Health and Safety Strategy

Transcription

1 Health and Safety Strategy July 2009 GOV 30 DATE: 29 July 2009

2 Document Management Title of document Health and Safety Strategy Type of document Strategy GOV 30 Description Target audience Author Department Directorate Approved by To define the Health and Safety Strategy of Northamptonshire Teaching Primary Care Trust Board and the required actions to ensure that a robust Health and Safety Management System operates across all areas of the Trust; addressing all Corporate Objectives. All staff Risk Management Team Risk Management Team Provider Services Governance Committee Date of approval 6 July 2009 Version Number 1 Next review date July 2010 Related documents Superseded documents Associated suite of Health & Safety Policy s Draft V 4.0 Internal distribution External distribution Availability Yes Yes All ratified policies, strategies, procedures and protocols are published on the Trust Intranet and Public Website Contact details (of main contact for this document) Name: Associate Director of Governance Address: Bevan House (Provider Services HQ) Kettering Parkway South, Venture Park, Kettering NN15 6XR Telephone: Fax: tbn@northants.nhs.uk GOV 30 Health and Safety Strategy 3GOV 30 Health and Safety Strategy 3 Page of 24 2

3 CONTENTS Page No Foreword... 4 An Introduction to Our Strategy... 5 Levels of Risk Management within the Trust... 6 Our Aims... 7 Health and Safety Aim... 7 Aim of this Strategy... 7 Our Objectives... 7 Objective To establish and implement a robust Health and Safety management system... 8 Objective Assurance that the Trust is operating to current legislative standards... 8 Objective To Develop and maintain an appropriate safety training strategy and system... 9 Objective Ensure that Consultation and communication strategy exists within the Trust... 9 Objective To develop, implement and maintain a Contractor Selection and Management Strategy Monitoring and Reporting structure Appendix 1 - Health and Safety Policy Statement Appendix 2 Key Features of the current (2009)Trust s Management System Appendix 3 - Trust Health and Safety Responsibilities Appendix 4 - Trust Health and Safety Annual Plan Appendix 5 - Equality Impact Assessment GOV 30 Health and Safety Strategy 3GOV 30 Health and Safety Strategy 3 Page of 24 3

4 Foreword NHS Northamptonshire (hereafter referred to as the Trust ) and its Board recognises that practical health and safety management is a core activity within the organisation. It is intended that this Health and Safety Strategy outlines our vision to achieve a successful record of workplace health and safety performance. This Health and Safety Strategy is the starting point that determines our plans to achieve our Health and Safety targets and goals. It outlines our principles and requirements for an effective health and safety management system and identifies the ways in which we will address these systematically through our health and safety framework. Our aim is to clearly establish, monitor and measure improvements in our health and safety practice and performance over the next 5 years. It is our intention that the Trust becomes an increasingly safer and healthier place to work and to receive care. The Trust Board recognises that successful health and safety management is an integral part of its effective business management. We recognise that to many people, health and safety can be seen as a hindrance and not as an enabler, we do not subscribe to that ideology. It is our intention to promote improved health and safety practice and make and ensure we achieve it. Having delivered on this strategy, we anticipate that effective safety management will shape the way we work and change the way we operate at present. This Health and Safety Strategy clearly sets out the ways in which the Trust is prepared to change to secure improved health and safety practice and performance. It is about doing things differently, safer and this document outlines the ways in which our health and safety systems will be strengthened, determining plans for improvement against practical targets. Through a clear structure of responsibility and accountability the Board, Executive Directors and Senior Management team will take a lead role. However, all staff have a key role if we are to deliver on our Health and Safety Strategy. Health and Safety practice is the responsibility of all of our staff and contractors and we look to them for assistance to secure it. The Trust Health & Safety Policy and associated documents support this Strategy, the policy itself describes in more detail the organisation, structure and arrangements of our Health and Safety management systems. This Strategy document has been based upon past activities, current management and future plans details of which are also recorded in our Annual Health and safety report. A signed Health and Safety Policy Statement is attached at Appendix 1. Together we can move forward to achieve good health and safety performance, help us to help you. Chief Executive GOV 30 Health and Safety Strategy 3GOV 30 Health and Safety Strategy 3 Page of 24 4

