Powys Teaching Health Board Annual Health and Safety Report

Transcription

1 Quality & Unit Sept 2013 Powys Teaching Board Annual Report Incorporating the End Review of the Strategic Action Plan Page 1 of 39

2 Quality & Unit Sept 2013 Contents Page 1. Introduction 3 2. Background Aim Strategic Action Plan 3 3. Key Areas of & Corporate Management of Statutory and Mandatory Training The Management of Violence and Aggression/ 7 Safe Lone Working 3.4 First Aid Control of Substances Hazardous to Estates Manual Handling Stress Identification and Management Audit and Review Conclusion References 18 Appendix 1: Corporate 20 Action Plan Page 2 of 39

3 Quality & Unit Sept Introduction. This report outlines the key improvements, challenges and opportunities in relation to health and safety within Powys Teaching Board (PTHB). In doing so it marks performance against the aims, objectives and targets documented within the Corporate Strategic Action Plan This report details not only the areas in which we are doing well but also those where we need to make improvements. It also outlines the work to be undertaken to improve the management of health, safety and welfare within the organisation. 2. Background 2.1 Aim The aim of Powys Teaching Board is to provide a safe and healthy environment for all employees, patients, visitors, contractors and other members of the public who have contact with the organisation. Executive guidance (HSE 2013) requires that organisations take a planned and systematic approach to achieving this by having an effective health and safety management system in place. 2.2 Strategic Action Plan As part of this system PTHB produces a detailed strategic health and safety action plan. The plan runs for two years and focuses on the key issues facing the organisation including, compliance with health and safety legislation. The plan also reflects the health and safety priorities of PTHB corporately, locally and nationally as part of NHS Wales. The action plan (Appendix 1) was developed as part of the & Intervention Strategy agreed by NHS Wales and the & Executive (HSE) in In March 2011 each Board had to submit Corporate Action Plans to HSE. The HSE then met with each Board to issue feedback on format, best practice etc before the plan was agreed by the PTHB Board in October The risk assessment process was used in conjunction with the key drivers noted below to identify the organisations health & safety priorities. As a working document the action plan has been reviewed and updated as actions have been completed. This report is a final review outlining the progress and effectiveness during the full course of the action plan ( ). Section 3 below evaluates each area in turn and notes key drivers, aims and achievements. The report also makes suggestions for the scope, format and content of future strategic health and safety action plans. Page 3 of 39

4 Quality & Unit Sept Key Areas of & 3.1 Corporate Management of (Action Area 1a- 1f) 3.11 Key Drivers The Management of at Work Regulations (MHSAW) 1999 require all organisations to have robust safety management systems in place. PTHB s Corporate Policy fully documents how this is to be achieved. Another key requirement of the regulations is for all organisations to assess health and safety risks to employees and to others. An understanding and application of risk assessments is a vital component of the risk management process What We Aimed to Do ( ) To develop a Corporate Strategy to complement the Risk Management Strategy in line with guidance from HSE. To review and update the Corporate Policy to reflect changes in legislation guidance and organisational structures. To ensure that the review of the Corporate Policy includes robust systems of monitoring and reporting. And that these are in place at local level to ensure identified risk, incidents and accidents are adequately managed. To introduce a robust system of monitoring and auditing at the corporate level to ensure the Strategy is effective. A detailed schedule of audits needed to be developed. To develop and reiterate the Corporate & Strategic Plan as a working document and update and review at regular intervals What We Achieved ( ) The organisation has developed an overarching Risk Management Strategy together with an implementation plan. The organisation s strategic health and safety aims and objectives are included within the Corporate Policy. The Corporate Policy has been reviewed, agreed by the Corporate Committee and was approved by the Risk Management Committee in December The policy also includes details of systems in place for monitoring and auditing at local and corporate levels. Page 4 of 39

5 Quality & Unit Sept 2013 The Corporate Strategic Action Plan has been regularly updated and presented at the Corporate Committee. Over the last 2 years one of the key developments to the strategic management of health and safety and risk management in general has been the formation of the Quality and Unit. The Unit, under the management of the Head of Quality and has continued to develop and mature. Originally, the Nursing had the directorial lead for the unit and some completed actions on the Strategic Action Plan reflect this. Following changes to the portfolios of the Executive Teams responsibilities, the Therapies and Sciences is now the lead for the Quality & Unit. This includes the role of Executive Lead for. The Quality and Unit has the following remit: Patient Patient Involvement and Experience including Redress, Claims and Litigation Standards for care Services Protection/ Infection Prevention and Control Risk Management Information Governance 3.14 What We Aim to do Next ( ) The next step is to develop the Strategic & Action Plan This will be informed by the priorities highlighted above and driven by the organisations risk management strategy. Recent Internal Audit of H&S also identified a number of areas for improvement. Recent discussions with HSE have centred on the next plan having a broader approach and not just focussing on key identified higher risk areas. The Unit will work with HSE to develop this approach. Another important part of the work the Quality & Unit will be undertaking going forward is around supporting managers at all levels within the organisation to manage risk and implement local monitoring and auditing. This is to develop and embed health and safety management as a core part of our day to day business. 3.2 Statutory and Mandatory Training (Action Area 2a- 2f) 3.21 Key Drivers Staff are required to attend training in health and safety to ensure they are knowledgeable about health and safety practices and procedures and are able to apply them in the workplace. PTHB s Corporate Policy outline responsibilities and duties of the employer and employee. Page 5 of 39

