Appendix: 1
2007/2008ANNUAL REPORT PREPARED BY
HEALTH AND SAFETY RISK MANAGEMENT
KEY OBJECTIVES AND ACTION PLAN for
2008/2009
APRIL 2008
Contents Page
Executive Summary:Page 3
Introduction:Page 4
A Review of 2007/2008Page 5
Where do we want to go?Page 6
Health and Safety ObjectivesPage 7
Health and Safety PolicyPage 8
Manual HandlingPage 9
Control of ContractorsPage 11 – 12
Control of LegionellaPage 13
Slips, trips and fallsPage 14
Management of Work related StressPage 15
Sharps incidentsPage 16
Latex SafetyPage 17
Workplace InspectionsPage 18
Incidents / Investigation / LitigationPage 19
Health and Safety TrainingPage 20
Health and Safety CommitteesPage 21
External Traffic route managementPage 22
Window ManagementPage 23
Appendix1Health and Safety StructurePage 24
Appendix 2TrainingPage 25
Executive summary
1. Health and safety arrangements within the RUH are continuing to be strengthened. Last year was primarily related to laying foundations for 2008/09 improvements and compliance. The most important action that will be undertaken this year will be ensuring effective communication of compliance and non compliance issues to the Trust Board.
2. The introduction of The Corporate Manslaughter and Corporate Homicide Act 2007, and the public’s desire for personal accountability in an organisation will change organisations attitude towards health and safety. The Health and Safety Executive’s (HSE) guidance to inspectorsis now to prosecute when it can obtain a likely conviction, rather than offer guidance. The Crown Prosecution Service (CPS) has identified that this legislation can provide a useful avenue for public redress against organisations.It appears at present that the likelihood for organisations that do not comply with health and safety legislation is prosecution rather than advice from HSE.
3. This report sets out a review of 2007 / 08 identifying health and safety weaknesses and where improvement will be planned for 2008 /09.
Introduction
Over 10 years ago the Health and Safety Executive (HSE) issued the guidance to all NHS Trusts via HSG (97)6 that they needed to “develop hospital wide strategies to minimise the level of accidents. These strategies need to be supported by effective reporting arrangements to assess trends…to achieve good progress, action should be led by the top by Trust Boards and Chief Executives, so that the health and safety of patients, visitors and employees is routinely accorded a high priority within and across all trusts.”
It was apparent to the HSE that insufficient action was implemented by the NHS. So five years ago it directed its inspectors through SIM07/2003/05 to assist and guide NHS Trusts in their implementation of health and safety management systems. “The main objective of the management inspections is to secure the drafting and implementation of action plans to improve standards of health and safety, and to address non compliance with legislation in NHS bodies.”
Since then, the NHS along with other public bodies have taken action to address their health and safety responsibilities and ensure that people are not harmed by their actions.
The HSE has now informed inspectors in situations where a successful prosecution is likelyto ‘prosecute rather than coach and guide.’
Other enforcement agencies apart from the HSE are starting to use Health and Safety legislation to obtain criminal convictions. The Crown Prosecution Service (CPS) have recently prosecuted a number of public bodies for failure in their duty of care.
The Health and Safetyat Work etc. Act 1974 states the general duties of employers to their staff in section 2 and to others in section 3. It also stipulates the responsibilities of an individual.
The potential consequences for failure can be the serving of improvement and prohibition notices, leading to criminal prosecution and civil claims for the organisation and directors. Directors and Managers need to be aware they are personally liable to be prosecuted under section 37 ”if a breach is proved to have been committed with the consent or connivance of, or to have been attributable to any neglect on the part of, any director, manager or secretary.”
This need only be of concern to organisations whose training, organisation, management systems and governance standards are weak.
A review of 2007/08
The health and safety department set itself a very large remit for the last year, and laid the foundations for further progress. It achieved the following -
- Obtaining necessary health and safety resources
- Reorganisation of the Trust health and safety committee, it purpose, role and communication links and the introduction of two H&S sub committees. (Appendix 1) This will now report to the newly formed Non-Clinical risk Committee.