5 An Introduction to Our Strategy This Health and Safety Strategy is built upon the concept of practical and sensible Health and Safety practice. Being risk aware, not risk averse is built into the Trust s whole approach to managing risk in all aspects of its service provision. Practical and sensible Health and Safety awareness is the key to ensure that managers and staff alike can deliver on their service priorities whilst ensuring the risks associated with their work are managed in a sensible, proportionate and legal manner. This strategy has been endorsed by NHS Northamptonshire through its Governance Committee and Board, it supports the implementation of the Corporate Health and Safety Policy across both the Commissioning and Provider Arms. It provides the direction for improvement of health and safety performance across all areas of Trust activities. Our Trust Health and Safety Annual (Improvement) Plan (Appendix 4) is based on the aim and objectives described within this strategy and Directorates, Departments and where appropriate Wards all of whom have a contribution to make in achieving this Strategy. This Strategy supports the Trusts goal of being the best primary care trust in the East Midlands. We plan to work with our partners in a climate of excellence to protect and deliver health, wellbeing and equality of opportunity. To achieve this we need to be able to deliver on health and safety, keeping people safe at work, patients and all those who visit our properties. Our Health and Safety Management system utilises as it s basis the guidance published by the Health and Safety Executive, in 'Successful Health and Safety Management '(HSG65). GOV 30 Health and Safety Strategy 3GOV 30 Health and Safety Strategy 3 Page of 24 5

6 Levels of Risk Management within the Trust To ensure that our Health and Safety Strategy provides focus at strategic level we must first identify the three levels of risk management approach that the Trust considers will assist in the development of an overall strategy (see also Appendix 2). Strategic (Policy makers) This level of health and safety management is conducted by the Trust Board and its corporate risk management team. To demonstrate their commitment they establish the Trust policy, set priorities, provide resources, demonstrate and promote a positive health and safety culture and monitor the effectiveness of the corporate strategy. They will also specify the structure of the Trust to ensure it can plan, measure, review and audit the management system. This will be updated as changes within the organisation take place. Systematic (Planners) Systematic health and safety management is carried out by Directorates and Departments supported by competent Health and Safety advisors to undertake risk assessments, prepare and implement local policies, procedures (systems of work) undertake safety inspections, provide health and safety training. They also provide appropriate levels of supervision and provide information to the Risk Group to assist strategic level decision makers to formulate and where appropriate review policies etc. The key role at this level is to plan effectively, to establish risk control systems, workplace precautions and performance standards. Co-ordination from both external advice and consultation with employees and safety representatives also sits at this level. Operational (Implementers) This level of health and safety management is conducted by the line managers and those undertaking and activities as part of their operational job role. Each part of the team must implement the management arrangements and provide feedback. This level of commitment requires that each person undertakes their tasks following; the training provided to them, by following established systems of work, reporting hazards and accident/incidents and embraces the overall health and safety culture within the Trust. GOV 30 Health and Safety Strategy 3GOV 30 Health and Safety Strategy 3 Page of 24 6