6 Quality & Unit Sept What We Aimed to Do ( ) Undertake a detailed review of the statutory and mandatory training needs of the organisation in order that the training programme reflects these training needs and the organisation meets its legal compliance. Realignment of budgets from different departments to come under the newly developed Quality and Unit. This will enable statutory and mandatory training budgets to sit with those responsible for organising and delivering the training in order to make best use of resources. Develop a resource plan that demonstrates effective use of current resources. The Statutory and Mandatory Training programme needed to be adequately resourced in order for the organisation to meet its legal requirements. Undertake a review of current resources required including, budget; staffing costs; bought in training; flexibility of current staff to deliver training programme; alternative ways of delivering training e.g. e-learning. Statutory and Mandatory Training programme needs to be developed that offers flexibility in delivery with the emphasis on supporting/ refreshing/ assessing competencies of staff in the workplace. Develop suitable programme that meets the needs of the organisation. Development of the programme must consider the administrative/technical support required in order for the on-line booking system. Work with Locality Teams/Department heads to ensure the development of robust systems for identifying their own staffs training needs and compliance What We Achieved ( ) Following a detailed review the Quality and Team, supported by subject experts, have developed comprehensive Core Modules for statutory and mandatory training. Delivery of these core modules began in April 2012 and initial written evaluation from participants and from managers was positive. The second phase of this review looked at the next shell around the core modules. This includes training at specific higher levels for each area of statutory and mandatory training. Key to this was the development of decision trees to assist managers in identifying the training requirements of their staff. Page 6 of 39

7 Quality & Unit Sept 2013 All training is now managed using the new OLM system which replaced the ATL system in April This is supported and managed by the Workforce and OD Team. Staff within the Quality and unit undertook additional training to enable them to deliver the full range of statutory and mandatory training required within the core modules. In addition, some staff members have also undertook additional training to support the next phase of the programme. In April 2013 the Head of the Quality & Unit began a restructuring of the unit. As part of the suggested restructure responsibility for the statutory and mandatory training programme will return to the Workforce and OD Directorate. The Assistant Director Workforce and OD is currently undertaking a training needs analysis across the organisation and future training will be aligned to the Skills4 UK Core Skills Training Framework, delivery of which will be primarily by e-learning What We Aim to do Next ( ) The Quality & Unit will continue to work closely with W&OD to ensure that the statutory and mandatory training programme meets the organisation s statutory obligations. Part of this programme should include training in the key principles of health and safety management/ risk management for managers at all levels within the organisation. This links in with work highlighted above to develop and embed health and safety management as a core part of our day to day business. Other important areas that have been identified by risk assessment as needing additional input include Fire Management and other estates compliance issues. 3.3 The Management of Violence and Aggression/Safe Lone Working (Action Area 3a- 3k) 3.31 Key Drivers The organisation has a legal duty to ensure all risks of violence and aggression within the workplace are adequately controlled. Previously, the All Wales NHS Ministerial Steering Group on the Management of Violence and Aggression set out the requirements of the Welsh Government and NHS Wales on how Boards manage these risks. Since this group completed its remit the focus has been to ensure that the principals of good management of violence and aggression are embedded within each health board and trust. All Wales guidance and best practice is also obtained from the All Wales NHS Advisory Group for the Management of Violence and Aggression which also produces the All Wales NHS Violence and Aggression Training Passport and Information Scheme. Page 7 of 39

8 Quality & Unit Sept 2013 The strategic health and safety action plan informed by the 2010 Executive inspection of the management of violence and aggression within PTHB. The resulting report and the guidance from the All Wales Groups have assisted the organisation to develop robust action plans and risk assessments What We Aimed to Do ( ) The primary aim was to ensure that the appropriate guidance and advice is given to all levels of the Board to ensure that violence and aggression is managed to all Wales standards consistently across the organisation. Review of all the relevant policies and guidance including the Management of Violence and Aggression Policy and the Lone Working Policy. Develop procedures to ensure that suitable health and safety management systems are in place in all organisations that we contract or commission services from. This would need to include: Agency Staff, Mental Services, Care Homes, Estates, G.P Practices and Information Technology Contractors. Development of the Case s role (as outlined by Welsh Government) as a core part of the s post. The key element of which is to support staff and liaise with outside agencies (Police, Crown Prosecution Service,) and to work with local managers to put in place safe systems of work that prevent reoccurrence and safeguard staff. Further develop the roles of the Quality and Advisors posts to ensure the continued delivery of high quality targeted Personal Training and support What We Achieved ( ) Achievements in this area include the following: Management of Violence and Aggression Policy and Lone Working Policy have been reviewed. Control of Contractors Policy is being developed. Case s role has developed as part of All Wales network. Types of incidents requiring case management are actively monitored by Quality and Unit. Quality and Advisors and & have undertaken General Services Association Instructor training in the management of violence and aggression. & and Page 8 of 39

