Health & Safety Policy Statement of Intent, Responsibilities & Arrangements To whom this document applies: Trust wide Trust Policy & Procedure Review Group Issue Date: June 2002 Version 1 Document reference:204 Date(s) reviewed: September 2004 Version 2 Approved by: Chairman Policy & Procedure Group September 2006 Version 3 Date approved:27th September 2006 July 2007Version 4 Next Review date:24th July 2007 Version No:4 Responsibility for review: Health & Safety Advisor Contributors: See Policy, Development, Consultation Proposal Form – page 2
Policy: 204 Version: 4
Archiving information held by secretary of the Policy & Procedure Group within Nursing & Quality
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Policy, Development, Consultation Proposal Form Title: Health and Safety Policy Policy Procedure Tick the box
Guideline
Protocol
Standard
Name of person presenting document: Mike McCarron Reason for document development: Review of existing policy
Names of development team (including a representative from all relevant disciplines): Mike McCarron Health and Safety Advisor, Jan Kieran Back Care advisor, Nigel Holt Risk Manager Who has been consulted? Policy & Procedure Review Group H&S Committee Specify groups of staff to whom the document relates: ALL TRUST STAFF Source of supporting evidence (references etc.) Health and Safety legislation
Are there resource implications? If yes please detail them:
Yes
No
Does the Policy/Procedure/Guideline meet latest CNST Standards for Better Health requirement? Yes No
Does this policy/guideline include children, if applicable? If yes has the relevant person been included?
Yes
No
Yes
No
A Trust review will occur every two years unless national guidance states otherwise. DATE:24th July 2007
Policy: 204 Version: 4
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Contents
Page No. Review, updating and archiving of the document
1
Policy Development & Consultation Process
2
Contents Page
3
1
Employee Register
5
2
Policy statement
6
3
Management/Health & Safety/ Departmental Structures
7
4
Organisation
9
5
Responsibilities & Arrangements
10
6
Evidence Base
16
7
Monitoring Compliance and Auditing
16
8
Fire
16
9
Hazardous Substances
18
10
Health & Safety Committee
18
11
Health & Safety Inspections
19
12
Incident Reporting
21
13
Laundry/Linen Procedure
25
14
Lift Emergencies
26
15
Lone Working
26
16
Manual Handling/Ergonomics
26
17
Mobile Phones
27
18
Safety
28
19
Security
28
20
Occupational Health
28
21
Risk Assessment
31
22
Slips, Trips & Falls involving staff and others
32
23
Safety Equipment and Safety Wear
34
24
Security
34
25
Training and Training Records
35
26
Employees
36
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The following policies and procedures referred to within this policy, can be found on the Trust Intranet Site on the following hyperlinks: Trust Policies: http://hermes/e-library/elibrary.asp?cat=80
HR Policies: http://hermes/e-library/elibrary.asp?cat=111 Risk Management: http://hermes/e-library/elibrary.asp?cat=76
Trust Policies 10
Manual Handling Policy, Guidance Notes, Forms etc.
44
Violence and Aggression Policy
063
Incident Reporting Policy
072
Display Screen Equipment Use
118
The Risk Management Policy
134
Mobile Phone Policy
210
Infection Control Policy
233
Security Policy
HR Policies 201
Stress Management Policy
212
Lone Worker Policy
Risk Management Risk Assessment Documentation Fire Policy Health & Safety Committee Terms of Reference First Aid Policy Environmental Management Policy
Policy: 204 Version: 4
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1.
Employee Register I am aware of the Trust’s Health & Safety Policy, and will comply with its requirements where appropriate. NAME
Policy: 204 Version: 4
SIGNATURE
DATE
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2.
Health and Safety Policy Statement The Policy is written in accordance with Section 2(3) of the Health and Safety at Work etc. Act 1974. Essex Rivers Healthcare Trust considers the employee to be its most valuable asset. It recognises the necessity for management and staff to work together to achieve a safe working environment. As Chief Executive, I have ultimate responsibility for the health and safety of the Trust’s employees while at work and to others who may be affected. I require all Directors and Managers to regard health and safety as one of their major priorities and ensure that the Trust conducts its activities so that it complies with all the relevant Statutory Legislation, Approved Codes of Practice and General Guidance. It is the Trust’s aims and objectives to: Comply fully with the law. Promote high standards of health, safety and welfare at work. Monitor the performance of activities and seek to continually improve Health, Safety and Welfare awareness. Develop health and safety awareness and responsibility. Encourage full and effective consultation and communication. Provide information, instruction, training and supervision to enable staff to meet the requirements of this statement. Maintain a safe and healthy working environment so far as is reasonably practicable. Make regular reviews of the Policy Statement and institute improvements. Ensure adequate resources are available to meet the requirement of this statement. All staff are reminded that they, as individuals, have responsibilities to take reasonable care for the health and safety of themselves and others, and to co-operate with the Trust in discharging its statutory duty. It is also the responsibility of employees not to intentionally or recklessly interfere with or misuse anything provided for the purposes of health and safety. The Health & Safety Policy must be accorded the same status as other Trust policies and procedures, and it is the responsibility of all personnel employed within the Trust to ensure compliance with its aims and objectives.
Mr P Murphy Chief Executive Essex Rivers Healthcare NHS Trust
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3.
Management Structure
CHIEF EXECUTIVE
DIRECTOR RESPONSIBLE FOR HEALTH AND SAFETY
EXECUTIVE DIRECTORS
SENIOR MANAGEMENT
HEALTH AND SAFETY COMMITTEE
LOCAL MANAGEMENT
RISK MANAGEMENT OCCUPATIONAL HEALTH INFECTION CONTROL
EMPLOYEES
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3.1
Departmental Structure To be completed by Individual Departments.
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4.
Organisation Safety Organisation
1.
CHIEF EXECUTIVE
Peter Murphy
(Ext. 2347)
2.
DIRECTOR RESPONSIBLE FOR HEALTH & SAFETY
Marion Wood
(Ext. 2645/2357)
3.
RISK MANAGER
Nigel Holt
(Ext. 4446)
4.
OCCUPATIONAL HEALTH
Shelia Boyle
(Ext. 4444)
5.
FIRE SAFETY ADVISOR
David Helm
(Ext. 2208)
6.
BACK CARE ADVISOR
Jan Kieran
(Ext. 4522)
7.
HEALTH & SAFETY ADVISOR
Mike McCarron
(Ext. 4537)
8.
SECURITY ADVISOR
Peter Symkiss
(Ext. 2921)
9.
INFECTION CONTROL
Heather Dakin
(Col. 4265)
10.
RADIOLOGICAL PROTECTION ADVISOR
Tony Baker
(Ext. 4580)
EMERGENCIES
Cardiac Arrest
2222
Security/Fire
3333
Switchboard
(Ext. 0)
Other (Direct)
(9) 999
11.
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5.
Responsibilities It is the responsibility of the Trust Management to ensure that, so far as is reasonably practicable, its employees are provided with a safe and healthy working environment. Responsibilities of specific members are defined below.
5.1
5.2
Chief Executive Has a responsibility to: •
Nominate a Director to take responsibility for health and safety within the Trust.
•
Ensure that a written Health & Safety Policy Statement is produced and revised as necessary.
•
Ensure that arrangements exist for the implementation of the Trust’s Health & Safety Policy and sufficient resources.