7 Our Aims The overall Aims and Objectives for the Trust will be established at Strategic level which when implemented effectively will ensure that both the Systems management and operational management of health and safety will support them. Health and Safety Aim To secure the health, safety and wellbeing of our work force, patients utilising our services, those who come onto our premises or who could be affected by our activities, services and premises. By health and safety we mean to include fire prevention and fire safety precautions. Aim of this Strategy Deliver improvements to enable the Trust to manage occupational health and safety risk effectively and produce a performance management framework. Such a framework will enable the Trust to demonstrate improvements made in the management of health and safety and the contribution that it brings to the overall handling of risk and that of achieving of goals and targets. Our Objectives Based upon the Aims identified above, a series of enabling objectives need to be established. Whilst those indicated in the following paragraphs outline the current objectives the Trust is committed to reviewing the objectives outlined in this strategy on a regular annual basis or on occasions that require a review of its strategic objectives. Such occasions may be as following significant changes to the management structure, in the light of lessons learnt from accidents and incidents, following independent external audits or any other similar occasion. It is recognised that as the Trust moves toward separation in line with National Policy (for PCT s) it will become crucial to maintain clear Health & Safety arrangements. Until such time as the organisation does become separate legal entities, a single system for managing Health and Safety will be maintained. (See appendix 2 for key features of the management system). Following the separation this strategy and it s Aims and Objectives will be reviewed in the light of that change. GOV 30 Health and Safety Strategy 3GOV 30 Health and Safety Strategy 3 Page of 24 7

8 Objective 1 To establish and implement a robust Health and Safety management system across all areas, which will improve the practice and standards of health and safety management within the Trust. Performance and progress against this objective will be measured by : Health and Safety management structures will be subject to review annually against authoritative guidance published by the Health and Safety Executive (HSG 65) Key performance measures for the whole of the Trust, individual directorates and departments will be agreed and published annually within; o Directorate/Departmental action plans (1 March each year) o Corporate action plans (1 April each year) In order to promote an effective health and safety culture amongst all staff the Trust s Individual Performance Review process will include consideration of health and safety performance (at least annually) The Trust s activities and premises will be subject to annual inspections and reviews undertaken jointly by managers and workplace safety representatives. Directorates and departments will establish departmental performance monitoring arrangements for health safety and welfare matters during 2009/10 Corporately, the Trust s Management Team will establish arrangements for monitoring corporate performance at Director level during 2009/10 At Executive Management level, the Governance/Integrated Governance Committee will monitor corporate health and safety management performance on a quarterly basis from June 2009 A Trust Health and Safety Annual Report and Plan will be published reporting by 30 June each year on health safety and welfare performance during the previous financial year. Objective 2 Assurance that the Trust is operating to current legislative standards (minimum), Department of Health regulatory requirements and industry best practice. Performance and progress against this objective will be measured by: A Benchmark review will be undertaken by the Risk Group to be completed by the end June 2009 and a report of the findings produced together with any appropriate Action Plan, for the Governance committee meeting July Such a review will specifically but not exclusively include; o Current Trust Policies, Procedures and Guidance Notes GOV 30 Health and Safety Strategy 3GOV 30 Health and Safety Strategy 3 Page of 24 8

9 o Knowledge of staff, contractors and other of the Trust Policies, Procedures and Guidance Notes Quarterly reviews by the Risk Group will be undertaken and a report produced, together with any appropriate Action Plan at the end of each quarter, for the Governance committee meeting closest to each quarter. A summative annual report of the performance and progress of achievement will be included within the Trust Health and Safety Annual Report and Plan Objective 3 To Develop and maintain an appropriate safety training strategy and system to ensure appropriate levels of staff competency, in order that they can work safely and efficiently, minimising the risks to themselves and to others. Performance and progress against this objective will be measured by: A Trust wide training needs analysis (TNA) will be completed by the end June 2009 by the Trust Health and Safety Advisors and a report of the findings produced, together with any appropriate Action Plan, for the Governance committee meeting July Based upon the TNA above, an initial audit will be undertaken by the Risk Group to; ascertain the types of training programmes delivered, mechanisms of confirmation of knowledge and skills acquired. Findings of the Audit will be presented to the Governance committee meeting August Training programme delivery and quality performance targets will be established, based upon the TNA and training audit, by the Health and safety Sub-group. Quarterly reviews of performance with appropriate plans will be produced and presented to the Governance committee meeting at the end of each Quarter. Directorates and departments will establish their own training performance monitoring arrangements for training programmes delivered to their staff during 2009/10 Objective 4 Ensure that Consultation and communication strategy exists within the Trust that allows the effective flow of information, into, within and out of the trust and that, consultation arrangements enhance the standards of health and safety management within the Trust. Performance and progress against this objective will be measured by: An initial review and analysis of the adequacy of the current consultation and communications systems will be undertaken by the Risk Group to be completed by the end September A report of the findings from the review will be produced together with any appropriate Action Plan, for the Governance/ Integrated Governance Committee meeting October GOV 30 Health and Safety Strategy 3GOV 30 Health and Safety Strategy 3 Page of 24 9