9 Quality & Unit Sept 2013 one Quality and Advisor have also undertaken instructor training in breakaway skills. & and Quality and Unit Administration Support underwent Accredited Customer Representative training. This should have enabled effective support and monitoring of the lone working (Reliance Protect) system. However, Unit Administration Support has since left the unit and the Reliance Protect contract is coming to an end What We Aim to do Next ( ) As noted above, in April 2013 the Head of the Quality & Unit began a restructuring of the unit. Specific post to cover personal safety posts/ breakaway advice and training are no longer within the suggested restructured Q&S Unit. Further work is required to ensure compliance. This will be developed as part of next Strategic Plan. Facilitated by the Q&S Unit localities will need to lead on violence and aggression risk assessments as specific post to cover personal safety posts/ breakaway advice and training are no longer within the suggested restructured Q&S Unit. Further work is required and this will be developed as part of next Strategic Plan. Closer working with Primary Care to ensure that when PTHB plans and contracts services at GP Practice, Minor Injuries Units, it ensures that relevant staff have received suitable health and safety training and have the right competence to deal with the management of the risk of violence. Further work is required and this will be developed as part of next Strategic Plan. Closer monitoring and support for managers in relations to risk assessments for violence and aggression. As noted above this will form part of training in the key principles of health and safety management/ risk management for managers at all levels within the organisation. Further work is required and this will be developed as part of next Strategic Plan. The Reliance Protect lone working devices contract is coming to an end. A review of the efficacy of this system and other alternatives available is currently underway and will be developed further as part of next Strategic Plan. Page 9 of 39

10 Quality & Unit Sept First Aid (Action Area 4a- 4e) 3.41 Key Drivers The (First-Aid) Regulations 1981 as amended require employers to provide adequate and appropriate equipment, facilities and personnel to ensure their employees receive immediate attention if they are injured or taken ill at work. In the past the organisation has relied on a combination of the provision of Minor Injuries Units within our hospitals and staff trained on an approved HSE First Aid at Work Course to meet its legal requirements. Following the re-organisation of Minor Injury Services and a number of incidents involving staff it was highlighted that the provision needed to be reviewed. The actions below outline the work required to meet our legal compliance What We Aimed to Do To review provision of first aid to ensure compliance with the First Aid at Work Regulations by undertaking a detailed review of the current provision of First Aid within the organisation. To have a policy, a procedure and risk assessment guidance to demonstrate how compliance with First Aid at Work Regulations will be met. Develop suitable policy and accompanying procedures and guidelines to identify levels of compliance. Work with non-complaint areas on local action plans that will then achieve compliance. To be able to demonstrate a prioritised risk based approach to the provision of first aid. Risk assessments need to be undertaken by local managers to determine the level of first aid provision currently and whether this meets the identified needs. First aid training needs to meet the requirements of the organisation. Review the supplier contract with First Aid training to ensure most relevant and up to date course is available. To have sufficient numbers of suitably qualified or trained staff to meet the organisation s first aid needs. Identify staff currently able to provide first aid and to what level. Identify when they need updating. Identify, following risk assessment the numbers requiring training and arrange for those to be trained within 6 months What We Achieved ( ) Progress on this section of the action plan to date has been limited What We Aim to do Next ( ) Continue to work towards the completion of the actions highlighted above. This will be included as part of next Strategic Action Plan. Page 10 of 39

11 Quality & Unit Sept Control of Substances Hazardous to (COSHH) (Action Area 5a- 5d) 3.51 Key Drivers The Control of Substances Hazardous to Regulations 2002 (as amended) requires the Board to protect employees and others who may be exposed by applying eight basic steps of good management. These steps are set out in detail in the organisations COSHH policy and will ensure the organisation has a robust system for assessing risks, implementing any measures. COSHH had not previously formed a core part of the Corporate Action Plan. However, audit and inspections have revealed that the organisation needs to review its procedures to ensure full compliance with its policy and the regulations What We Aimed to Do ( ) PTHB needs to have a policy, procedure and risk assessment guidance to demonstrate how compliance with COSHH Regulations 2002 will be met. A review of current policy and procedure is required. A robust system (SYPOL RMS is currently used) should be in place and used to generate suitable and sufficient risk assessments from information submitted by managers in line with current policy. Review of SYPOL system is required to ensure suitability of current systems for managing the database and to assess its efficacy. Schedule of audits is required both on a local basis and corporately. Audit is required on a regular basis to ensure guidance within the COSHH risk assessments generated by the SYPOL has been implemented. All staff that potentially comes into contact with hazardous substances must have adequate training and instruction. A review of current Training provision to ensure COSHH training is included in the action plan What We Achieved ( ) Policy and procedures have been reviewed, agreed at CHSC and approved at Risk Management Committee. Further progress on this section of the action plan to date has been limited What We Aim to do Next ( ) Recent issues raised at Corporate H&S Committee around compliance and administration of the SYPOL system means that this now requires a detailed review. SYPOL is no longer accessible due to failure to Page 11 of 39

