Risk Assessment Procedure

Transcription

1 Risk Assessment Procedure Version: 1.1 Ratified by (Committee) : EMG Date ratified: Name of originator/author: Developed in association with: Catherine McGowan Workplace Law Name of executive lead: Tina Quinn Date issued: July 2014 Review date: July 2016 Name of responsible committee/individual for reviewing: Quality Team Review and Amendment Log Version No Type of Change Date Description of change 1.1 Section More detail added regarding risk assessment tools Page 1 of 12

2 Contents 1. Introduction 3 2. Purpose 3 3. Target population 3 4. Explanation of terms 3 5. Duties Individual staff responsibilities Responsible committee Chief Executive 4 6. Requirements Risk assessment process Generic risk assessments Managing the risks Monitoring / reviewing the assessments Risk assessment procedure 6 7. Equality Impact Assessment 7 8. PREVENT 7 9. Consultation process Dissemination and implementation Dissemination Training Monitoring compliance with the document Process for monitoring compliance Key performance indicators References / Bibliography Guidance References Associated policy documentation 8 Appendix A Equality Impact Assessment 9 Appendix B Consultation process 10 Appendix C Checklist for the Review and Ratification of Procedural Documents 11 Page Page 2 of 12

3 1 Introduction The purpose of this document is to ensure that all health and safety hazards and risks produced by Locala CIC activities are formally assessed, recorded and managed. Employees have a legal requirement, under the Health and Safety at Work Act, to cooperate with their employer and comply with any safe working practices. Should you have any specific queries or concerns relating to health and safety in the workplace, talk to your manager or a member of the Quality Team. 2 Purpose The purpose of risk assessment is to identify hazards and carry out the necessary risk control measures generated by Locala activities. Risk assessments are not only a legal requirement but also serve the purpose of preventing accident and incidents and assist in the planning of a risk control strategy. By following the procedures laid out in this document, Locala employees will ensure risks are identified and acted upon correctly and safely. 3 Target population These procedures are intended for all Locala employees, including those on temporary contracts. 4 Explanation of Terms Audit systematic, independent and documented process for obtaining audit evidence and evaluating it objectively to determine the extent to which audit criteria are fulfilled. Corrective action action to eliminate the cause of a detected non-conformity or other undesirable situation. Competent person someone with the necessary skills, knowledge and experience to carry out a task and their duties. The other consideration is, understanding the limits of one s expertise. Hazard source, situation, or act with a potential harm in terms of human injury or ill health. Hazard identification process of recognising that a hazard exists and defining its characteristics. Non-conformity non-fulfilment of a requirement. Risk combination of a likelihood of an occurrence of a hazardous event or exposure(s) and the severity of injury or ill health that can be caused by the event or exposure(s). Hierarchy of control General principles of prevention when considering risk control measures. Risk assessment process of evaluating the risk(s) arising from a hazard(s), taking into account the adequacy of any existing controls, and deciding whether or not the risk is acceptable. Page 3 of 12

4 So far as reasonably practicable weighing up the hazard against the time, cost and resources required to reduce or eliminate the risk. 5 Duties 5.1 Individual staff member s responsibility To be involved with the risk assessment process To ensure that they are aware of the outcomes of risk assessments To advise line managers on any suggestions to improve risk control measures. 5.2 Managers To ensure that risk assessments are produced in written form for all significant activities that they are responsible for. Managers must also ensure that the colleagues they are responsible for have been consulted on the outcomes of the risk assessments and that control measures are being followed. 5.3 Chief Executive The Chief Executive is ultimately accountable for the implementation of these organisation-wide processes. With regards risk assessments, adequate resources must made available for their implementation and for the control of significant risks. 6 Requirements 6.1 Risk assessment process Risk assessments must only be undertaken by a competent person. They must generally be recorded on the relevant Locala risk assessment template, although other forms and documentation are in existence and may be used where considered more appropriate. All risk assessment templates and tools can be found under the Health & Safety section of the staff intranet (Elsie). Risk assessments relating to patients must be attached to the clinical record. Non-clinical risk assessments should be sent to the Safety and Property Management Officer and stored on SharePoint. In the first instance, hazard identification must be undertaken. This can be achieved through a number of methods which include: health and safety inspections, health and safety audits, accident investigations, interviews and/or complaints. Risk management: Five steps to risk assessment Once this process has taken place, the assessor must consider which groups of people may be harmed by the hazard, consider existing control measures and evaluate the risk using the risk matrix. Any corrective action required to reduce to an acceptable risk should then be identified and implemented. In determining corrective action, the health and safety Page 4 of 12

5 hierarchy of control (as specified in the Management of Health and Safety Regulations) should be considered and applied as far as reasonably practicable. The risk assessment should then be briefed to all employees / contractors who are likely to be exposed to the hazards. Any non-compliance must then be acted upon accordingly. Note: If the risk assessment identifies a specific risk associated to Manual Handling, COSHH, Work Equipment, Fire, Display Screen Equipment then a specialist risk assessment may need to be undertaken. This would involve competent assistance (Workplace Law). 6.2 Generic risk assessments A list of generic work related activities has been compiled and the health and safety risks assessed. The Health and Safety Register contain details of Locala activities and the associated hazards and risks. Management controls have been developed to mitigate foreseeable health and safety hazards (as far as reasonably practicable) and are integrated into Locala s health and safety management documentation. All Locala s employees must cooperate and follow any necessary precautions in order to ensure their own health and safety. 6.3 Managing the risks It is the responsibility of the managers to ensure that risk assessments have been prepared for all Locala s activities. The managers should ensure that the control measures are being followed (in accordance with the risk assessment) by reviewing actual working practices. 6.4 Monitoring / reviewing the assessments All risk assessments must be monitored regularly to ensure action has been taken. Assessments should also be examined as part of the annual audit programme and reviewed at least annually, or if it is believed that they are no longer valid or if there have been significant changes e.g. introduction of a new or process or chemical, change in legislation, in light of new technology information, as a result of an accident. Page 5 of 12

