safety training packages to ensure that they in line with the NHS guidelines Tool: mandatory and ad hoc training power point packages Developed specific on-line Health, Safety and Welfare training using on-line training systems Tool: Online training software Mandatory Training Project Steering Group program. Outcomes: 1. The mandatory on-line training packages have been developed and have been implemented by Workforce Development. The development of specific on-line Health, Safety and Welfare training, using on-line training systems, is in progress in line with the Mandatory Training Project Steering Group program. 2. Compliance for mandatory training in health and safety as at end of March 2015 had an increase of 3.25% from previous year (Data obtained from Oracle Learning Management (OLM). Overall Trust Training Compliance Report Fire Awareness Health and Safety Outcome Total number of staff compliant as at 31 March 2014 2177 of 2663 2177 of 2663 81.75% Total number of staff compliant as at 31 March 2015 2265 of 2663 2265 of 2663 85.00% 3. There has been a focus on providing personal safety training to specific staff groups as part of regular training and support to staff. During 2014/2015, 10 courses were provided with a total of 124 staff attending. In addition, 10 Prevent training sessions were held during 2014/2015 with a total of 153 staff attending 4. Workforce development has continued to outsource the provision of manual handling training for high and medium risk teams and resuscitation training. C. Control and Co-operation Ensure participation and consultation at the Health Safety and Welfare committee Page 4
Staffing Stress Violence and Aggression Lone Working Slips and Trips Infection Control Display Screen Equipment Manual Handling Building Maintenance Physical Security Emergency Planning COSHH (Control of Substances Hazardous to Health) Awareness Outcome: 1. The Heath Safety Welfare Committee Representation was from a combination of service lines, directorates, risk team staff and the unions. Health and Safety is a standing agenda item at local and trust wide clinical governance meetings thus ensuring that the health and safety agenda remains at the fore front of all trust discussions. 3.3 Do A. Planning and implementation Complete the meridian on-line team risk assessments and Datix risk register up-date as per findings Complete fire risk assessments and fire drills in medium and low risk areas as per fire safety work plan Complete new Security s NHS Protect Organisation Crime Profile using the spread sheet provide and development of relevant action plan Outcomes: 1. The Team risk assessment was completed by all the team leaders across the service lines. Team risk assessments (173) were completed in both financial years 2013-14 and 2014-15. In addition, the team risk assessments reports provided a link to the new service line risk registers on Datix. The effectiveness of the team risk assessments has been demonstrated by the reduction of average risk score of 4 to 1 in some team risk assessment s categories over the last 2 years. 6 5 4 3 2 1 0 Comparison of Results of Average Risk Scores per Categories of the Team risk Assessment Internal Average Risk Score 2013-14 Average Risk Score 2014-15 Page 5
2. On-line Medium and High Manual Handling risk assessment tools were designed in conjunction with the Audit Team, based on the current Manual Handling Policy, for completion by Team leaders of specific teams (the wards and the specific teams at Enfield Community Services). Total number of team risk assessments completed was 75. 3. An on-going programme of fire risk assessments is in place for all trust owned and operated properties. 4. Specific and assessments were undertaken such as: display screen assessments, fire safety risk assessments, ligature risk assessments, Disability Discrimination Act assessments. 5. Specific survey on staff lone working was undertaken with a response of 84 submissions. 6. The new Security s NHS Protect Organisation Crime Profile s spread sheet objective was rag rated green as it was submitted with the requested action plan. B. Communication Update the health and safety pages of the Trust s Intranet whilst ensuring proper document control Ensure timely communication of changes and promote Health and safety training to staff via electronic / notice board up-dates and the implantation of The Risk Management and Wellbeing Calendar 2014-15. Outcomes: 1. Health, Safety and Welfare information and Guidance were published using the Trust s publications such as: Trust Matters, Take Two, Desktop Screen Advertisement and Intranet Pages. 