12 Quality & Unit Sept 2013 update subscription and changes made to procurement services provision. Continue to work towards the completion of the actions highlighted above. This will be included as part of next Strategic Action Plan. 3.6 Estates (Action Area 6a- 6i) 3.61 Key Drivers Before 2011 health and safety issues within the Estates and Works Departments had not formed a core part of the Strategic Action Plan. However, key areas for consideration include: the legal compliance around Fire, Asbestos, Legionella, Medical Gases etc. Although the lead role and function still rests with the Head of Estates and Property this is supported by the. External review and Internal Audit have also undertaken a number of reviews and audits on a range of health and safety issues within the Estates and Works Departments. Following the issue of improvement notices by HSE for the management of asbestos in 2011 and for the management of Legionella in 2012 a considerable amount of work was required to enable the organisation to comply with these notices What We Aimed to Do ( ) Develop a detailed action plan from the report produced following the audit of health and safety within the Estates and Works Departments undertaken by Internal Audit (Capital) Asbestos Management System need to be reviewed in light of Internal Investigation. Recommendations from an Internal Investigation Report need to be action planned and implemented. A policy and robust procedures need to be developed to ensure the organisation meets its legal requirements for Electrical. Safe systems of work to be developed and the implementation of a Permit to Work systems is required. Risk based Permit to Work Policy/System needs to be reviewed and developed for all high risk work activities. Development of detailed policy/ procedures for the management of water systems, including safe temperatures, hot surfaces to ensure the organisation meets its legal requirements for Safe Water Systems Estates/Works Training needs analysis needs to be undertaken and Estates/Works Training programme needs to be reviewed/ developed to ensure competencies and legal compliance What We Achieved ( ) Page 12 of 39

13 Quality & Unit Sept 2013 Significant amount of work has been undertaken to meet the HSE improvement notices outlined above. For asbestos this has included the development of the Management of Asbestos Policy and a detailed Asbestos Management Plan; resurveying of all the estate to identify asbestos containing materials; the training of Works, Estates and & staff to the required standard; the roll out of the MICAD asbestos management system. Full details can be found in the Asbestos Management Policy and Asbestos Management Plan. For Legionella and water management compliance a Water group was established to oversee the process; appropriate policies and management procedures were drawn up; detailed risk assessments have been completed and appropriate systems engineering fixes have been put in place. Action plan from Internal Audit report has been drawn up and actions are monitored by the Audit Committee. Work continues to improve the management of other key estates health & safety areas What We Aim to do Next ( ) Policies are under development for key estates areas including fire and electrical safety. These need to be consulted on, approved and issued. Estates and Property Department are in the process of appointing a Compliance to continue the work required to ensure compliance. A single estates compliance board is to be established under the chairmanship of the Interim Planning to accelerate the pace of change and management of risk in relation in Estates Compliance. This meeting will replace the current arrangements and groups for managing estates compliance. Further actions and strategic estates health & safety issues will be included as part of next Strategic Action Plan. 3.7 Manual Handling 3.71 Key Drivers The organisation has a legal duty under health and safety legislation particularly the Manual Handling Operations Regulations 1992 to ensure that all manual handling risks are adequately controlled. All Wales guidance and best practice is obtained from the All Wales NHS Manual Handling Group which also produces the All Wales Manual Handling Training, Passport and Information Scheme. Powys staff continue to play an important part within this group with the Senior Quality and Advisor taking a lead role in the development of the All Wales Treatment Handling Guidelines for Therapy Staff. Page 13 of 39

14 Quality & Unit Sept 2013 Other key drivers include response to manual handling incidents recorded on Datix and responses to alert notices issued by the Medicines and care products Regulatory Agency (MHRA). Following the amalgamation of the Manual Handling Team into the Quality and Unit, staff roles were broadened out to include all aspects of Quality and, although some degree of speciality remained What We Aimed to Do ( ) The organisation s primary aim during this period was to continue to meet its legal obligations. This was achieved not only by following the All Wales guidance but also in active participation in their development. Some of the key aims are noted below: All areas to complete any generic manual handling assessments needed. Any high risk manual handling activity identified to have full manual handling risk assessment. Review of current Display Screen Equipment (DSE) Policy and how DSE assessments are completed and acted upon. Develop and deliver a course for standard DSE assessments for line managers. This could be part of the for Line s course. Develop an accurate database for medical devices including hoists and slings. This was taken forward by the Senior Quality and Advisor as part of the new job role within the Quality and Unit What We Achieved ( ) Considerable work has been undertaken to transfer and data cleanse the previous information on medical devices and develop an accurate database. This now forms part of the Datix Risk Management System and has trained local in-putters to facilitate this within the localities. Majority of items are now entered onto Datix. Quality checking needs to be undertaken. X ray equipment and capital items still need to be entered on to the system What We Aim to do Next ( ) To ensure business continuity in the delivery of high quality manual handling management and training during and after the restructure of the Quality and Unit maintaining compliance with the All Wales Manual Handling Training, Passport and Information Scheme. Localities, directorates and central departments are currently identifying, prioritising and developing risk registers for all risk within their areas. These are being monitored by the Risk Management Committee and should enable generic manual handling assessments to Page 14 of 39