- Establishment of a Sharps group and Stress group
- Taking responsibility for the management of Non clinical claims
- Introduction of health and safety refresher training via the core skills day. Participation on training courses which has been a great success, and it is expected to surpass 2700 delegates, which would equate to over 75% of the total work force. (appendix 2)
Number of Staff trained
Clinical Induction Health and Safety training / 334Clinical Non Induction Health and Safety training / 230
Core skills Health and Safety training / 702
Risk Assessment training / 24
Other Health and Safety training / 85
Patient Induction handling / 287
Core skills Manual Handling training / 664
Return to work Manual Handling training / 22
Loads training / 28
Other Manual handling training / 163
- Full compliance with the RIDDOR regulations
- Raising the profile of health and safety within the Trust
- Enhanced relationships with Occupational Health, Human Resources and the Unions
- In response to the 2006 Healthcare Commission staff survey the Health and Safety update was introduced in 2007 within the core skills training day, following its success and the high attendance take up, this is planned to continue throughout 2008. Training figures for the year up to the end of February
- Estates resources have improved with the appointment of Head of Estates and additional managerial staff.
Where do we want to go?
Through investigation of reported serious adverse incidents whether they are power loss in NICU, fire alarms activated by contractors, visitors and staff suffering injury in the car park, trolleys damaging cars, or staff having to use damaged equipment, theTrusts management competency of health and safety has to be the primary objective.
The Trust is failing in its legal duty if it is failing staff to maintain their skill as laid out in core dimension 3 for their KSF.
The aim this year is to progress towards statutory compliance and ensure that relevant information is communicated to the relevant people. It is a strategic priority that the Trust board are aware of issues of compliance and non compliance and for what reasons.
For this reason the department will be implementing actions to comply with Health and Safety Guidance (HSG65), the preferred health and safety management model of the HSE. There are six key sections
Policy – Effective health and safety policies contribute to business performance
Organising – Defining the responsibilities and relationships which promote a positive health and safety culture, and secure the implementation and continued development of the health and safety policy. Structures and processes need to be implemented.
Planning – is essential for the implementationof health and safety policies. Adequate control of risks includes controlling risks, reacting to changing demands.
Measurement – Essential to maintain and improve a positive health and safety performance via reactive and proactive methods
Audit and review – Maintain and improve the organisations ability to manage risks by learning from experience.
Health and Safety Objectives 2008 / 09
The following objectives (pages 8 – 24)
are key to successful implementation of Health and Safety Guidance (HSG 65) and have been prioritised by using the traffic light systemRED and AMBERwith the justification criteriaof 1 to 3 as follows.
Priority order
PRIORITY 1: Highest risk to the Trust board and Chief Executive Officer, non-compliance and H&S Breaches could result in serious consequences followed by HSE prosecution and adverse publicity. Action Plan to be monitored by Non-clinical risk committee.PRIORITY 2: Risk reduction required immediately, implement as necessary short term and long term action plan to be monitored by Trust Health and Safety Committee.
PRIORITY 3:Potential risk to be monitored by Health and Safety Risk Management Team
PRIORITY 1 Action plan falling behind schedule, reasons for slip to be reported to H&S Committee for approval of delay.
PRIORITY 2: Improvements meeting plan and progress monitored by H&S risk management team
PRIORITY 3: Update planned and within satisfactory time limit for completion
KEY OBJECTIVE: Meet statutory requirement to have an up to date Trust Health and Safety Policy and arrangements and communicate to Trust Board and all Employees.
LEAD DIRECTOR: James Scott.