2. Development and circulation of guidance on a variety of health and safety related subjects were achieved through the Risk and Wellbeing calendar 2014-15 which has a monthly theme. The calendar was supported by the trust wide Desktop Screen Advertisement, Take 2 and the Trust s intranet via the communications team. 3. During 2014/2015 has seen a number of security capital projects in the Trust for example replacement of the lobby doors in Camlet 3 CFH, a refurbishment of the Section 136 Suite at St Ann s, replacement of keys in Camlet 1 and 2, enhancement of CCTV in the St Ann s corridor. In addition, there have been 4 drugs dogs operations on all three main hospital sites over the past year to deter consumption of, and dealing in drugs. While none of these operations have yielded huge quantities of drugs, they have all found small quantities or evidence of consumption. 4. A review of the security contract at Chase Farm Hospital has resulted in a dedicated mental health security guarding service bring established on the site, (where the vast majority of inpatient services are located), to help provide a safe and secure environment for patients, staff and visitors. Page 6
3.4 Act (Measuring performance/auditing) Passive: A. Monitor accidents and incident investigations and statistical analysis using Datix quarterly reports to report back to the HSWC for information and action B. Ensure correct RIDDOR reporting is provided to the HSE (over seven days reporting) and reduce the RIDDOR reportable incidents by 10% as per internal reduction target for financial year 2014-15. C. Ensure all teams across the Trust have two trained fire wardens Tool: Fire Warden training Sessions and Health and Safety Notice boards Specific Data Monitoring: 1. Datix Incidents Data: There were 6143 incidents reported on the Trust s risk management system Datix for last financial year. 4346 were incidents that affected patients, 2459 were submitted onto the National Reporting and Learning System (NRLS) as patient safety incidents. The latest published feedback report from NRLS covers the period April 2014 to September 2014, and compares the Trust s submitted data with other mental health organisations. The reporting rate for the Trust was calculated as 8.39 incidents per 1000 bed days. The previous report showed a rate of 11.6 which indicates a decline in the reporting of incidents from the previous year 2013/14. Page 7
Top 5 types / categories of the Number of Non-Patient Safety incidents 1st April 2013 31st March 2014 1st April 2014 31st March 2015 Outcome Violence and aggression (including all types of physical and verbal abuse) 845 596 29.46% Slips, trip and falls (excluding patient falls) 50 46 8.00% All types of Manual Handling 13 6 53.00% Needlestick injuries and sharps (including needle stick / sharps) 21 11* 47.00% Bites and/or scratches (excluding those from patients) 67 0 100.00% * This figure is related to the use of pen needles with non-safer needle devices provided by local pharmacies to patients. This was addressed by providing staff with the safer option and by a written communication from team leaders to the local GP s of the requirements of the EU Directive and the new legislation. 2. The 2014-15 s internal target reduction of RIDDOR Reports was 10% by the end of financial year. Total annual reduction was 0% in 2014-15; the RIDDOR Reporting incidents have increased 3.7% from previous year from 50 to 52 reports, giving this objective a red rag rating within the plan. It is important to highlight that the number of reports have remained stable over the last 3 financial years and we will continue to aim for a reduction. 60 50 40 30 20 Number of RIDDORS Per Financial Year 40 50 52 Internal Base Line Number of Riddors 10 0 2012-13 2013-14 2014-15 These are the significant RIDDOR incident data findings: RIDDOR Reporting Type Of 1st April 2013 1st April 2014 Outcome Reportable Incident 31st March 2014 31st March 2015 Staff s Slip, Trips and Falls 6 6 14.28% Patient s Slip Trips and Falls* 9 13 38.46% Staff s Manual Handling Sustained Injury 4 5 20.00% Staff s Violence and Aggression 26 30 13.33% Sustained injury (This figure includes incidents related to restrain and restriction training injuries to staff) *The falls increase might be a statistical blip, with a number of patients especially prone to falling all on the ward at the same time. Page 8
3. During 2014-15, the 70% of the teams achieved to have 2 trained fire wardens which have given this objective amber rag rating within the plan. However, the Fire Warden training sessions have been increased to enable the Trust to achieve 100% target. These are the significant Fire Safety data findings: Fire Safety Reporting Data 1st April 2013 1st April 2014 Outcome 31st March 2014 31st March 2015 Fires 11 23 47.82% False Fire Alarms 74 114 35.08% Unwanted Fire Service Attendance 59 66 10.06% Number of Fire Brigade Audits * 0 2 100.00% *the Fire Safety Audits had no significant outcomes and in all cases constructive discussion took place and no formal notices were served 4. Reason for the increase on the number of false alarms was largely due to the fact the Fire Alarm, within the in-patient wards in the chase building, were being activated as a result of steam from the shower rooms, patients having showers with the door opened; the trust has changed the fire detector type within Dorset, Suffolk and Sussex to a multy type sensor which is less susceptible to steam. This improvement has contributed to a significant reduction in the number of false alarms since they were installed, and on the number of times that the fire brigade have been called to site as a result of unwanted fire alarm signals (UFAS s). 