15 Quality & Unit Sept 2013 be completed. Any high risk manual handling activity identified will then require a full manual handling risk assessment. 3.8 Stress Identification and Management (Action Area 8a- 8d) 3.81 Key Drivers The management of stress within the workplace is a key component of the Wellbeing at Work agenda and forms part of the Corporate Standard assessment process. The HSE s Management Standards for Workplace Stress also give clear guidance on management, risk assessment and training etc. Stress identification and management have not previously formed a core part of the Corporate Action Plan. However, a considerable amount of work has been done in this area What We Aimed to Do ( ) To improve stress management awareness for managers. To facilitate stress risk assessments for all areas. Review of Wellbeing in the Workplace Policy to reflect organisational changes Roll out Stress Management Training for all levels of staff. Incorporating Mental First Aid training and Emotional Wellbeing Training 3.83 What We Achieved ( ) Stress Management Toolkit for managers has been developed as part of Corporate Standard Gold Award. This includes a range of tools for managers to assess their own competency and knowledge of stress management; a training package; risk assessment tools etc Gold Award achieved for Corporate Standard. Review and approval of the Wellbeing in the Workplace Policy. Stress Management and Awareness was a core component of the Work Roadshows that visited all Powys hospital sites during the summer months during 2012 & Mental First Aid Training and Emotional Wellbeing Training have been rolled out as part of the training programme. Page 15 of 39

16 Quality & Unit Sept What We Aim to do Next ( ) Review the Stress Management Toolkit, evaluate and improve and include training on this within the health & safety training programme for managers. Re-launch the toolkit with the approach being targeted at the localities and directorates. 3.9 Audit/ Monitoring 3.91 Key Drivers Having an effective system of audit and review is an important component of any health and safety management system. HSE in its guidance Successful Management HSG 65 notes that organisations need to learn from all experiences and apply the lessons. There needs to be...a systematic review of performance based on data from monitoring and from independent audits of the whole health and safety management system. (HSE 1997) What We Aimed to Do ( ) The organisation s main aim was to continue to develop effective monitoring and auditing of compliance with health and safety legislation (including an assessment of management performance in appraisal and document in annual health and safety report) What We Achieved ( ) Achievements in this area include: Continuing to work in partnership with trade union members of the Corporate Committee (CHSC) to develop and improve the proforma for health and safety inspections together with accompanying guidance for inspectors and managers. Unison members of the CHSC undertook a detailed audit schedule for all areas. Reports are fed back to the CHSC via local management and the. Detailed monitoring and audits have been carried out in certain high risk areas including ligature points, manual handling, violence and aggression and lone working. Other areas including Control of Substances Hazardous to (COSHH) still need to be developed. Linking the audits into the appraisal process has been more difficult and further action is documented below to address this What We Aim to do Next ( ) The following key actions have been identified: Recent Internal Audit of H&S identified that a formal audit plan should be developed to ensure procedures are being adhered to by each Page 16 of 39

17 Quality & Unit Sept 2013 locality within the Board. This will be developed as part of next Strategic Plan. Responsibility for monitoring currently being undertaken by Q&S Advisors needs to be clarified within the new structure of the Quality & Unit and transfer of some staff to the W&OD Team The formal audit plan should focus on developing regular performance reporting against the following key areas, identifying trends in performance, analysing performance and identifying the action being taken to improve under-performance: o risk assessment o estates health and safety issues o asbestos management o violence and aggression o stress management o first aid at work o manual handling o other specific issues Continue to work closely with Trade Unions/Professional Bodies in their capacity as Representatives. Maintain a spreadsheet of all inspections and keep track of actions outstanding. Work with Locality/Service Leads to ensure outstanding actions are remedied quickly or an adequate explanation given for non-compliance, escalating to the Head of Quality and and then Executive Lead for where continued nonperformance becomes an issue. Provide a summary to the Corporate Committee. 4. Conclusion The report above highlights the good work that continues throughout the organisation both locally and corporately. The Quality and Unit along with the Corporate Committee will play an increasingly important part in assisting, monitoring and advising managers and staff on health and safety related issues at all levels within the organisation. The next step is to develop the Strategic & Action Plan This will be informed by the priorities highlighted above and driven by the organisations risk management strategy. As noted above, discussions with HSE have identified that next plan should have a broader approach and not, as previously, be so focussed on key identified higher risk areas. The Q&S Unit will work with HSE to ensure this occurs. The main challenges over the next two years: (i) supporting managers at all levels within the organisation to manage risk and implement local monitoring and auditing. This is to develop and embed health and safety management as a core part of our day to day business. (ii) ensuring legal compliance particularly around Estates issues. Page 17 of 39