•
Promote and support the aims and objectives of the Health & Safety Policy.
•
Ensure that arrangements exist to bring the Health & Safety Policy and any subsequent amendments to the attention of employees.
•
Ensure that arrangements exist to monitor the Trust’s health and safety performance.
•
Ensure that an annual Trust Health & Safety Plan is prepared specifying set objectives.
•
Monitor the achievements of the Trust Health & Safety Plan and evaluate the overall Trust health and safety performance to ensure satisfactory standards.
•
Ensure that arrangements exist to consult with staff on matters appertaining to health and safety at work.
•
Ensure that arrangements exist for the provision of advice on matters appertaining to health and safety at work within the Trust.
Executive Directors – Clinical and Non-Clinical Have a responsibility to: •
Monitor and evaluate the health and safety performance of areas under their control in respect of safety inspections, safety training, accident statistics and Trust safety objectives and advise the Chief Executive accordingly.
•
Promote and support the aims and objectives of the Health & Safety Policy and accord it equal importance with all other management functions.
•
Ensure that arrangements exist to implement and disseminate the Health & Safety Policy and bring any revisions to the attention of all employees.
•
Ensure time is allocated to health and safety issues at briefings and meetings.
•
Ensure that arrangements exist for new plant and equipment to be supplied and installed in compliance with health and safety legislation.
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•
Ensure that arrangements exist for the investigation of any accident, dangerous occurrence, untoward incident, fire, theft or property damage.
•
Ensure that an annual health and safety audit is conducted in areas under their control.
•
Ensure that arrangements exist for “Safety Representatives” and “Representative of Employee Safety (ROES)” to be consulted on all matters appertaining to health and safety at work.
•
Ensure that arrangements exist for the provision of safety devices and personal protective equipment.
•
Be aware of statutory requirements applicable to the work activities under their control and ensure that arrangements exist for the identification where necessary of safe systems of work.
•
Ensure resources are available to enable staff to implement the aims and objectives of the Health & Safety Policy.
Ensure that health and safety objectives are incorporated within the Individual Performance Review (IPR) Scheme for all Line Managers. 5.3
5.4
Nominated Officer (Fire) Has a responsibility to ensure that arrangements exist for:•
The provision of fire advice to the Nominated Director responsible for health and safety.
•
Compliance with the Trust Fire Policy and Procedures.
•
Employees to receive fire instruction and training.
•
Fire drills to be carried out in Trust premises.
•
Reviewing and updating site fire evacuation plans.
•
Monitoring the Trust Fire Policy and procedures.
Nominated Directors Responsible for Health & Safety and Fire Has a responsibility to ensure that arrangements exist for: •
Advising the Chief Executive on all matters relating to health and safety within the Trust, including impending legislation, codes of practice and guidance notes.
•
Advising Chief Executive and Directors of serious and potentially serious health and safety incidents at work.
•
The production and dissemination of the Health & Safety Policy and amendments within the Trust.
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5.5
•
The regular review of the Health & Safety Policy. This is a two yearly review carried out by the Health and Safety Advisor
•
Adjudication in cases of conflict between the requirements of health and safety, and the demands of work, when line management discussions have failed to resolve the issue.
•
An annual programme of inspections of all workplaces in respect of health and safety.
•
The recording of incidents at work relating to health and safety together with any statutory notification to enforcement agencies.
•
Regular meetings for the Trust Health and Safety Committee.
•
The production of an annual report identifying numbers and trends of accidents at work.
Divisional Managers and Senior Managers Have a responsibility to: •
Monitor and evaluate the health and safety performance of the department and advise their Director accordingly.
•
Promote and support the aims and objectives of the Health & Safety Policy and accord it equal importance with all other management functions.
•
Ensure that the Health & Safety Policy and any revision is disseminated within the department and that arrangements exist for its implementation and monitoring.
•
Ensure time is allocated to health and safety issues at briefings and other departmental meetings.
•
Ensure that new plant and equipment is supplied and installed in compliance with the health and safety legislation.
•
Ensure that any accident, dangerous occurrence, untoward incident, fire, theft or property damage is investigated and recommendations made to prevent a recurrence
•
Ensure that arrangements exist for regular Departmental health and safety inspections to be conducted in all areas under their control.
•
Co-operate with the Trust’s annual health and safety inspection of areas under their control.
•
Ensure that “Safety/Employee Representatives” are consulted on all matters appertaining to health and safety at work.
•
Ensure that safety devices and personal protective equipment is provided where necessary.
•
Ensure that where work of a hazardous nature needs to be performed, a risk assessment is carried out and a safe system of work produced.
•
Ensure that Directorate/Departmental policies and procedures are formulated where necessary.
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•
5.6
Ensure that employees are made aware of and comply with all relevant statutory and Trust health and safety requirements. •
Ensure the provision of information, instruction, training and supervision to enable staff to perform their work safely.
•
Ensure that all planned maintenance, statutory examinations, and departmental inspections are carried out.
•
Motivate staff by stimulating interest in health and safety matters.
Line Managers, Charge Nurses and Supervisors Have a responsibility to: •
Monitor the health and safety performance of employees under their control and advise Senior Management accordingly.
•
Promote and support the aims and objectives of the Health & Safety Policy and accord it equal importance with all other managerial functions.
•
Ensure that the Health & Safety Policy and any revision is disseminated, implemented and monitored.
•
Ensure time is allocated to health and safety issues at briefings and meetings.
•
Ensure that new plant and equipment is installed and used in compliance with health and safety legislation.
•
Investigate any accident, dangerous occurrence, untoward incident, fire, theft or property damage and make recommendations to prevent a recurrence.
•
Ensure that Departmental health and safety inspections are carried out within the department and recommendations are actioned or referred.
•
Liaise with the “Safety/Employee Representatives” on all matters appertaining to health, safety and welfare at work.
•
Contribute to the formulation of policies and procedures in relation to health and safety, and where necessary make recommendations.
•
Promote health and safety in the workplace and ensure that there is no breach of statutory requirement and that undesirable activity, including horseplay, does not occur.
•
Ensure that employees receive information, instructions, supervision and training to enable them to perform their work safely and identify future training needs.
•
Ensure that all planned maintenance, statutory examinations and departmental inspections are completed.
•
Ensure that all machinery and equipment provided for use at work is safe and without risk to health.
•
Ensure that when safety devices and personal protective equipment is provided, it is used.
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•
Ensure that all employees, contractors and visitors are advised of known hazards that exist in the area under their control.
5.7 Employees Have a responsibility to: •
Co-operate with the Trust Management in discharging its statutory duty to comply with the Health and Safety at Work Act 1974, and other relevant legislation.
•
Take reasonable care for the health and safety of themselves and of others who may be affected by their acts or omissions.
•
Ensure that they do not interfere with or misuse anything provided in the interests of health and safety at work.
•
Co-operate with the Trust Management in promoting health and safety in the workplace.
•
Use only the correct tools and equipment for the job and follow laid down procedures or system of work.
•
Comply with all Trust health and safety rules, and statutory requirements, including the use of safety equipment and personal protective clothing where required.
•
Report any hazardous defect in plant, materials, systems of work, safety equipment or personal protective clothing immediately to their Supervisor/Manager.
•
Ensure that Trust property entrusted to them is maintained in good condition and kept in a safe place.