10 Quarterly reviews of the Action plans that arise out of the Health and Safety Sub-committee will be undertaken by Risk team to ensure that key issues have been actioned. A report on the review findings will be passed to the Governance committee meeting for the next available meeting. The effectiveness of the communications systems will be included within the Trust s summative annual report. The performance and progress of achievement in relation to communications will be included within the Trust Health and Safety Annual Report and Plan. Ongoing monitoring of information from Staff side and employees on hazards, incidents and accidents will be undertaken by the Health and Safety Advisors and a quarterly report produced for the Governance committee. Objective 5 To develop, implement and maintain a Contractor Selection and Management Strategy to ensure that they can work safely and efficiently, minimising the risks to themselves, staff, patients and others. Performance and progress against this objective will be measured by: An initial review and analysis of the adequacy of the current arrangements will be undertaken by the Risk Team to be completed by the end June A report of the findings from the review will be produced together with any appropriate Action Plan, for the Governance/Integrated Governance Committee meeting July Such a review will specifically but not exclusively include; o Current Trust Policies, Procedures and Guidance Notes appertaining to the selection, appointment and management of contractors o Information management to and from the contractor service provider and the Trust o Knowledge of staff, contractors and others of the current Trust Policies, Procedures and Guidance Notes. Quarterly analysis and reviews by the Risk team Provider services, will be undertaken and a report produced, together with any appropriate Action Plan. The report will be presented to the Governance committee meeting closest to each quarter. A summative report of the performance and progress of achievement in the management of contractors will be included within the Trust Health and Safety Annual Report and Plan. Monitoring and Reporting structure To ensure that our Corporate Health and Safety Aim and Objectives detailed in this strategy are met, an annual review will be conducted and a Health and Safety (Improvement Plan) will be developed. GOV 30 Health and Safety Strategy 3GOV 30 Health and Safety Strategy 3 Page of 10 24

11 The Governance/Integrated Governance Committee will monitor the overall effectiveness of each part of the organisations arrangements for managing Health and Safety. Such monitoring will be based upon the actions detailed within the annual Health and Safety (Improvement) Plan. The day to day monitoring of health and safety performance will be undertaken by the Risk Team details of which can be found in the Trusts Health and Safety policy. Directorates and Departments will support the implementation of this strategy and its attendant policy and performance will be assessed through the annual appraisal process for managers. This strategy will be reviewed annually and revised where this is necessary. Equality Impact Assessment Legal Compliance When designing a new policy, review or changing an existing policy the dynamics of health and safety legislation, human rights and equality legislation will need interpreting together in order to determine how a policy will be developed to meet needs of employees, patients and the public. There will be tensions between these pieces of legislation and policies will need to strike a balance between the needs of the individual and the employee' s needs and sometimes the employee's needs will need to be subordinated to the patients needs with the consequences that may have for the employee and vice-versa. GOV 30 Health and Safety Strategy 3GOV 30 Health and Safety Strategy 3 Page of 11 24