18 Quality & Unit Sept References H.M. Government: Statutory Instrument (2002) Control of Substances Hazardous to. The Control of Substances Hazardous to Regulations 2002 as amended, H.M. Stationary Office, London. Accessed at: H.M. Government: UK Public General Acts (1974) at Work etc Act 1974 H.M. Stationary Office, London. Accessed at: H.M. Government: Statutory Instrument (1999) The Management of at Work Regulations 1999 (SI 1999 No: 3242) H.M. Stationary Office, London. Accessed at: H.M. Government: Statutory Instrument (1992) The Manual Handling Operations Regulations 1992 as amended (SI 1992 No:2793) H.M. Stationary Office, London. Accessed at: H.M. Government: Statutory Instrument (1981) The (First Aid) Regulations 1981 as amended (SI 1981 No:917) H.M. Stationary Office, London. Accessed at: Executive, 1997: HSG65 Successful Management HSE Books, Norwich, England. Accessed by free PDF Download at: Powys Teaching Board (2011): The Corporate Policy PTHB, Bronllys, Wales. Powys Teaching Board (2011): The Control of Substances Hazardous to Policy and Procedure PTHB, Bronllys, Wales. Powys Teaching Board (2011): Manual Handling Policy PTHB, Bronllys, Wales. Welsh Assembly Government (2005): All Wales NHS Violence and Aggression Training Passport and Information Scheme. WAG, Cardiff, Wales. Page 18 of 39

19 Quality & Unit Sept 2013 Accessed at: Welsh Assembly Government (2003): All Wales NHS Manual Handling Training, Passport and Information Scheme. WAG, Cardiff, Wales. Accessed at: pdf Page 19 of 39

20 Quality & Unit Sept 2013 Appendix 1: Corporate Action Plan ( : Strategic Plan) Version 6- Final Page 20 of 39

21 : Strategic Plan V6 Final Quality & Unit Sept 2013 Ref Intended Outcome Action Executive Lead Corporate Management of ial Lead Timescale Final Status and Forward Action S HCS link 1a PTHB needs to have a Corporate Strategy. Develop strategy to complement Risk Management Strategy in line with guidance from HSE Science Nov 2012 Strategic Aims and Objectives are included within CHS Policy. Need to review in light of new Risk Management Strategy and Implementation Plan. 1, 7 & 22 Action: Development of H&S Strategy to be considered as part of next Strategic Plan. 1b Corporate Policy needs to be reviewed and updated to reflect changes in legislation, guidance and organisational structures. This will also include references to Standards for Services in Wales (Standard 22) Review of current policy. Nurse Director (Responsible Director at Time of Completion) Aug 2011 Completed Approved Risk Management Committee Dec 2011 Action: Closed 1, 7 & 22 1c Corporate Intervention Plan needs to be developed and submitted to HSE Corporate Intervention Plan needs to be developed that follows the guidance given by HSE. Nurse Director (Responsible Director at Time of Completion) March 2011 Completed Action: Closed 22 Page 21 of 39

22 : Strategic Plan V6 Final Quality & Unit Sept d Robust systems of monitoring and reporting need to be in place at local level to ensure identified risk; incidents and accidents are adequately managed. Review of Corporate Policy includes systems for reporting and monitoring Nurse Director (Responsible Director at Time of Completion Corporate Advisor Aug 2011 Completed Action: Closed 22, 23 1e Robust systems of monitoring and auditing needed on a corporate level to ensure the strategy is effective. Detailed schedule of audits required. Nurse Director (Responsible Director at Time of Completion) Sept 2011 Documented in CHS Policy. Action: Recent Internal Audit of H&S identified that a formal audit plan should be developed to ensure procedures are being adhered to by each locality within the Board. This will be developed as part of next Strategic Plan. 1, 22 1f (IA) An annual report should be produced and sent to the Board as required by the Corporate Policy. Develop an Annual report. Nurse Director (Responsible Director at Time of Completion) May 2011 Completed Action: Closed 1, 22 Page 22 of 39