6 6.5 Risk assessment procedure Risk Assessment Procedure Has a significant hazard / risk been identified that requires a risk assessment? Yes Arrange for a competent person to undertake the risk assessment Risk Controlled Can the hazard be eliminated? Evaluate the risk and decide upon precautions Risk Controlled Record the findings and implement them Review your findings and implement them Page 6 of 12

7 7 Equality Impact Assessment Locality aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. The Equality Impact Assessment Tool (Appendix A) provides evidence of analysis it undertook to establish whether its policies and practices would further, or had furthered, the aims set out in section 149 (1) of the [Equality Act 2010]. 8 PREVENT All healthcare employees have a role to play in protecting and supporting vulnerable individuals, especially those who may be vulnerable to radicalisation. Prevent aims to stop people becoming terrorists or supporting terrorism. In carrying out their day to day work, colleagues may notice unusual changes in the behaviour of someone (patient, carer or employee) which are sufficient to cause concern. It is important that if anyone has a cause for concern, they contact their line manager, who will inform the Locala PREVENT lead. 9 Consultation Process It is a requirement for all managers to ensure that they have discussed the contents of this document with colleagues and any other person who may be affected. This document has been developed in association with Workplace Law. A full list of stakeholders consulted in the process can be found in Appendix B. 10 Dissemination and Implementation 10.1 Dissemination The Quality Team will place the ratified document in the Clinical Policy section of the staff intranet (Elsie). Any previous versions will be archived by the team Administrator Training All persons affected should have been consulted on this procedure. An analysis of all training needs has been identified and captured within Locala s mandatory and essential training matrix. Employees are required to address any training needs with their line manager. 11 Monitoring compliance with the document Locala has a procedure to ensure that our safe systems of work are formally reviewed at least annually. However, on occasions further monitoring may be required in the following circumstances: Where there is a change in legislation. Where there is evidence of non-compliance. Following the event of an accident or near-miss. Following the consultation process. Page 7 of 12

8 11.1 Process for monitoring compliance Reference should be made to the Monitoring Compliance Procedure Key Performance Indicators All risk assessments to be reviewed annually. Managers trained on how to undertake risk assessments 12 References / Bibliography Five steps to risk assessment INDG Associated policy documentation Locala Risk Management Occupational Health and Safety Policy. Locala Legal register Page 8 of 12

9 Appendix A - Equality Impact Assessment Yes/No Comments 1. Does the document/guidance affect one group less or more favourably than another on the basis of: Race No Ethnic origins (including gypsies and travellers) No Nationality No Gender (including gender reassignment) No Culture No Religion or belief No Sexual orientation No Age No Disability - learning disabilities, physical disability, sensory impairment and mental health problems No 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are there any valid exceptions, legal and/or justifiable? 4. Is the impact of the document/guidance likely to be negative? No N/A No 5. If so, can the impact be avoided? N/A 6. What alternative is there to achieving the document/guidance without the impact? 7. Can we reduce the impact by taking different action? N/A N/A Page 9 of 12

10 Appendix B Consultation Process with Key Stakeholders Stakeholder name and designation Date feedback requested Date feedback received Details of feedback received Action taken Sheena Kelly. Senior Infection Prevention and Control Nurse Gemma Fowler. Quality Manager Neill Spawforth. Head of Estates Vicki Jones Quality Manager Sheila Higgins. Safety and Property Management Officer Sheila Sorby. Quality Manager Should to must pg No response No response Needs a risk assessment template Happy with contents Inconsistent use of Locala company name No response Changed Will be added once received from Workplace Law Amended Jane Customer Manager Kennedy. Liaison No response Amanda Thomas. Communications Manager Tina Quinn. Deputy Chief Executive No response No suggested amendments Senior Team Management (JR only) Link to website 12.1 doesn t work Removed. Reference changed Page 10 of 12

11 Appendix C - Checklist for the Review and Ratification of Procedural Documents 1. Title Title of document being reviewed: Yes/No Comments Is the title clear and unambiguous? Is it clear whether the document is a guideline, policy or protocol? 2. Rationale Are reasons for development of the document stated? 3. Development Process Is the method described in brief? Are individuals involved in the development identified? Do you feel a reasonable attempt has been made to ensure relevant expertise has been used? Is there evidence of consultation with stakeholders and users? 4. Content Is the objective of the document clear? Is the target population clear and unambiguous? Are the intended outcomes described? Are the statements clear and unambiguous? 5. Evidence Base Is the type of evidence to support the document identified explicitly? Are key references cited? Are the references cited in full? Are local/organisational supporting documents referenced? 6. Ratification Page 11 of 12

12 Title of document being reviewed: Yes/No Comments Does the document identify which committee/group will ratify it? If appropriate, have the Staff Side committee been consulted about the document? 7. Dissemination and Implementation Is there an outline/plan to identify how this will be done? Does the plan include the necessary training/support to ensure compliance? 8. Document Control Does the document identify where it will be held? Have archiving arrangements for superseded documents been addressed? 9. Process for Monitoring Compliance Are there measurable standards or KPIs to support monitoring compliance of the document? Is there a plan to review or audit compliance with the document? 10. Review Date Is the review date identified? Is the frequency of review identified? If so, is it acceptable? 11. Overall Responsibility for the Document Is it clear who will be responsible for coordinating the dissemination, implementation and review of the documentation? 12. Policy Review Date Page 12 of 12