12 Appendix 1 - Health and Safety Policy Statement THE HEALTH AND SAFETY POLICY STATEMENT The Trust Board regards its responsibility for the Health, Safety and Welfare of employees, clients, patients, residents, students, contractors, visitors and members of the general public as a matter of great importance. The Board seeks to ensure that everything that is reasonably practicable is done to preserve the welfare and well being of all concerned. Particular attention will be paid to the promotion of the following: A safe place of work and with safe access to and from the workplace; A healthy working environment without risks to health; Provision of adequate welfare facilities; Provision of sufficient training, instruction, supervision and information to enable all employees to contribute positively to their own Health and Safety at work and to avoid hazards and control the risks; Ensuring plant and equipment are safe; Ensuring that Safe Systems of Work are set and followed; Safe arrangements for the use, handling, storage and transport of articles materials and substances. The Trust Board accepts full responsibility for safety at work and will do everything possible to carry out both the duties and the spirit of the Health and Safety at Work Act, etc 1974, Management of the Health and Safety at Work Regulations 1999 and other relevant legislation. The Trust Board endorses the need for Trust managers and staff to work together positively to achieve a situation compatible with the provision of high quality services to patients and clients where the risk of personal injury and hazards to the health of staff and others can be reduced to as far as reasonably practicable, accordingly risk must be assessed and significant findings recorded. NHSN Chief Executive Officer (J. Parkes) NHSN Chair (Professor W. Pope). Managing Director Provider Services (L. Proctor) GOV 30 Health and Safety Strategy 3GOV 30 Health and Safety Strategy 3 Page of 12 24

13 Appendix 2 Key Features of the current (2009)Trust s Management System 1. Management System 1.1. As the Trust moves toward separation in line with National Policy (for PCT s) it will become crucial to maintain clear Health & Safety arrangements. Until such time as the organisation does become separate legal entities, a single system for managing Health and Safety will be maintained. Key features of this system are as follows: The Trust CEO retains overall accountability for both parts of the Organisation; The Director of Policy & Operations has delegated responsibility for Health and Safety for the Commissioning Arm; The Managing Director of Provider Services has delegated responsibility for Health and Safety for Provider Services; Health and Safety and Fire advice and support will be provided by the Risk Team across the whole Trust; The Estates & Facilities Dept will have lead responsibility for all estates related risk, e.g. CDM, control of contractors, asbestos and legionella; A single Health and Safety Group (the Risk Group) will exist within Provider Services but with representation from across the whole Trust The management of Health and Safety within the Trust will be a system approach and will include the following: Policies, that identify all key Health and Safety Acts, Regulations, Codes of Practice and NHS Regulatory requirements, which: o Support a positive Health and Safety culture; o Ensure a systematic approach to the identification and control of hazards and risks; o Support human resource development; o Minimise financial losses; o Support continuous improvement. Organising to: o Establish and maintain management control; o Promote co-operation so that Health and Safety becomes a collaborative effort; o Ensure communication routes are in place at all levels; o Secure the competence of all employees. Planning: GOV 30 Health and Safety Strategy 3GOV 30 Health and Safety Strategy 3 Page of 13 24

14 o For the implementation of the Health and Safety policies; o To ensure hazards and risks are identified and controlled; o To react to changing demands and emergencies; o To sustain a positive Health and Safety culture. Measuring Performance, through: o Active systems which monitor achievement and compliance with plans and standards; o Reactive systems which monitor accidents, ill health and incidents. Reviewing and Auditing Performance, that o Enables the organisation to learn from its experiences, through a structured review and audit process. For the Health and Safety Management System to be robust then all of the above elements must be incorporated. GOV 30 Health and Safety Strategy 3GOV 30 Health and Safety Strategy 3 Page of 14 24