•
Work safely at all times and do not participate in horseplay or other undesirable behaviour.
•
Co-operate with and participate in departmental safety inspections when requested.
Arrangements 5.8
Clinical & Non-Clinical Waste The Environmental Protection Act 1990, amended in 1995, places duties on holders of waste to dispose of it correctly and safely. Breaches of the legislation can lead to fines and/or imprisonment. Typical waste in a healthcare environment would include: Domestic waste Clinical waste Syringes, needles and blades Broken glass Toxic waste Confidential waste It is the responsibility of each Department Head to ensure that waste produced in their Department is disposed of correctly. For further information or guidance, please see the Environmental Management Policy which can be found on the Trust Intranet.
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5.9
Equipment Testing & Maintenance
5.9.1
Electrical Equipment New portable electrical appliances should be tested by a competent person prior to use wherever possible, or as soon as is reasonably practicable thereafter. Patient’s property (e.g. radios) should also be tested as soon as is reasonably practicable. All portable electrical appliances should be checked by a competent person on an annual basis. All portable electrical appliances should be visually checked by the user prior to use, any defects reported immediately and a Trust Incident Report Form completed.
5.9.2
Mechanical Equipment All mechanical or electro-mechanical equipment should be tested by a competent person prior to use wherever possible, or as soon as is reasonably practicable thereafter. Equipment used for lifting persons must be further tested every 6 months, by a competent person. Other lifting equipment must be tested annually by a competent person. All mechanical equipment should be visually checked by the user prior to use, any defects reported immediately and a Trust Incident Report Form completed.
5.9.3
Mobile Equipment The Trust carries out annual inspections of wheelchairs, trolleys and beds. Employees, however, are expected to check that such equipment is in good working order prior to use, and any defects reported immediately, and a Trust Incident Reporting Form completed.
5.9.4
Fire Fighting Equipment Extinguishers, hoses and blankets should be tested annually by a competent person and the date of testing displayed in a prominent position. Extinguisher or hose discharges (whether accidental or not) must be reported immediately to Facilities Management, and a Trust Incident Report Form completed so that equipment can be recharged and brought back into service.
5.9.5 Radiation Producing Equipment For information on testing and maintenance of radiation producing equipment, please contact your Radiation Protection Supervisor (RPS).
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PLEASE NOTE: It is the responsibility of Heads of Department to ensure that all equipment requiring testing is within the dates as detailed above. It is the responsibility of all employees to visually check all equipment prior to use, to report any defects and to not use any equipment which is, or appears to be, defective.
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6.
Evidence Base The policy is in full compliance with the following legislation: The Health and Safety at Work Act 1974 The Management of Health and Safety at Work Regulations 1999 The Control of Substances hazardous to Health Regulations 2002 The (Health and Safety) Display Screen Equipment Regulations 1992 The Workplace, Health Safety and Welfare Regulations 1992 The Manual Handling Operations Regulations 1992 The Provision and Use of Equipment Regulations 1998
7.
Monitoring Compliance and Auditing The health and safety advisor/risk management department is to monitor that all members of staff are compiling with all the procedures laid down in this policy. Staff will be surveyed to establish their understanding of the policy and associated risks. A review of procedures and practices may take place as a result of the audit process. The health and safety advisor/risk management department is responsible to conduct yearly health and safety audits and produce written reports on any department failings regarding compliance of this policy. The health and safety advisor is to ensure the policy is reviewed on a two yearly basis and any amendments distributed throughout the trust. The health and safety advisor will obtain a monthly report of all health and safety related incidents from the datix system. Perform a trend analysis and if appropriate inform divisional managers and advise on any additional control measures. The health and safety advisor/risk management department is to report to the Health and Safety Committee on a quarterly basis all incidents, accident investigations, lost time accidents, RIDDOR incidents. A synopsis of this report is taken to the Risk Management Committee and Clinical Governance Committee. The health and safety advisor/risk management department is to report to the Health and Safety Committee on a quarterly basis any accident trends including route cause analysis investigation detailing any additional control measures where applicable. A synopsis of this report is taken to the Risk Management Committee and Clinical Governance Committee.
8.
Fire Fire is a potential hazard in every Health Service building. It is imperative that all staff without exception understands what action is to be taken in the event of a fire. Manual Call Points (MCP’s) are situated at numerous locations throughout the Trusts’ buildings, and can be operated by breaking the glass panel. Certain departments and wards are protected by either smoke detectors, heat detectors or a combination of both, which will automatically raise the alarm when the detector is affected by smoke or heat.
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The fire alarm has two distinct sounds, continuous and intermittent:A continuous sound indicates that a fire has been detected in your area. An intermittent sound indicates that a fire has been detected in an adjacent area. Each of the sounds will necessitate that you act in a particular manner, as follows:8.1
Non-Patient Areas Continuous sound – suspected fire in your area. Action: all persons should leave the area and report to the assembly point, as shown on the evaluation/fire notice, without delay. Intermittent sound – suspected fire in adjacent area. Action: continue working, close all doors and windows. Person in charge should send one member of staff to the affected area to assist if required.
8.2
Patient Areas Continuous sound – suspected fire in your area. Action: the senior member of staff should establish the extent of the problem. If appropriate, evacuate patients and visitors to a safer area inside the hospital/department (Stage 1). Intermittent sound – suspected fire in adjacent area. Action: senior member of staff should send one member of staff to affected area to assist and prepare to evacuate your area if the situation becomes more serious. On discovering a fire, it is everyone’s responsibility to:•
Raise the alarm by activating the nearest Manual Call Point (MCP). The alarm will be automatically transmitted to the switchboard who will call the Fire Brigade. An immediate follow-up call should be made to the switchboard by dialing 3333.
•
Remove patients (if appropriate) to a place of safety.
•
Confine the fire by closing all windows and doors.
•
Evacuate the building and report to your Line Manager without delay at the designated assembly point.
Further information, if required, can be found in the Fire Policy on the Trust Intranet.
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9.
Hazardous Substances The Control of Substances Hazardous to Health (COSHH) Regulations 1988 (amended 2002) were introduced to safeguard persons who work with substances which may be hazardous to health such as chemicals which are toxic, harmful, corrosive and irritant plus dusts and microorganisms. The regulations require the employer to identify ALL hazardous/potentially hazardous substances which may be used in the workplace or that may be produced by a process e.g. end product, bi-product etc. or that may be emitted during any process e.g. dust, fume etc. The employer must then conduct an assessment of these substances, evaluating the risk of exposure to personnel and, where necessary, take the appropriate precautions to control that exposure. Nominated persons must have received specific training in the application of the COSHH regulations and are designated Competent Persons (contact Risk Management for details of courses). These Competent Persons will conduct assessments of substances used, produced or emitted in the area of their responsibility. Names of COSHH Competent Persons are listed at the front of each Department’s COSHH Manual. When a new substance or work activity is introduced into the workplace the Departmental Head will ensure that the Competent Person carries out an assessment and makes recommendations for its safe use. Managers are responsible for ensuring that new/existing substances and work activities receive an assessment this includes the use of Latex. He/she will consider all recommendations, arrange where necessary for monitoring to be conducted and take the appropriate remedial action. Health surveillance shall be deemed to be appropriate where the employee is exposed to a substance hazardous to health, which is such that an identifiable disease or adverse health effect may be related to that exposure. It is the responsibility of the Departmental Head to notify the Occupational Health Department immediately of all identifiable diseases or adverse health effects which may be caused by exposure to substances used at work. Completed COSHH assessments for the information of employees are held in each Department’s COSHH Manual. Department Heads are responsible for ensuring that a COSHH Competent Person is nominated and trained for their area, and that all staff have access to the Manual at all times when on duty. Employees are responsible for complying with the COSHH Assessments, and reporting any accidents or near misses on the Trust Incident Reporting Form.
