Health and Safety Executive Inspection Report

Transcription

1 Trust Board Public 5 August 2010 Agenda item: 3.5 Health and Safety Executive Inspection Report For: For information and acceptance. Summary: This is a summary of the findings and recommendations of the HSE Inspection visit June 2010 including the Improvement Notice served under Section 21, 22 and 23 Health and Safety at Work Act. Action: The Board is asked to: Accept the findings of the report and subsequent Improvement Notice Presented by: Author: Yvonne Parker (Acting Director of HR) Diane Mahoney (Environmental Safety Manager) Notes: Trust objective: Legal: Please list number and statement this paper relates to. Safe, High Quality Co-ordinated Care Better Information, More Choice Revitalising Our Environment What are the legal considerations and implications linked to this item? Please name relevant act Health and Safety at Work etc Act 1974 Regulation: What aspect of regulation applies and what are the outcome implications? This applies to any regulatory body key regulators include: Care Quality Commission, MHRA, NPSA & Audit Commission Management of Heath and Safety at work Regulations HSE Report Summary July 10.docPage 1 30/07/2010

2 Health and Safety Inspectors Visit June 2010 Director Briefing HSE Report HSG65 Summary of main issues Policy Health and Safety (H&S) Policy to be reviewed to include the setting of H&S performance targets for managers, development of H&S action plans and implementation of the risk register Monitoring arrangements for risk assessments to be added to H&S Policy Manual Handling (MH) Policy to be revised MH Policy to include Bariatric patients and Physiotherapy and Therapeutic handling No real evidence of MH risk assessments being undertaken following Trust Policy Implementation of HTM61 guidance by Estates as detailed in the Slips, Trips and Falls Policy Separate Work at Height Policy required. Risk Assessment policy to include how to populate the risk register Needlestick and Dermatitis policies to be reviewed to reconcile inconsistencies between them. Sharps Management and Exposure to BBV policies does not make reference to the need to undertake risk assessments at a local level Organising for Control health and safety Accountability for health and safety performance needs to be strengthened at all levels. This should be achieved through increased usage of health and safety performance targets/ objectives. Senior managers do not have specific/measureable H&S objectives and targets - just a broad link to the corporate objective of reducing avoidable harm Tools used by the Board to give an indication of H&S performance, including the risk register and Datix incident statistics, do not currently give a true reflection of the significant risks of each department. Health and safety objectives and performance targets should be applied to managers work plans to emphasise a proactive approach to health and safety. Health and safety objectives should be regarded as being of equal importance to other business aims i.e. number of empty beds, waiting times, sickness absence etc. Care should be taken to ensure that targets are Specific, Measurable, Achievable, Realistic and Time-bound (SMART) Degree of implementation of policies remains reliant on the commitment, understanding and application of HSE Report Summary July 10.docPage 2 30/07/2010

3 H&S Policy states that performance is measured against standards but there are no specified standards currently in place. Anecdotal evidence was given which indicated that the incident forms which populate Datix are not always completed as they are too lengthy and too complicated. Cooperation The Governance and Patient Safety Group is intended as a forum for H&S monitoring and consultation but the title suggests otherwise and the recommendation is to change the title to Governance and People Safety Group thus keeping the abbreviation the same (GAPS) There is a Trust H&S Committee which discusses and monitors reports from Directorate H&S Groups Not all Directorates hold a regular H&S Group meetings; this is left to the discretion of the departments manager There are no formal links between Occupational Health (OH), Environmental Safety and Manual Handling departments Communication Measures should be taken to make alternative arrangements for ensuring key health & safety messages are delivered to those members of staff without access to the Trust intranet or electronic mail Competence The lack of sufficient resources and personnel available to release the Trust s competent advisers (OH, H&S, MH) to undertake their strategic role and the subsequent effect on prioritising and planning what actions are needed to control risk is seen as a significant failing in the Trust s health and safety management system. This falls short of the minimum legal requirement of Regulation 7 of the Management of Health and Safety at Work Regulations As such, an Improvement Notice has been served requiring the Trust to address the above issues. The Trust should formally identify H&S training necessary for all roles, including refresher training Risk assessments and other information such as job descriptions, personal performance monitoring, accident investigations, etc to help determine required levels of training TNA to be undertaken to ensure that all job holders have completed the necessary training, within reasonable timeframes The Trust needs to ensure that training provision is consistent across all departments Where training is delivered as a risk control measure then it must be delivered HSE Report Summary July 10.docPage 3 30/07/2010