15 Appendix 3 - Trust Health and Safety Responsibilities Chief and Executive Directors (In very general terms) Director of Policy & Operations and Managing Director Provider Services. Associate Directors Policy Organising Planning Measuring Audit Give authority to policies and allocate sufficient resources to attain policy commitments Configure the Trust in such a way that responsibility for achieving goals is clear and duties are appropriately assigned Establish and maintain a committee structure to review all potential areas of loss of relevance to the whole Trust Receive reports from relevant officers identifying significant hazards and showing trends in performance Prioritise actions to control loss and enhance performance at Trust level Executive directors must develop policies to avoid health and safety problems and must respond quickly where difficulties arise or new risks are introduced and non-executives must make sure that health and safety is properly addressed. Delegated Board Level responsibility for Health and Safety to lead on the above within Commissioning and Provider Arms respectively. Give authority to policies with limited local application and allocate sufficient resources to attain policy commitments Assign within job descriptions clear safety criteria and review their attainment at appraisal Support within the service a committee structure to allow consultation on all areas of risk and safety capable of local resolution Receive reports from relevant officers identifying significant hazards within the service and trends in performance and consult on control measures Identify hazards capable of control and set action targets to minimize loss and assign responsibilities to services for their attainment Senior Management Team Prepare action plans to reduce identified hazards to acceptable levels and provide necessary resources Assign targets to be achieved and resources to individuals within appraisal Track progress on assigned targets within the business agenda and address difficulties to maintain progress Review data on losses such as incident and claims reports and liaise with appropriate officers to review performance Participate in Root Cause Analysis to identify and control causes of significant loss to prevent repetition Ward/Dept Manager Ensure all staff are aware of safety hazards and safe working practices Liaise with staff and advisers to identify and control hazards via inspection and assessment Correct bad practices as observed and identify and control causes by investigation Periodically review incident reports to ensure that lessons have been learned Review and revise Risk Assessments to ensure all risks are controlled in a practicable manner All staff Be familiar with significant local hazards and know safe work systems Take care for your own and other s safety and follow safe working procedures Do not deviate from or amend work systems without proper consultation Report any incidents or actual accidents to your supervisor and assist in investigation Contribute to risk assessment where required to ensure that the actual hazard is controlled GOV 30 Health and Safety Strategy 3 Page 15 of 24

16 Appendix 4 - Trust Health and Safety Annual Plan 2009 Subject Health & Safety Strategy Action Required Further develop H&S Strategy to underpin Trust commitment & support Policy Promote strategy via AD s Put in place system to monitor & review Priority HIGH Lead AD Governanc e Target date May 2009 Control of Contractors Develop Trust Policy Review & Revise process to meet Trust & legislative requirements Establish and implement process for management of contractors for all Trust sites Establish program of monitoring contractors HIGH Estates Team June 2009 Management of Asbestos Develop new Policy and procedures (link to control of Contractors Policy) Undertake appropriate Asbestos Surveys as required to enable management of risk. Appoint competent Asbestos advisor to the Trust Source and implement staff training in line with risk exposure HIGH Estates Team June 2009 Incident Reporting Review Incident reporting form to meet organisational / national & legal reporting needs Revise policy & procedures Introduce training update for all staff in reporting incidents HIGH Risk Team July 2009 Needle Stick Injuries Benchmarking to take place with other organisations to compare needlestick statistics Latex Policy Review organisational needs Develop Trust policy to meet national & legislative best practice Establish procurement plan to Latex free procurement New & Expectant Mothers Develop new policy Produce guidance notes for managers Incorporating new risk HIGH MEDIUM MEDIUM Risk Team/ Occupatio nal Health Risk Team/ Infection Control/ Occupatio nal Health July 2009 Sept 2009 Risk Team/ HR Sept 2009 GOV 30 Health and Safety Strategy 3 Page 16 of 24