10.
Health and Safety Committee The Health and Safety at Work Act 1974, the Safety Representatives and Safety Committees Regulations 1977 and the Health and Safety (Consultation with Employees) Regulations 1996 require employers to:-
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•
Establish a Health and Safety Committee when requested to do so by 2 or more Trade Union appointed Safety Representatives.
•
Consult with Safety Representatives on the arrangements for co-operation on safety measures, and
•
Consult with Safety Representatives on the monitoring of safety measures.
The Trust recognises the importance of co-operation between the Trust and it’s employees and have, therefore, established a Health and Safety Committee. The Committee meets four times per year and the chairing of the Committee rotates between staff side and management side on an annual basis. (Management side and staff side are only denoted for ease of reference). A copy of the Trust’s Health and Safety Committee’s Terms of Reference can be found on the Trust Intranet. 11.
Health and Safety Inspections
11.1
Departmental Inspections Are to be conducted periodically using the Departmental Inspection Report (page E7a). Clinical areas should be inspected every 8 weeks and non-clinical areas every 12 weeks. The inspection should be undertaken by employees on a rotational basis to give as many people as possible the opportunity to be involved. The completed report should be forwarded to the Line Manager for action of any issues raised. The Inspection Report, along with comments of action taken by the Manager, should be retained in this section of the Health & Safety Policy for inspection.
11.2
Trust Annual Inspection A routine Health & Safety Inspection of all areas within the Trust takes place on an annual basis, and is co-ordinated by the Health & Safety Advisor. Inspections are usually undertaken by a small team consisting of the Health & Safety Advisor, an Occupational Health Nurse, a Facilities Management Representative and a staff representative. Following the inspection, a report is issued to the appropriate person who can action any points raised. Confirmation that action has been taken is to be returned to the Health & Safety Advisor within one month of the report being issued.
11.3
Health & Safety Inspectorate The Health & Safety Inspectorate are empowered to make unannounced visits to work premises. Inspectors have the right to carry out investigations, order that areas be left undisturbed, take samples, take statements, photocopy any relevant documentation and use any personnel she/he deems necessary.
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The Inspector will, however, usually make her/his presence known to the senior person on site at the time. On completion of any inspection/investigation, it is usual for the Inspector to consult with an appropriate Trade Union Safety Representative, and then submit a Report to the Trust. 11.4
Departmental Inspection Report
Department / Ward……………………………………… Date………………………..
Yes
No
Proposed action to be taken
Action taken and date taken
Health & Safety Policy: Is it accessible by all staff? Has it been signed by all staff? Risk Assessments: Have Risk Assessments been completed? Are they in the H&S Policy? Are they less than 2 years old? COSHH folder: Is it accessible by all staff? Has it been signed by all staff? Are all assessments less than 2 years old? Hazardous Substances: Are all containers clearly marked? Are all substances stored appropriately? Medical gases used appropriately and switched off (& cylinders stored safely) when not in use? First Aid: Is FA box stocked as per Trust list? Is a FA notice displayed? Are named First Aiders current? Needles (if appropriate): Are sufficient boxes provided? Are all boxes correctly assembled? Are boxes changed when ⅔ full? Are temporary closures activated? Waste: Is domestic waste stored correctly? Is clinical waste stored correctly? Electrical Equipment: Have all been tested during last 12 months? Are all plugs and leads in good condition? Mechanical Equipment: Is all equipment in good working order? Are all attachments in good working order? Fire: Do all fire doors open & close freely? Are evacuation routes clear at all times? Have ext’s and hoses been tested in last 12 months? Are Fire Alarm call points accessible & clear? Are completed evacuation notices displayed? Display Screens: Have all ‘users’ been identified & trained? Is lighting adequate for ‘users’? Cleanliness: Are toilets & bathrooms clean? Are floors & walls clean? Lighting: Is lighting adequate in all areas? Do all light fittings work? Storage: Are heavy items stored in appropriate places?
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Are all shelves accessible? Are gangways and corridors free of obstructions? Environment: Is temperature reasonable? Is ventilation reasonable?
Inspection carried out by (name)………………………..(signature)……………………………. Action Points addressed by (name)……………………..(signature)……………………………. 12.
Incident Reporting The Trust's Incident Reporting Policy 063 can be found on the Trust Intranet. The following pages are guidance on how the Incident Reporting Form should be completed.
Guidance For Completion Of Incident Reporting Forms The following information has been prepared to provide guidance for staff completing the Incident Reporting Form. An Incident Reporting Form must be completed for any accident to staff, patients, or other person, this includes injury, near miss, fire, theft and property damage. If more than one person in injured as a result of an incident, a separate IRF must be completed for each person. Completed forms MUST be forwarded to the RISK MANAGEMENT DEPARTMENT within 24 hrs of the incident. If you have any queries regarding incident reporting please contact the Risk Management Department on 01206 744446. SECTION A: THE INCIDENT – COMPLETE IN ALL CASES a)
The person sustaining or witnessing the loss/injury should complete this section.
b)
‘Name of the person involved in the incident’ - the person who was affected by the incident, e.g.; the injured party or the recipient of the incident/near miss.
c)
‘Occupation or Job Title’ employees/contractors ONLY.
d)
‘No. of days absent’ to be completed for incidents/near misses involving employees ONLY.
e)
‘Hosp/Site (Work Base)’, ‘Directorate’ and ‘Ward/Dept’ – location where the person affected by the incident/near miss works, is receiving treatment or is visiting.
f)
‘Location of Incident’ should include exact location e.g.; top of stairs adjacent to Jefferson Ward, Essex County Hospital etc.
g)
‘Time of the incident’ should be recorded either in 24-hour clock or use AM or PM.
h)
In the case of incidents/near misses involving patients, ‘Patient No.’ and ‘If patient referred, name of ward/department and consultant’ to be completed.
i)
RIDDOR – The RIDDOR box on the IRF must be dated if a RIDDOR form has been completed.
to
be
completed
for
incidents/near
misses
involving
NB: For Information regarding RIDDOR refer to pages 23/24 in the Health and Safety Policy. Policy: 204 Version: 4
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j)
‘Description of Incident/near miss’’ should only include fact and not opinion. This should be a brief account of the events leading up to and including the incident/near miss, if relevant include diagnosis. Use additional paper if further space required.
k)
If incident/near miss is a medication incident, a copy of the treatment card must be attached to the IRF.
l)
‘Person in charge to whom injury reported’ and ‘Name and job title of person completing section A’ must be completed.
m)
If copies of the incident reporting form are supplied to anyone else within the Trust, please state to whom copies have been sent to in ‘Copies of IRF sent to’
n)
‘Statements required: YES/NO’, if statements have been written ie; statement of injured party or witness statement, ensure that they are attached with the IRF, and include the name, address or ward/department of individual making statement.