Chief Executive Officer(CEO) / Target Date / Actual Date
Action Plan
a) To updatethe RUH Health and Safety Policy Statement to be approved by trust board and signed by the Chief Executive. / Jun 08
b) To review current Health and Safety Policy and update arrangements to include the Management of Health and Safety / July 08
c) Present Annual Health and safety update to Trust Board and Non-clinical Risk committee / July 08
Responsible
Person / Progress Report on Action Plan
(a) / The Trust H&S policy requires updating to include a revised statement signed by the Chief Executive.
David Robinson / James Brind / Statement to be submitted for approval by Trust H&S Committee in May and for trust board approval in June for Chief Executiveto sign and displayed throughout the trust.
(b) / Current policy has not been updated for several years and does not reflect changes in current H&S Legislation
David Robinson / James Brind / H&S Legislation currently being cross referenced against existing policy and upgraded as required
(c) / DON to ensure presentation is included on July Trust Board agenda for July
(c)
David Robinson / Planned for July 2008
(2) KEY OBJECTIVE: Meet safetylegislation and NHS standards for manual handling with regards to clinical and non-clinical moving and handling.
ORITY
LEAD DIRECTOR: Director of Nursing
Francesca Thompson / Target Date / Actual Date
Action Plan / Aims for 2008 / 2009
a)To develop a manual handling policy to meet HSE, NHSLA and DoH standards for better health / April
2008
b) Deliver training to clinical staff on moving and handling of patients to meet HSE, NHSLA and DoH Standards for Better Health requirements ( as per training matrix) / March 2009
c) Deliver Manual Handling training programmes to Non-clinical staff to meet HSE, NHSLA and DoH Standards for Better Health requirements. / March
2009
d) Deliver training to manual handling champions every 3 months / March
2009
e) Develop patientmanual handling risk assessment and a patient care plan / March 2009
f) Audit and MonitorTrust management of patient lifting equipment (Hoist and slings). / December
2008
g) Evaluate manual handling incidents throughout the Trust and produce monthly reports. / Per Incident
Responsible
Person / Progress Report on Action Plan
(a) / The policy in place needs to be updated to meet the new NHSLA standards
(a)
Mary Chapman / Policy due to be completed and meet the NHSLA standards by end March 2008
(b)
Mary Chapman / Patient manual handling training has been part of the core skills training package for the past 12 months. Attendance figures are encouraging.
(b) / Course planned to continue throughout 2008
(c) / Manual handling is available to all non clinical staff monthly
(c)
Mary Chapman / Need to improve advertising and selling the awareness
(d) / The manual handling champions are meeting every three months and the clinical departments are only sending one champion
(d)
Mary Chapman / Need to ensure senior nurses on board and improve advertising for the meetings
(e) / the review of documentation has taken place and has identified that an initial patient handling assessment is needed and a patient handling risk assessment and action/care plan needs to be reviewed and updated in line with the Trust documentation.
(e)
Mary Chapman / The patient initial assessment and risk assessment and action/care plan will need to be developed and training on the completion of the assessment will need to be established and the monitoring of this will be by audit
(f) / Non compliance issues to meet the statutory requirements for testing and examination
(f)
Mary Chapman / Undertake an annual inspection of patient handling equipment and report to the Trust Health and Safety Committee.
(g) / Manual handling incidents reported on PRISMcontinue to be reviewed. Comparison of reported musculoskeletal injuries from OH would suggest there are discrepancies
(g)
Mary Chapman / Increase awareness of the ‘Back to work’ programme for manual handling.
(3) KEY OBJECTIVE: Health and Safety Compliance of Building works and of the control of contractors on site
LEAD DIRECTOR: Directorof Facilities / Target Date / Actual Date
Action Plan
a) Complete set of local procedures within facilities / Dec 2008
b) To have arrangements in place for the vetting and approval for competent contractors to work on-site / Sept 2008
c) Establish system to identify non-compliance of building activities / Sept 2008
d) To allocate resources able to manage projects competently and to the requirements of CDM Regulations if applicable. / Sept 2008
Responsible
Person / Progress Report on Action Plan
(a) / Initial position : A number of policies on the H&Sintranet section were outdated.