17 Subject Action Required assessment processes Communicate to all managers Priority Lead Target date Young People Review organisational policy Establish young people work activity within Trust Identify departments linked to young people placements Link with HR protocols Review trust protocols Review current pre trust visit training Ensure risk assessments process is in place MEDIUM Clinical Placement Facilitator / Risk Team Dec 2009 COSHH Review Policy & align to legislative and organisation requirements Undertake organisational review to assess compliance Audit chemicals and products used and safety data sheets. LOW Hotel Service Manger/ Risk Team August 2009 PUWER Review Policy & align to legislative and organisation requirements Undertake organisational review to assess compliance Promote policy requirements LOW Estates and Risk Teams / Clinical Placement Facilitator August 2009 Stress Review Trust Policy Link with HR to identify organisational needs Develop campaign to raise awareness and organisational commitment to dealing with reports & links to occupational health MEDIUM Risk Team/ HR/ Staff side July 2009 Bedrail Policy Establish bed rail policy & assessment process to meet NPSA & national guidance notes Obtain Trust wide commitment for process Link with Falls coordinator in the development of policy Review risk assessment process for system Identify training needs and program for staff HIGH Clinical Governanc e and Effectivene ss Group/ Clinical Risk Advisor Monitored through CG Group GOV 30 Health and Safety Strategy 3 Page 17 of 24

18 Subject Action Required Establish a process for the monitoring and review of new systems Priority Lead Target date DSE Assessments Review trust policy to meet DDA Identify and introduce E Learning training program for staff and managers MEDIUM Risk Team May 2009 Lone Working Pilot new policy assessment process in key areas Develop best practice guidance Evaluate training & education needs Review process / equipment needs in lined with national initiatives. MEDIUM Health, Safety and Security Advisor May 2009 First Aid Identify organisational requirements Introduce training to meet organisational needs LOW HR/ Risk Team September 2009 Maintenance of Properties Identify & understand maintenance program for Estates to meet H&S / Fire needs. Establish investment process for H&S / Fire needs based on risk assessment program MEDIUM Estates Team May 2009 Risk Assessments Review risk assessment form to meet organisational /national & legal reporting needs Tests unified form for all assessments Revise policy & procedures Obtain organisational agreement to new process Introduce training update for all staff & managers Ensure common risk matrix is utilised. Review e learning module for training HIGH Risk Team June 2009 Training Review training database to unify data within ESR Establish organisational training needs Identify & support resource HIGH Training Dept/ Risk Team April 2009 GOV 30 Health and Safety Strategy 3 Page 18 of 24

19 Subject Action Required requirements for key training Review & introduce E learning to compliment H&S training Link with staff appraisals Priority Lead Target date Workplace inspections Establish unified workplace inspection sheet and protocol Develop guidance to compliment inspection sheet Ensure all reps are trained MEDIUM Risk Team/ Staff side Dec 2009 Safety Representatives H&S Committee to promote role of representatives Introduce H&S representative day to promote role MEDIUM H&S Committee May 2009 Manual Handling Review manual handling policy and training arrangements Set up manual handling working group to monitor risk. MEDIUM Training Dept/ Risk Team Dec 2009 GOV 30 Health and Safety Strategy 3 Page 19 of 24

20 Appendix 5 - Equality Impact Assessment Department/Team: Risk Management Lead Officer: Dave Thomas Contact details: A. Function (policy, strategy, plan etc) Aims/Purpose/objectives B. Policies, Strategies and Procedures used to carry out the above function C. Groups who the function should benefit; - Patients - Staff - Other internal or external stakeholders Risk management Setting the Strategy The Health and Safety Strategy is the starting point that determines our plans to achieve our Health and Safety targets and goals. It outlines our principles and requirements for an effective health and safety management system and identifies the ways in which we will address these systematically through our health and safety framework. Health & Safety Strategy and its associated suite of policies and documents Patients, carers, service users, anyone (along with staff) effected by trust services from all our population groups including neighbours. Step 1 Question 1 Tips Who should be served by the function? Baseline information on the general population and the groups the function should benefit, e.g.: This policy seeks to protect all those who come into contact with or use our services and facilities or who might be affected by our actions and activities regardless of background. o o o Census data (or more up to date population projections) Other survey data Information of social and economic factors, such as age, income levels, health etc which are indicators of need. Population - In 2007 the estimated county population was 678,300 with a higher population under 20 years than the national average and a lower population over 65 years. Migration - Over 8000 overseas nationals were allocated a NI number in 2007/2008. A considerable proportion of these people are Polish. Gypsy/traveler community There are 207 caravan pitches across the county and slightly more caravans than the average for the East Midlands. Ethnicity From experimental statistics in 2005 the population of Northamptonshire is 90.2% white British. However in Northampton and Wellingborough the figures are 85.4% and 86.4% respectively. Children - The schools census (2007) shows that Northampton has the highest number of children and GOV 30 Health and Safety Strategy 3 Page 20 of 24