SECTION B: THE INJURY a)
Section B must be completed ONLY if an injury has been sustained. This section should be completed for all injuries including those sustained in Fire and Security incidents.
b)
This section should be completed by the person sustaining injury/loss or a witness to the incident.
c)
This section requires details of; the injury, circumstances surrounding the incident e.g.; ‘condition of site’, ‘protective clothing/equipment’. The information provided in this section can be used for risk avoidance purposes in the future.
d)
Ensure that relevant signatures are at the bottom of Section B. If the injured person is unable or refuses to sign then the person completing the section must sign on their behalf and advise that they are doing so.
SECTION C: INVESTIGATION AND COMMENT – COMPLETE IN ALL CASES a)
The Person in Charge of the Ward/Department where the incident occurred is responsible for completing this section. The investigation must be made at the time of the incident. The investigation should be a factual account, not opinion, and should include events leading up to the incident/near miss and the incident/near miss itself. If necessary, additional information should be provided on a separate sheet and attached to the IRF.
b)
The Person in Charge will investigate and must consider the following: What was the person involved in the incident doing at the time of the occurrence? Were the correct procedures/protocols followed? (Identify relevant policy/procedure/protocol). Describe the factors, which are known to have caused or contributed to the incident. What immediate action was taken as a result of the incident and by whom? e.g.; put out warning signs, remove offending equipment etc. What action is recommended to eliminate/reduce the likelihood of a recurrence? As a result of the investigation have any other factors come to light? If yes, please describe.
•
The Person in Charge must sign this section.
Policy: 204 Version: 4
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SECTION D: RISK ASSESSMENT MUST BE COMPLETED BY WARD/DEPARTMENT MANAGER IN ALL CASES a)
The Ward/Department Manager is responsible for completing this section.
b)
A risk assessment must be completed as soon as possible following the incident/near miss and a µ placed in the appropriate box. After remedial action is taken, the risk assessment process is repeated, only this time the date of the re-assessment is inserted in the appropriate box. Determining the Severity The Ward/Department Manager would need to consider the severity by assessing the impact of the incident/near miss on the injured party and/or the Trust. Insignificant Minor Moderate Major Extreme
-
e.g.; no injury noticeable. First aid not required e.g.; Injury requiring treatment e.g. First Aid e.g.; Lost time injury or illness – RIDDOR reportable > 3 days absence e.g.; Serious and RIDDOR reportable e.g.; Death, Major Media inquiry
Determining the Likelihood The Ward/Department Manager needs to consider the likelihood of a reoccurrence of the incident/near miss. Remote Unlikely Possible Likely Almost Certain
- Could only occur in exceptional circumstances - May occur in time. Very infrequently over a period of time - May occur from time to time - Likely to occur imminently or in the short term - Will occur or does occur regularly
Determining the Risk Assessment The risk assessment table is broken down into colours, these colours represent the following: Green (Low Risk) - Review control measures, if appropriate Yellow (Moderate Risk) - Reduce risk to as low a level as possible Orange (Significant Risk) - Control measures to be enhanced to reduce the risk to Low or Moderate Red (Extreme) – Root cause analysis to be carried out and control measures to be introduced immediately to reduce risk to as low a level as possible. The risk assessment is where the Severity and Likelihood columns meet, e.g.; if the severity is major and likelihood is unlikely then the result would be a Significant Risk c)
The Ward/Department Manager must summarise their comments concerning the incident/near miss and action taken following the occurrence in the space provided, continuing on a separate sheet if necessary.
d)
The Ward/Department Manager must sign this section.
Policy: 204 Version: 4
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SECTION E This section is completed by the Risk Management Department. F:
RIDDOR
a)
There is a statutory requirement under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995, to notify the Health & Safety Executive of any death, major injury, dangerous occurrence or occupational disease arising out of or in connection with work (see Appendix xii for Incident Reporting Policy. Before notifying the HSE of the incident, the Risk Management Department should be contacted to establish whether or not the incident is RIDDOR reportable Notification must be by the quickest practicable means e.g.:Telephone Number: Fax Number: E-Mail: Internet
0845 0845
300 9923 300 9924
[email protected] www.hse.gov.uk
(Local (Local
Rate) Rate)
and confirmed in writing on Form 2508 available from Risk Management. F2508 to be sent to:HSE Incident Contact Centre Caerphilly Business Park Caerphilly CF83 3GG b) Death – Persons at Work/Not at Work Any death as a result of an accident arising out of or in connection with work, which occurs within one year of the date of the accident, is reportable.
c) Major Injury – Persons at Work (e.g. Employee, Self-employed, Contractor) Any major injury, as defined below, arising out of or in connection with work, is reportable:a) Any injury resulting from an electric shock or electric burn leading to unconsciousness or requiring resuscitation or admittance hospital for more than 24 hours b) Any Fracture, other than fingers, thumbs or toes. Any dislocation of the shoulder, hip, knee and spine c) Any Amputation. d) Loss of consciousness caused by asphyxia or exposure to a harmful substance or biological agent e) Absorption of any substance by inhalation, ingestion or through the skin f)
Acute illness requiring medical treatment where there is reason to believe that the illness resulted from exposure to a biological agent or its toxins or infected material.
g) Over 3 Day Injury – Persons at Work (e.g. Employees or Self-employed) Any injury as a result of an accident arising out of or in connection with work, when the injured person is away from work or unable to do their normal work for more than three days (including Policy: 204 Version: 4
Page 25 of 39
Saturday and Sunday), is reportable. h) Major Injury – Persons NOT at Work (e.g. Client, Visitor, General Public) Any major injury, as defined above, arising out of or in connection with work at a hospital, is reportable. i)
Any Injury – Persons NOT at Work (e.g. Client, Visitor, General Public) Any injury as a result of an accident arising out of or in connection with work when that person is taken from the accident site to a hospital for treatment of the injury, is reportable.
j)
Dangerous Occurrence Dangerous occurrences are defined as incidents with the potential to cause major injury which arise out of or in connection with work – see Schedule 2 RIDDOR (copy held by Risk Management Department).
k) Occupational Disease Occupational diseases arising out of or in connection with work are related to a schedule listing a wide range of diseases and adverse health conditions – see Schedule 3 RIDDOR (copy held by Occupational Health Department). 13.
Laundry/Linen Procedure
13.1
Socially Soiled Linen (Patients) For linen and clothing used by patients not suffering from an infectious disease, dry and not stained or fouled by bodily discharges: Use WHITE Laundry Bag
13.2
Foul/Infected Linen (Patients and Staff) For patient clothing and patient linen stained by discharges, i.e. contamination from blood, body fluids, urine, faeces or from isolation rooms. Infection would include; a) b) c) d) e) f)
Enteric Disease Dysentery Infectious Hepatitis A & B Open Tuberculosis Acquired Immune Deficiency Syndrome (A.I.D.S.) Multiple Antibiotic Resistant Infections Use inner RED alginate bag and outer Red sunlight bags
The linen must not be sorted by laundry staff – if in doubt discuss with the Laundry Manager or Control of Infection Team. N.B.
Policy: 204 Version: 4
Disposable gloves and aprons must be worn when handling fouled or infected linen.