5. Recent works have been approved to install repeater panel s on all in-patient wards on St. Ann s Hospital Site and to extend the investigation period from 3.5 to 8 minutes across all Trust occupied sites with the aim to further reduce the amount of UFAS s. These works have been approved by the London Fire Brigade who has welcomed the Trusts efforts to reduce the amount of times that the London Fire Brigade is called out unnecessarily as a result of UFAS s. Work has commenced and is on-going with the Communications Department to highlight the requirement of appropriate reporting of false alarms and extension of agreed fire investigation 6. During 2014-15, the Occupational Health Service provided a new service for individual Musculoskeletal Triage/Assessment as part of the benefits of providing early access to advice; this is so muscular pain is approached in a structured way to help staff who are suffering with a general condition and back problems. However, it reflected in a decrease of group sessions. The number of individual referrals related to mental health and support therapy increased, indicating the importance of providing support to staff after an incident related to violence and aggression. Occupational Health Number of 1st April 2013 1st April 2014 Outcome Referrals 31st March 2014 31st March 2015 Individual Staff referrals for Musculoskeletal Triage/Assessment No service 38 N/A Number of Support Physiotherapy Treatment Sessions (Groups) 302 125 58.60% Individual Staff Referrals for Mental Health Disorders 25 189 86.77% Individual Staff Support: Wellbeing Sessions 7 26 73.07% Individual Staff support: Cognitive Behaviour Therapy 11 12 8.33% Page 9
Outcomes: 1. Slips, trips and falls can affect both patients and staff but the consequences of a patient incident are generally more serious, especially on wards with elderly patients. The control systems to prevent patients slips trips and falls range from patient risk assessment to ensuring correct levels of staffing and physical environment, and patients had their care plan reviewed to reflect identified levels of risk. Contributory factors have been identified as a patient s mental health illness or by failing to follow the instructions of the nursing staff. In addition, the local fall steering groups reviews patients falls in order to learn from incidents and implement good practice. 2. Moving and handling sustained injuries are a consistent health and safety challenge for Trust staff, particularly those who work on elderly wards or those staff working in the community. In some cases a back injury can mean the end of someone s career, so it is vital that targeted training according to risk is provided to staff, and that thorough risk assessments (particularly of patients) identify moving and handling tasks with a foreseeable and preventable risk of injury. 3. The implementation of health and welfare initiatives continued such as: Zumba Classes, Chinese Chi Gong Exercise; Thai Massage and Aromatherapy Staff Discount and Theatre Offer Adverts; Competition time and the flu campaign. A new scheme was launched, the stress awareness workshops which aimed to provide support to staff in identifying and managing stress. 4. The implementation of Sustainability Schemes, continues, in conjunction with the estates and facilities department, e.g. Walk to Work Week, Cycle to Work initiative and the Ride2Work Scheme. 5. The Occupational Health Service delivered 5 Stress Awareness workshops to staff. 6 management training days were provided to support managers in their management and identification of some of the generic issues and to support the implementation of the Health and Safety Executive s Stress Management Standards which cover 6 key areas of work that, if not properly managed, are associated with poor health and well-being, lower productivity and increased sickness absence. 3.5 Act (Measuring performance/auditing) Active A. Ensure that evidence is available to meet statutory standards requirements B. Finalised the health and safety audits of the teams locations across the Trust to ensure compliance with current regulations as per the plan Outcomes: 1. Evidence was collected and made available to meet outcome 10 of CQC standards. 2. Audits were conducted to identify areas of good practice and highlight hazards to health and safety, and to listen to the concerns of employees and Safety Representatives. The number of H&S Audits completed was 173. Compliance was high in areas such as general organisation and administration, first aid / resuscitation, COSHH hazards, staff health and welfare, refrigeration temperatures, hygiene, cleanliness and waste disposal, environmental factors, equipment and machinery, entrances and exits, means of escape, fire precautions, general infection control. Page 10