23 : Strategic Plan V6 Final Quality & Unit Sept 2013 Statutory and Mandatory Training 2a The Statutory and Mandatory training programme should reflect the training needs of the organisation in order to meet its legal compliance. Undertake a detailed review of the statutory and mandatory training needs of the organisation. Science Senior Quality & Advisor/ Sept 2012 Responsibility for The Statutory and Mandatory training programme transferred to W&OD as part of restructuring process. Assistant Dir W&OD undertaking detailed training needs analysis. Action: Ensure this is monitored by Corporate & Committee and developed further as part of next and Strategic Plan. 22, 26 2b 2c Management of statutory and mandatory training budgets need to sit with those responsible for organising and delivering the training in order to make best use of resources. The Statutory and Mandatory Training programme needs to be adequately resourced in order for the organisation to meet its legal requirements. Realign budgets from different departments to come under the newly developed Quality and Unit. Develop a resource plan that demonstrates effective use of current resources. Review of current resources required including, budget; staffing costs; bought in training; flexibility of current staff to deliver training programme; alternative ways of delivering training e.g. e learning Science Nurse Director (Responsible Director at Time of Completion) Senior Quality & Advisor/ Senior Quality & Advisor/ Oct 2012 June 2011 Completed Responsibility for The Statutory and Mandatory training programme including budget was transferred to W&OD as part of restructuring process. Action: Closed Completed Responsibility for The Statutory and Mandatory training programme including budget was transferred to W&OD as part of restructuring process. Action: Closed 22, 26 22, 26 2d Statutory and Mandatory Training programme needs to be developed that offers flexibility Develop suitable programme that meets the needs of the organisation. Nurse Director (Responsible Senior Quality & Sept 2011 Completed Action: Closed 22, 26 Page 23 of 39

24 : Strategic Plan V6 Final Quality & Unit Sept 2013 in delivery with the emphasis on supporting/ refreshing/ assessing competencies of staff in the workplace. Director at Time of Completion) Advisor/ 2e Development of the programme must consider the administrative/technical support required in order for the on line booking system to function and also for the room booking/ external trainer liaison etc Linked to action 2a, ensure the booking and monitoring of training is adequately administered with identified roles and responsibilities for doing so. Nurse Director (Responsible Director at Time of Completion) Senior Quality & Advisor/ Sept 2011 Completed Action: Closed 22, 26 2f (IA) The Training Administrator should identify and inform all members of staff who are overdue renewing their mandatory training requirements on a regular basis determined by the Board and ensure that this is completed as a priority. Identify who within the Quality and team will have responsibility for checking the compliance of mandatory training; and work with Locality Teams/Department heads to ensure they develop robust systems for identifying their own staffs training needs and compliance. Science Senior Quality & Advisor/ with Locality/ Directorate s Oct 2012 Responsibility for The Statutory and Mandatory training programme transferred to W&OD as part of restructuring process. Action: Ensure this is monitored by Corporate & Committee and developed further as part of next and Strategic Plan. 22, 26 Page 24 of 39

25 : Strategic Plan V6 Final Quality & Unit Sept 2013 Violence and Aggression 3a 3b PTHB should ensure that it has sufficient resources to fulfil the management functions outlined in the Corporate Policy; Lone Working Policy and Procedures and the Policy for Protecting Employees for Violence and Aggression. The Corporate Action Plan and the Violence and Aggression Action Plan needs to be updated and reviewed Review of health and safety polices need to reflect changes in organisational structure. These include: (i) the move from a directorate structure to a locality based structure; (ii) the proposed merger between PTHB and Powys County Council; (iii) The formation of the new PTHB Quality and Unit. Resource implications need to be identified to reflect these changes to ensure sufficient resources are available. Corporate Action Plan needs to be updated, signed off and outstanding actions transferred to CHSAP for Science Nurse Director (Responsible Director at Time of Completion) Oct 2012 March 2011 Resourcing of the management function of health & safety is now managed at the operational locality /directorate level. Action: Ensure this is monitored by Quality & Unit and reported through the Corporate & Committee as part of formal audit plan. This needs to be and developed further as part of next and Strategic Plan. Completed Action: Closed Page 25 of 39

26 : Strategic Plan V6 Final Quality & Unit Sept c PTHB should develop a policy to ensure that it has suitable health and safety management systems in place to manage, control, monitor and review those that we contract or commission services from. Broad management responsibilities to be documented within reviewed Corporate Policy. New policy for the control of all contractors to be developed (see below). Procedures need to be developed to ensure that suitable health and safety management systems are in place to manage, control, monitor and review all organisations that we contract or commission services from. This would need to include: Agency Staff, Mental Services as well as Estates, and Information Technology Contractors. Science March 2013 Draft Control of Contractors Policy for Estates but this does not cover the broader issues of non estates contractors. Action: Further work required. This will be developed as part of next Strategic Plan. 22 Management of External Contractors Policy to be reviewed and revised. Page 26 of 39

27 : Strategic Plan V6 Final Quality & Unit Sept d PTHB should ensure that there are suitable management arrangements in place to review and update the existing violence and aggression risk assessments at the three Minor Injuries Units Annual Review of Risk assessments as minimum; plus following specific incidents to take place. Existing policy to be reviewed and revised as necessary. Personal Team to work with Minor injuries leads to review and develop risk assessments using All Wales format. Science Dec 2012 Policy for Protecting Employees from Violence and Aggression updated and reviewed Oct Action: Localities will need to lead on risk assessment in MIU s as specific Personal posts are no longer within restructured Q&S. Further work required. This will be developed as part of next Strategic Plan. 22 3e PTHB should review its approach to contracting of the Minor Injuries Units at GP Practices and identify how incidents of violence and aggression are recorded and managed. PTHB needs to be satisfied that GP practices providing Minor Injuries Services have robust systems in place for recording and investigating incidents of violence and aggression. Practices have access to PTHB Datix incident reporting system and this could be utilised to report incidents. At present practices are only contracted to provide details of a limited number of incidents per year. Science with Senior Primary Care Dec 2012 Action: Further work required. This will be developed as part of next Strategic Plan. 22 Page 27 of 39