4 Planning and Implementing Where agency staff are in post there need to be checks in place to ensure that statutory training has been attended A robust system for confirming agency staff have received appropriate mandatory/statutory should be established immediately Suitable training needs to be completed by those identified as risk assessors Manual handling training for non-clinical and theatre staff should now be revised and consideration should be given to the tasks that they complete and aids available to them Training should be in an appropriate format, pitched accordingly given the level of training, knowledge and experience of the employee. Given in a form which takes account of language barriers and disabilities Mandatory IC, OH and Induction training includes information on hand hygiene, sharps etc. however there are deficiencies which reflect the failings in no risk assessments being carried out for sharps injuries, dermatitis, latex glove use and the requirement for health surveillance There was an issue raised relating to the training of aseptic non touch techniques resheathing. This is to be clarified back to the HSE by the Director of Nursing/IC Lead The H&S Policy states that ward/department managers are responsible for risk assessments and that General Managers are responsible for auditing them. Not all managers were clear on what this process entailed Many significant risks have not been captured during the assessment process. Assessments are also not being used to prioritise remedial actions to reduce or prevent risks There is confusion in some areas between risk assessment and the audit process H&S risks to staff, patients and visitors from ad hoc events such as refurbishment is poorly managed. On inspection no action had been taken to control noise levels created during construction works in Endoscopy Although some evidence of COSHH risk assessments are in place. No evidence was found that activity based risks such as dermatitis associated with wet work, frequent hand washing and glove use (latex) have been taken into account Use of latex gloves appear to be preference based rather than on assessment of the risk In Phlebotomy there is conflict between infection control/hand hygiene requirements and the risk of dermatitis which needs to be resolved In Domestics and Housekeeping, a number of cleaning/disinfection products are in use and risk assessments have been prepared. However, these are not task based and the control conclusions are either not sufficiently specific (e.g. glove material) or incorrect (e.g. glove use specified where there is minimal risk of skin contact) No current Trust-wide use of latex risk assessment There is no evidence that the ongoing issue with sharps injuries has not been entered onto the risk register There was little or no evidence that risk assessments had been undertaken for sharps/needlestick injuries The Trust should provide a corporate steer on conducting assessments for dermatitis, latex gloves and sharps HSE Report Summary July 10.docPage 4 30/07/2010

5 Measuring performance Auditing and Reviewing There needs to be a system implemented to ensure that all cases of work related dermatitis are properly reported under RIDDOR There are discrepancies in the number of sharps injuries reported via Datix and OH. There are a number of factors for this. Whilst discussions between staff and OH are confidential, it is imperative that information on work related injuries is relayed to managers for their actions. The good practice exemplified by the IC trials and implementation of safe technologies should be rolled out to other areas The Quality Dashboard does not currently have H&S issues incorporated Completing TNA and training attendance levels could be added The Trust should devise systems to improve both proactive and reactive monitoring of health and safety so that policies, procedures and risk assessments are implemented fully. The Trust must ensure that it has a reactive monitoring system to ensure that when accidents are investigated lessons are learned and applied across all premises. The Trust must ensure that information from proactive and reactive monitoring is used to update Trust health and safety plans to ensure that risks are minimised across the Trust. The current reliance on self auditing has resulted in variable quality of outcomes Matters of evident concern Mortuary A boot wash or step over transition should be installed to reduce the risk of cross contamination The supports to the sinks in the PM room are wooden which is unacceptable in a high risk area. Similarly the wooden desk in the body store is not advisable AMU Suitable fixed transitional flooring on entrance or other means of reducing the likely ingress of water or other contaminants on incoming footwear should now be adopted in this area Leigh/Abinger Newdigate The flooring in the toilet, sluice and kitchen areas should be replaced or the risk assessment reviewed to reflect the greater residual risk of slips on standard flooring within these areas. Consideration should be made as to any additional control measures required including revising cleaning regimes. Portering An appropriate system of planned preventative maintenance for the food trolleys, linen cages and other similar portering handling aids should now be arranged. If a spare trolley or cage were to be made available then repairs, servicing or replacement could be carried out on a rotational basis with minimal disruption The Trust should assess the consequence of transferring (or at least supplementing) the security role to the Portering department and ensure that sufficient resource is available to undertake both functions. Additionally, HSE Report Summary July 10.docPage 5 30/07/2010

6 Kitchen The risk assessment should be reviewed for the Pot Wash area - as the equipment is leaking more frequently due to increased usage and the floor has limited slip resistance - to ensure that it considers the evidence of the significance of the risk for example by measuring the slip resistance of the floor with a Surtronic Roughness Meter (Kenny) or Pendulum test. There needs to be a clear link between the reviewed assessment and the priority given by the Trust to take action to address this risk. Short term measures must be taken to reduce the risk from these slip risks. Consideration should be given to the need to amend cleaning regimes or provide appropriate footwear. A suitable and sufficient assessment of repetitive tasks should now be undertaken for loading and unloading of meal trays on the belt service. Due consideration should be made to the use of the HSE published guidance Assessment of Repetitive Tasks of the upper Limbs (the ART tool): Guidance for health & safety practitioners, consultants, ergonomists and large organisations. Medical Records There is only one toilet available for this whole department which is also utilised by staff from other departments. There is also no area available within the Medical Records Department for staff during their comfort breaks for the preparation of tea and coffee. They are currently using the single toilet facility to wash up their crockery. Suitable and sufficient rest facilities and sanitary conveniences should be made available in a readily accessible place for staff within the Medical Records Department. The movement of patient records should be considered as part of a suitable and sufficient manual handling assessment. Furthermore, the trolley used as a mechanical aid should now be included in a planned preventative maintenance scheme. Housekeeping The flooring outside the Domestics store, alongside Goods-in was lifting at the time of our inspection, posing a tripping risk. The damaged flooring outside the Domestics store should be repaired or replaced HSE Report Summary July 10.docPage 6 30/07/2010