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13.3
Theatre surgeon gowns and theatre drapes. Use GREEN plastic bag All laundry should be placed in the appropriate coloured bag and when two-thirds full, secure top firmly and arrange for transportation to the laundry. Due regard must be paid by staff to the compatibility of various types of articles i.e. coloured items should not be mixed with white linen but placed in a separate bag. This is most important for the yellow bag category, where laundry is not sorted. Supplies of bags and liners are available from the linen room staff or laundry staff.
13.4
Dry Cleaning (Patients and Staff) For socially soiled clothing from patients and certain items of staff uniform which require dry cleaning: Use WHITE Laundry Bag •
13.5
The Laundry Management reserve the right to wash articles of clothing which would normally be dry-cleaned if they are found to be contaminated with urine or faeces.
Special Laundry For soiled curtains, hoist slings, slide sheets and other Manual Handling equipment Use PURPLE Laundry Bag
13.6
Reject linen Any item which is ripped or damaged – sheet which is heavily stained but not soiled Use ORANGE Laundry Bag
14.
Lift Emergencies Facilities Management have full procedures in place to be followed in the event of a lift breakdown. If you are in a lift which breaks down, raise the alarm by using the internal telephone or, if unavailable, by calling to someone outside. If you have someone in the lift who needs to be released as a matter or urgency (e.g. post-operative, in labour, suffering from claustrophobia) make this very clear to whoever you speak to, so that the Fire Service can be summoned to effect the rescue.
15.
Lone Working Many of the Trust’s employees may find themselves designated as a ‘Lone Worker’ at times. The Trust recognises the importance of these employees being afforded the same H&S environment as those working in the main buildings.
The Trust has, therefore, introduced a Lone Worker Policy No 212 which can be found on the Trust Intranet. Policy: 204 Page 27 of 39 Version: 4
Employers duties are to:1. Undertake a Risk Assessment detailing hazards to which employees may be exposed. 2. Put control measures in place to reduce the risk, and 3. Monitor the effectiveness of these control measures. Employees duties are to:1. Follow all instructions given by the Line Manager with regard to lone working, and 2. Report all incidents or near misses relating to lone working. See Policy for further details. 16.
Manual Handling/Ergonomics “Manual handling is the transporting or supporting of a load including lifting, putting down, pushing, pulling, carrying or moving of a load by hand or by bodily force”. The Manual Handling Operations Regulations (MHOR) 1992 requires an Employer to ensure that:•
So far as is reasonably practicable, employees do not undertake manual handling tasks which involve a risk of injury.
•
Where it is not reasonably practicable for employees to avoid manual handling tasks which involve a risk of injury, an assessment of the working procedure must be made.
•
An assessment must take the following factors into consideration: The Task The Load The Working Environment The Individual’s Capability (see Assessment Guidance)
•
Staff required to perform manual handling tasks which involve a risk of injury are given the appropriate instruction, information, supervision and training.
•
All manual handling procedures must be reassessed if the task changes significantly.
•
Written operating instructions, training and information will be provided for staff using mechanical aids.
•
The selection and purchase of manual handling aids are suitable for their purpose.
Only approved manual handling techniques are adopted.
Policy: 204 Version: 4
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•
Where manual handling aids have been provided, they are used.
•
They notify the employer of all previous injuries and/or physical conditions which might affect their ability to undertake manual handling tasks safely.
Staff failing to follow safe manual handling procedures may be subject to disciplinary action. Please note that a “Load” includes any person. Please see for the Manual Handling Policy No. 10 - Statement of Intent, and Manual Handling Assessment Form for Clinical Areas; and the Patient Manual Handling Procedure. 17.
Mobile Phones
17.1
Health Mobile phones are low power devices which emit and receive radio waves. Radio waves have been used for communication for over 100 years now, but the rapid rise in numbers and usage is unprecedented and has led to concerns about possible impact on health. The balance of current research evidence suggests that exposure to radio waves below levels set out in International Guidelines do not cause health problems to the general population. All mobile phones sold in the U.K. meet these guidelines. There is, however, some evidence to show that changes in brain activity can occur below these guidelines, but it is not clear why. A precautionary approach to the use of mobile phones is, therefore, recommended. Department of Health Guidelines suggest that to minimise your exposure to radio waves you should:a. consider the SAR (Specific Absorption Rate) of the phone you may be buying or using, and b. keep your calls short - talking for long periods prolongs exposure and should be discouraged c. consider use of a hands free kit d. consider purchasing a phone with a built in shield. For further information you can visit the Department of Health website on:www.doh.gov.uk/mobile.htm
18.
Safety The law states that you must be in proper control of your car when driving. It is against the law to use a mobile phone whilst driving unless the vehicle is fitted with a “hands free” system. Mobile phones may be used in designated areas within the hospital (see Mobile Phone Policy – 134) which can be found on the Trust Intranet.
Policy: 204 Version: 4
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19.
Security The number of incidents of mobile phone thefts is growing at an alarming rate. Try to keep your mobile phone out of view as much as possible; carrying it in your hands or on a belt clip is inadvisable. Do not leave it on view in a parked car. Be aware of your surroundings when using it in public areas. Most muggings occur when people are using the phone and unaware of what is going on around them.
20.
Occupational Health The following sections are health issues, and if you require any further guidance or advice, you should contact the Occupational Health Department.
20.1
Alcohol and Drugs A Policy on Drug and Alcohol Abuse is currently being considered by the Trust, however, should you require any information or advice in the meantime, please contact the Occupational Health Department.
20.2
Display Screen Equipment Use The Trust acknowledges that health and safety hazards may arise from the use of this type of equipment (for employees who use DSE as a significant part of their normal working day). Employers’ duties are to:•
Provide information and training on DSE use
•
Ensure each workstation is assessed
•
Provide eye and eye sight tests where appropriate
Employees’ duties are to:•
Follow instructions and training in DSE use
•
Report any ill effects thought to be caused by the use of DSE immediately to their Line Manager and the Occupational Health Department
For further information or guidance, please see the Display Screen Users Health & Safety Policy No. 072 which can be found on the Trust Intranet. 20.3
First Aid The Health & Safety (First Aid) Regulations 1981 require employers to ensure that there is adequate first aid provision for their employees. The Trust has, therefore, produced a First Aid Policy which can be found on the Internet.
20.3.1 First Aid Facilities
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First Aid boxes are located throughout the Trust.
20.3.2
First Aid Assistance The Trust has qualified First Aiders and appointed persons, please see your nearest First Aid notice for names and extension numbers.
20.3.3 Emergency Assistance In the event of a suspected cardiac arrest (or at the request of the First Aider or appointed person), prompt assistance can be obtained by dialing 2222 and giving details of the incident and an exact location. 20.4
HEPATITIS “B”
20.4.1 What is Hepatitis “B”? It is a serious disease of the liver caused by the Hepatitis “B” virus. It may cause liver damage, liver cancer and even death but many sufferers make a complete recovery. Approximately 10 cases are reported each year in the North East Essex region. How is Hepatitis “B” Spread at Work? •
By sharps injuries from an infected needle, syringe, scalpel etc.
•
By wounds or bites received from an infected person.
•
By infected blood or body fluids coming into contact with the eye, uncovered scratches or cuts.
How to Protect Yourself •
Immunisation.
•
Cover wounds and cuts.
•
Wear personal protection where necessary, i.e. gloves etc.