(a)
David Robinson / With Directorial agreement DR has removed a number of outdated and non compliant policies including confined spaces, asbestos and management of contractors
(a)
Andy House / A procedure requirement matrix has been produced by Estates.
Estates have indicated the following procedures are required for setting local standards for the following:
Asbestos
Construction Design and Management
Concealed and buried services
Confined Spaces
Control of Contractors
Dangerous substances and explosive atmospheres
Electricity management including earthing, high and low
Voltage
Working at heights
Fire,
Glazing
Hot water and surface temperature
Hoists
Lasers in Estates
Legionella
Lightning protection
Lifting operations and lifting equipment
Local exhaust ventilation
Medical Gas systems
Natural gas systems
Personal Protective Equipment PPE
Noise at work
Pressure systems
Refrigerant gases
Safe systems of work/competence
Traffic routes
Ventilation systems general
Ventilation systems special
Water systems
Waste management for domestic, clinical and hazardous
Environmental risk assessment
Management of inclement weather (Frost and Ice)
(b)
Andy House / There is presently an outdated list of current contractors approved to work on site, and no known established system for new contractors seeking approval to work at RUH.
(b) / Liaison with Estates on how to assist in the review and development of their database to ensure the competence of contractors on site.
(c)
Andy House / There is presently no formal work inspections undertaken. There is no evidence of contractors receiving safety induction training which should include RUH incident reporting.
(c)
H&S Department / Audit programme to be developed with Projects Team, and contractors induction training to be developed.
(d )
Director of Facilities / Liaison with appointed Facilities Director regarding ownership of project and refurbishment work.
(d ) / Consider a temporary working group to include estates, H&S and projects to consider the management process and resources required to be compliant.
(4) KEY OBJECTIVE: Control of Legionella
LEAD DIRECTOR: Director of Facilities / Target Date / Actual Date
Action Plan
a) To replace existing sub-standardwater systems throughout RUH. / March 2009
b) To maintain Works programme for monitoring the effective control of all water systems throughout RUH / ongoing
c) Remove filters from taps within the next 18 months / June 2009
d) Ensure a suitable policy is produced with responsibilities and arrangements in place to comply with L8 ACOP. / April 08
Responsible
Person / Progress Report on Action Plan
(a) / A programme is required to plan closure of wards over agreed period to replace old contaminated pipework.
a) Water and Air Hygiene Manager / Current prevention / control is by using filters on all taps to prevent legionella. Estates Officer to submit plan to manage replacement of contaminated pipework throughout Medical Assessment Unit and then plan for other outstanding areas before filters can be removed.
(b) / Monthly findings/ results and action taken are reported to water hygiene group
(b)
Water and air Hygiene Manager / Abnormal results are discussed during monthly WHG meetings with a documented action plan in WHG minutes.
(c) / On completion of new water services, record results of water testing and seek approval from Microbiological Doctor to remove all filters
(c)
Sarah Meisner / As required
(d) / As per objective 3
(5) KEY OBJECTIVE: Evaluate the causes of Slips, Trips and Falls (STF)
LEAD DIRECTOR: Director of Facilities / Target Date / Actual Date
Action Plan
a) Inspect all current flooring throughout RUH and produce report on suitability / March 09
b) Establish risk assessment criteria for assessing flooring standard appropriate to needs. / March 09
c) Complete site survey of internal pedestrian routes and report findings to H&S Environmental group / March 09
d) Slip trips and falls on trust risk register number 169 To be reviewed and action taken accordingly / March 09
e) Safety Department to develop a trust wide flooring procedure. / March 09
Responsible
Person / Progress Report on Action Plan
(a,b,c,d,e) / Risk Identified to the Trust (Risk register 169) Sept 07
(a,b,c,d,e,)
Andy House / Environment Group to set up sub group to implement a Trust wide risk assessment producing a report and action plan.