Low compliance was identified only in local issues such as: the lack of space for the storage of medical notes, evidence of trip hazards, lack of good housekeeping and some overcrowded spaces. 4. The Health Safety and Welfare Committee Annual Work Plan 2015-16 Framework Plan, Do, Check, Act 1. Plan A. Policies Review and revise the Trust s Health, Safety and Risk Management Policies to ensure they are up to date and aligned with current legislation, contact details and good practice using the Trust Intranet Encouraging and support consultation in policy development and Continue with the implementation of approved Health and Safety Policies B. Competence Develop specific on-line Health, Safety and Welfare training on the Online system 2. Do Develop the ligature meridian on-line team risk assessment tool Datix risk register up-date as per findings of the developed on-line tools Complete fire risk assessments and fire drills in medium and low risk areas as per fire safety work plan Complete new Security s NHS Protect Organisation Crime Profile using the spread sheet provide and development of relevant action plan Ensure timely communication of changes and promote Health and safety training to staff via electronic / notice board up-dates and Risk calendar 2015-16 3. Check (Measuring performance /auditing) Passive: Monitor accident and incident investigations and statistical analysis using Datix quarterly report via Deep Dive Meetings and Team Meetings, HSWC to address any outcomes of the monitoring of incidents Ensure correct RIDDOR reporting is provided to the HSE (over seven days reporting) and reduce RIDDOR reportable incidents by 10% as per internal target Ensure all teams across the Trust have a maximum of two trained fire wardens or more as per identified in the fire risk assessment 4. Act (Measuring performance /auditing) Active: Ensure that evidence is available to meet outcome 10 of CQC standards Page 11
Implications 5. Budgetary / Financial Implications 5.1 Funding maybe required to ensure that The Health and Safety at Work Regulations are implemented throughout the Trust and the Trust spends money on remedial action when risk assessments identify this as being necessary. 6. Risk Management 6.1 Continue with comply with the Trust s Risk Management Strategy. 7. Equality and Diversity Implications 7.1 None. 8. Consultation 8.1 Health Safety and Welfare Committee. Page 12
Appendix: 1. Trust and The Health Safety Executive (HSE) objectives 2014/2015 HSE s objectives by 2015: Drawn the distinction between real health and safety and bureaucracy and over interpretation ; made it even easier for people to understand devote a greater proportion of effort where risks are highest and where we can have greatest impact And continued to hold to account those who expose their employees and others to Trust s s 2014-15: 1. To provide excellent and innovative services for patients 2. To develop our staff to be the best they can be 3. To be clinically and financially sustainable Trust s s 2014-15: Excellent and innovative services for patients Providing high quality, clinically and cost effective services, delivered with care and compassion Developing our staff and our organisation Supporting and developing our staff to be the best they can be for our patients and always learning as an organisation Clinical and financial sustainability Ensuring the on-going clinical and financial sustainability of the Trust and our services Health Safety and Welfare Committee s s 2014-15: To have oversight of up-dated health and safety at work regulations by ensuring policies are current. To have oversight of the local team risk assessment processes, ensuring that all teams carry out developed on-line risk assessments and agree actions where necessary. To have oversight of the health and safety audits for each team and agree actions where necessary. To have oversight of external information, reports and visits from regulatory bodies Service Line s s 2014-2015: Ensure that the remedial actions required following risk assessments are put in place by the Team Managers Establish the relationship between the risk assessment, team risk registers, service lines risk registers, the Corporate risk register Ensure that Risk Registers are up-dated on a regular basis Ensure funding is allocated for health and safety Teams s for 2014-2015: Ensure on-line team risk assessments and on-line audits are completed and actions are completed Ensure the team risk register is up-dated on regular basis Ensure that staff attend mandatory training Promote the reporting of incidents or near misses with focus on the community teams via Datix Ensure two fire wardens are trained per team Ensure staff have access to wellbeing information and schemes and programs Page 13