•
Wash hands before and after patient contact.
•
Dispose of sharps in a designated sharps box – never re-sheath used needles.
•
Clear up spillages of blood and other body fluids promptly and disinfect surfaces.
What Action to Take If Possible Contamination Occurs - Irrespective Of Immunity Status of Staff Member or Patient/Resident 1. Clean wounds with soap and water. 2. Inform Line Manager of the incident as soon as possible. Policy: 204 Version: 4
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3. Ensure that within 24 hours a blood specimen is taken to test for Hepatitis “B” antigens from:a) The person on whom a needle, syringe, scalpel etc. was used (if known) OR b) The person inflicting an injury i.e. bites, scratches etc. OR c) The person whose blood or body fluids have been in contact with uncovered cuts/scratches or the eyes.
The Consultant Microbiologist must be contacted if there are any problems in obtaining the blood specimen. 4.
A blood specimen must also be obtained from the injured person to test for Hepatitis “B” antigens, irrespective of whether they have a known immunity. The Microbiology Form must state the name of the patient/resident inflicting the injury (if known).
5.
Complete a Trust Incident Reporting Form.
6.
Inform the Occupational Health Department on completion of the above procedure.
7.
If the blood results show that urgent immunisation is required, the Consultant Microbiologist will decide on the appropriate treatment to be given. This treatment will be carried out by the Occupational Health Department within 72 hours of the injury. FOR FURTHER INFORMATION CONTACT THE OCCUPATIONAL HEALTH DEPARTMENT.
20.5
Needlestick and Puncture Wound Injuries •
All cuts and puncture wounds from contaminated objects must be washed at once with soap and water, encouraged to bleed, and a wound dressing applied if necessary.
•
Inform your Departmental Manager as soon as possible. Complete a Trust Incident Reporting Form.
•
If possible:a) identify the source of the needle or contaminated object b) obtain 10mls of clotted blood from the source (person upon whom the sharp object was used) c) obtain 10mls of clotted blood from the victim d) consult Appendix 7 of the Control of Infection Handbook if there is any reasonable suspicion that the source is HIV positive.
•
Policy: 204 Version: 4
Both blood specimens must be sent to the Microbiology Department with separate Microbiology forms stating clearly who is the victim and who is the source. Mark these “NEEDLESTICK INJURY – URGENT”. The specimen from the victim will be held untested by the Microbiologist for medico-legal reasons. Page 32 of 39
•
Inform the Occupational Health Department by telephone immediately (01206 - 744444 – answerphone out of hours). For advice only, ring the Sharps line (24 hours) on 01206 – 742297.
•
If the victim has been successfully vaccinated against Hepatitis “B”, or successfully boosted within the last year, no further action is required. In other cases, Occupational Health and the Microbiologist will arrange appropriate treatment.
IT IS YOUR RESPONSIBILITY TO ENSURE THAT YOU RECEIVE THE NECESSARY FOLLOW UP TREATMENT. 20.6
Organisational Stress Stress is a reaction that people have to excessive pressure or other types of demands placed upon them. It arises when they worry that they cannot cope. The Stress Management Policy has been approved and can be found on the Trust Intranet.
20.7
Smoking The Trust’s No Smoking Policy has been approved and can be found on the Trust Intranet.
20.8
Work Related Trauma/Trauma Debriefing A Policy on Work Related Counseling and Trauma Debriefing is currently being prepared and will be attached to this Policy when approved. If, however, you feel you need to talk to someone, please contact the Occupational Health Department.
21.
Risk Assessment The Health & Safety at Work Act 1974 requires employers to “ensure so far as is reasonably practicable, the health, safety and welfare at work of all his employees”. The Management of Health & Safety at Work Regulations 1999 clarify this by specifying that all employers must “make a suitable and sufficient assessment of the risks to the Health & Safety of his employees to which they are exposed at work…”. Risk assessments, however, only need be completed where a significant risk is present. Risk assessments should:1.
Identify work hazards with the potential to cause harm (including work activities, machinery, equipment and substances).
2.
Take into account the measures already in place to prevent injury, loss or damage.
3.
Assess the level of risk present in terms of likelihood and severity, and
4.
Prioritise any action needed to control the risk further.
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21.1
Documentation The Trust’s Risk Assessment documentation, including guidance notes, is shown in Risk Assessment documentation and can be found on the Trust Intranet. Specific Risk Assessment documentation is required for the following:Voluntary workers and work experience students Lone Workers (see Lone Worker Policy also) Pregnancy Slip/Trip/Falls Infection Control Needlestick Injuries Burns/Scolds Portable Electrical Equipment Physical Assault Manual Handling (see Manual Handling Policy also) Hazardous Substances (see COSHH Manual also) VDU Equipment (see Display Screen Equipment Policy also)
22.0
Slips, Trips & Falls involving staff and others
22.1
Introduction The most common cause of accident in the workplace is slips, trips and falls. Nationally statistics reveal that 38% of all ‘reportable accidents’ are slips, trips and falls, outcomes can vary from a damaged ego to serious and fatal injuries. Within Essex Rivers Healthcare Trust the 2006 – 2007 figures show that slips, trips and falls accounted for 10% of the total for non-patient incidents.
22.2
22.3
Duties (in addition to the responsibilities on page 10) 1.
It is the duty of all employees to report unsafe acts and unsafe conditions that give rise to slip, trip and falls risks to their line manager.
2.
It is the duty of all employees to carry out activities safely, and not use equipment in a manner that could increase the risk of slip, trip and fall.
3.
It is the duty of the line managers to respond to reports of slips, trips and falls risks and to take measures to make the area/activity safe.
4.
It is the duty of the line managers to ensure that the housekeeping department are notified immediately of spillages that could result in a slip, trip or fall.
5.
It is the duty of the line managers to raise identified risks with Service Area Managers in circumstance that require capital investment.
6.
It is the duty of the Service Area Managers to assess the risks of identified slip, trip and falls and take all measure necessary to eliminate or reduce the risk.
Types of Incidents A)
Slips, Trips and Falls – Same Level
Slip incidents may be caused by: • Wet or damp floor surfaces Policy: 204 Version: 4
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• • •
Greasy of oily floor surfaces Wet of icy pavements or roads Smooth soles or well worn soles of shoes
Trip incidents may be caused by: • Trailing cables • Steps and doorway thresholds • Uneven floors and walk ways • Potholes • Worn carpet or floor covering • Obstacles in the walk way. B)
Falls from height
Falls from height may be caused by: • Wet or damp staircases • Overstretching when using ladders or stepladders • Using inappropriate equipment to reach articles at height e.g. chairs, boxes etc. • Makeshift working platforms e.g. desktop, window sills, loose wooden or metal planks suspended above ground. 22.4
Risk Assessment A generic risk assessment in respect of slips, trips and falls must be completed by each ward and department. The generic form can be found in the Trust Health and Safety Policy. The generic risk assessment covers those activities that have been identified as part of the everyday working activities e.g. trailing vacuum cleaner cable. A specific individual risk assessment in respect of slips, trips and falls would be required for an unusual activity or following an incident e.g. damaged carpet or floor covering. Risk assessment must be reviewed at least once per year and sooner if the circumstances of the original risk assessment change. * Further information on the Risk Assessment process can be found on page 31
22.5
Training and Raising Awareness Slip, Trip, fall awareness and risk assessment completion is covered at both Trust Induction and Update Risk Management training sessions. Risk assessment training is provided to both organised groups and to individuals by the Risk Management Department. This training and frequency has been identified in the Training Needs Analysis (Procedure no 203) and within the Training and Development Prospectus.