28 : Strategic Plan V6 Final Quality & Unit Sept f PTHB should review arrangements for securing adequate communication within the Board including a review and update of the Corporate Action Plan and the V and A Action plan Review of health and safety polices need to reflect changes in organisational structure and how health and safety information is communicated through the organisation. These include: (i) the move from a directorate structure to a locality based structure; (ii) The formation of the new PTHB Quality and Unit Science Oct 2012 Communications Officer now appointed. Action: Recent Internal Audit of H&S identified timely policy updating as an issue. A timetable for the systematic ongoing review of all nineteen policies within the remit of H&S will be developed and submitted to the Corporate & Committee in November to approve and monitor. 22 3g PTHB should review the training needs of ALL relevant staff (including medical staff) for violence and aggression, risk assessment and incident investigation to ensure that individuals have the right competence to deal with the management of violence and aggression. Review of Statutory and Mandatory Training for training for violence and aggression. Root cause analysis training to be undertaken delivered by National Patient Agency. Risk assessment training to be delivered to a targeted audience in line with new Risk Management Strategy implementation plan. Science / Senior Quality & Advisor Sept 2012 Responsibility for The Statutory and Mandatory training programme transferred to W&OD as part of restructuring process. Assistant Dir W&OD undertaking detailed training needs analysis. Action: Ensure this is monitored by Corporate & Committee and developed further as part of next and Strategic Plan. 22, 26 3h PTHB should ensure that there is adequate resource available to Review of Statutory and Mandatory Training Nurse Director Oct 2011 Complete as above 2a 22, 26 Page 28 of 39

29 : Strategic Plan V6 Final Quality & Unit Sept 2013 ensure training can be provided. (Responsible Director at Time of Completion) /Se nior Quality & Advisor 3i When PTHB plans and contracts services at GP Practices Minor Injuries Units, it should ensure that relevant staff have received suitable health and safety training and have the right competence to deal with the management of the risk of violence. Revised policy on Management of Contractors will include a section on violence and aggression, including training. Awareness raising will take place in Primary care to encourage access to PtHB provided courses. Medical Director with Senior Primary Care Dec 2012 Draft Control of Contractors Policy for Estates but this does not cover the broader issues of non estates contractors. Primary Care liaison yet to be developed Action: Further work required. This will be developed as part of next Strategic Plan. 22, 26 3j PTHB should put in place effective monitoring procedures. The organisation should also ensure that it has adequate resource to fulfil this important function. The Quality and Team will determine its monitoring arrangements in line with discussion with Welsh Assembly Government, Localities and Directorates, local Staff Side and the Executive team/ Board. Science March 2013 Action: Recent Internal Audit of H&S identified that a formal audit plan should be developed to ensure procedures are being adhered to by each locality within the Board. This will be developed as part of next Strategic Plan. Responsibility for monitoring currently being undertaken by Q&S Advisors needs to be clarified within the new structure of the Quality & Unit and transfer of some staff to the W&OD Team 22 Page 29 of 39

30 : Strategic Plan V6 Final Quality & Unit Sept k The Ministerial Taskforce Action Plan should be completed and closed as soon as all actions are complete. Ongoing actions should be included within annual/bi annual Work Programme Review all actions to ensure they can each be evidenced. Add into this plan any outstanding actions that cannot be satisfactorily evidenced. Sciences Sept 2012 Completed 1, 22 First Aid 4a PTHB needs to review its provision of first aid to ensure compliance with the First Aid at Work Regulations. Undertake detailed review of the current provision of First Aid within the organisation. Science March 2013 Action: Further work required. This will be developed as part of next Strategic Plan. 22 4b 4c PTHB needs to have a policy, procedure and risk assessment guidance to demonstrate how compliance with First Aid at Work Regulations will be met The organisation needs to be able to demonstrate a prioritised risk based approach to the provision of first aid. Develop suitable policy and accompanying procedures and guidelines to identify levels of compliance. Work with non complaint areas on local action plans that will then achieve compliance. Risk assessments need to be undertaken by local managers to determine the level of first aid provision currently and whether this meets the identified needs. Science Science Oct 2012 March 2013 Action: Further work required. This will be developed as part of next Strategic Plan. Action: Further work required. This will be developed as part of next Strategic Plan d First aid training needs to meet the requirements of the organisation. Review the supplier contract with First Aid training to ensure most relevant and up to date Senior Quality & March 2013 Action: Further work required. This will be developed as part of next 22, 26 Page 30 of 39