22.6
Monitoring The Trust Health and Safety Advisor will carry out safety tours on a regular basis to ensure members of staff and contractors are in compliance with their duties and responsibilities to themselves and others (see Duties). Failings will be reported to the Health and Safety Committee, Contract Review and Carillion Safety Action Group Meetings.
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The Trust Health and Safety Advisor will produce a report including trend analysis for discussion and action by the Health and Safety Committee. The minutes of the meeting will be forwarded to the Risk Management Committee for their information and action where necessary. During annual departmental health and safety audits the Health and Safety Advisor will check that all risk assessments relating to slip/trip/falls have been reviewed and are “suitable and sufficient” and notify the line management in writing when this is not the case. The Risk Management Department will produce monthly reports on slip/trip/falls from the DATIX incident reporting system. The data will be analysed by Risk Management personnel who will identify trends including locations, personnel, specific hazards etc. The Risk Management Department will advise line managers of areas recording a high level of slip/trip/falls and request action plans. 23
Safety Equipment and Safety Wear The Personal Protective Equipment at Work (PPE) Regulations 1992 require employers to provide protective clothing or equipment to employees where risks to their health and safety exist, e.g.:-
23.1
Protective Clothing are items such as aprons, gloves, lead aprons and safety footwear, and
23.2
Protective Equipment are items such as eye protectors and face masks. Employers’ duties are to:•
Provide PPE where required, following completion of a Risk Assessment (completed departmentally).
•
Not to charge for the provision of PPE.
•
Provide accommodation for the PPE.
•
Provide employees with information, instruction and supervision.
Employees’ duties are to:-
24.
•
Correctly wear PPE, provided by the employer, and in accordance with information and instructions provided. Failure to comply with this regulation may render the employee liable to disciplinary action.
•
Store PPE correctly, and
•
Report any loss or defect to their Line Manager.
Security The Trust recognises the importance of providing the best possible security environment without unnecessary restrictions; but with control measures for the safety and convenience of employees, contractors, patients and visitors. The Security Policy contains advice on such subjects as:
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Physical Security : Security of Motor Vehicles : Bomb Threats : Missing Patients : Security of Information : Identification Badges : Untoward Incidents : Security of Stores : Medicine/Drug Security : Cash Handling : Lost and Found Property : Fraud : Covert CCTV Policy. Effective security can only be achieved by each individual taking reasonable steps to safeguard the property of the Trust, patients and staff. Our work places are, by and large, public areas, and allowing access to the public also invites the would-be thief, vandal and burglar. We can help ourselves – and the Trust – by taking some simple precautions:•
Locking away and limiting the personal property we bring to work.
•
Persons not wearing an Identification Badge, and whose identity is unknown, must be challenged and asked to account for their presence. This should be done politely and quietly and in a helpful manner.
•
Report any untoward activity to the Departmental Manager and the Trust Security Advisor.
•
Ensure that an Incident Reporting Form is completed, and forwarded to the Risk Management Department.
•
Ensure that the Trust’s property and equipment is kept as secure as possible (this includes employee or patient information).
•
Ensure that policies, procedures and systems are not only in place, but adhered to.
•
Maintain good key security.
The Trust has in place the following system to ensure appropriate response to security incidents and emergencies:Dial 3333 Dial 9-999 in Emergencies Inform Security Advisor (2921) 25.
Training and Training records
25.1
Induction All new permanent and temporary employees must attend Induction Training at the earliest practicable time after commencing employment. This training will include Health, Safety and Welfare, Fire, Security and Back Awareness.
25.2
Update All staff must attend Update Training within 2 years of Induction Training and within every 2 years, thereafter. This training will include Health, Safety and Welfare, Fire, Security and Back Awareness.
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25.3
Site Specific All staff must receive information and/or training to ensure that they are aware of the general and specific hazards, safe systems of work, working practices and departmental rules of their places of work.
25.4
Records The Risk Management Department is responsible for maintaining training records via the OnCore training system.
25.5
Monitoring The Risk Management Department will advise service managers when their staff are due to attend the 2 yearly update training courses
25.6
Non-attendance The Risk Management Department will advise service managers in writing when their staff fail to attend courses for which a place has been reserved. Non-attendees will be offered an alternative training date.
26
Employees The Trust has prepared the Policy, Responsibilities for Violence & Aggression at Work which can be found on the Trust Intranet. Violence and aggression at work is defined by the Health & Safety Executive (1998) as:“any incident in which a person working in the healthcare sector is verbally abused, threatened or assaulted by a patient, a member of the public, or another employee, in circumstances relating to his or her employment”. 1.
Essential to the prevention of employees being exposed to violence and aggression, is the risk assessment process (the identification, evaluation and control of risks), training, information and planning.
2.
Recommendations to eliminate or reduce the risk to the lowest level reasonably practicable should be documented on a Trust Risk Assessment Form.
3.
Appropriate training will be provided by the Trust to equip employees with the skills to avoid/manage violent and aggressive situations.
4.
Details of ‘Aggression Management’ training courses may be obtained from the Training and Development Department. It is currently mandatory for all front line staff to attend “Conflict Resolution” training which is in compliance with the Counter Fraud Security Management Service directive.
5.
Employees should consider the following:-
a) Where possible create space between themselves and the aggressor. b) Communicate from a tactical position, i.e. not directly ‘face to face’ to that person and in a position of good balance. c) Attempt to calm the situation by keeping your own temper – listen, empathise. d) Be aware of the non-verbal signs being exhibited by that person, i.e. facial expression, clenched fists etc. Policy: 204 Page 38 of 39 Version: 4
e) As far as possible keep yourself between the aggressor and your exit or escape route. f) Be prepared to react to sudden movement from the aggressor. 6.
If violence erupts, or a threatening situation develops, employees should dial 3333 (Colchester General Hospital and Essex County Hospital only). In an emergency the Police should be summoned by dialing 9-999. Often a few well-chosen words from a member of staff, who has knowledge of the person, will be sufficient to stop an incident without physical restraint being required. If a person needs to be physically restrained, the degree of force used should be the minimum required to control the violence or aggression and should be applied in a manner calculated to calm, rather than provoke, further violence or aggression.
7.
Employees should report all incidents of violence and aggression to their Line Manager at the earliest opportunity.
8.
The employee should complete a Trust Incident Reporting Form. The Line Manager should investigate the incident.
9.
All Incident Report forms completed due to acts of violence and aggression are seen by the Trust Security Advisor, and the Occupational Health Department who can provide support for employees who feel traumatised by an incident.
10.
In addition to any recourse to criminal law, if a member of the public, i.e. patient, relative or visitor repeatedly carries out acts of unacceptable behaviour, Trust Managers should consider the procedure set out in Policy 044, Responsibilities and Arrangements for Violence & Aggression at Work which can be found on the Trust Intranet.
11.
In extreme cases an application could be made to a Civil Court for an injunction to restrain the person responsible from visiting Trust property for all but emergency medical treatment.
Policy: 204 Version: 4
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