21 young people from a non-white British ethnicity (24.47%) and Wellingborough has the second highest (19.12%). In comparison. Older People and children living in deprivation. Deprivation is constructed and weighted from 7 domain indices: - Income 22.5% Employment 22.5% Health/Disability 13.5% barriers to housing 9.3% crime 9.3% living environment 9.3%. There are 41 Lower Super Output Areas in the county which are in the bottom 20% in the county (28 areas in Northampton). Hearing/visual impairment County RNID estimates for hearing impairments 2006 are 96,000 aged between 16and 80. RNIB facts: - 70% of blind or partially sighted adults have other disabilities or long term conditions. The majority of people with sight problems are older people 2006 figures for our county are 1525 people registered blind 1,190 people registered as partially sighted. Learning/Physical Disabilities estimated prevalence in the county s adult population is approximately 1718 (0.3% - the figure may be higher as it is estimated that 2% of the national population has a learning disability). There are approximately 5043 children and young people with a learning disability in the county (under 1% - the national average is between 1-3% depending on whether IQ or adaptive functioning is used) Physical disability In November 2007, there were 26,210 people aged between who were registered as receiving Disability Living Allowance (DLA). Of these, 17,000 people were receiving DLA for physical conditions. In ,120 children and young people were in receipt of disability benefits. The public health paper used in this report gives a breakdown of conditions. Step 2 Question 2 Tips Do you have monitoring data? Workforce Data Audit or Review Information Satisfaction survey results Workforce or service user profile broken down into:, Gender, Race, Disability, Religion, Sexual Orientation, Age The effectiveness of the policy can be measured in a number of ways including: Incident and accident statistics, put before the Health and Safety committee every two months. Claims data Staff Survey Physical assault monitoring Proactive Risk Assessment outcomes GOV 30 Health and Safety Strategy 3 Page 21 of 24

22 Step 3 Question 3 Tips Who is using the function/policy? What does your monitoring data on your service users tell you? Are any groups under or over represented compared to what you would expect to see from the baseline data What does your monitoring data outcomes tell you? E.g. are some groups more likely to be served better by your function, service and policies etc compared to what you would expect to see from the baseline data on their needs? Ongoing monitoring of incident data shows that the situation regarding Health and Safety in the trust is not of major concern, the incidents common to most healthcare organisations require continual monitoring (slips, trips, falls, violence and aggression and back care). These affect a wide range of people but particularly patients and staff. Accordingly the Trust has put in place training and awareness sessions (including Induction) to help minimise the incidence of such occurrences. Step 4 Question 4 Tips What evidence do you have that your service is accessible equitably to all groups taking into account sexual orientation, gender, age, race, religion, belief and disability. Potential sources of evidence: Customer Satisfaction Survey results Local and national research Consultation Observation User Groups The service and policy is accessible to all who use our services and is enshrined in law under the Health & Safety at Work etc Act. It also has the full support of the TUC. The strategy and subsidiary policies and guidance notes are available on the PCT intranet and are referred to in mandatory training programs including induction. No specific monitoring takes place with regard to equitable access. Step 5 Question 5 Tips What action have you taken to ensure that your users are all served equitably? Staff training in how to treat individuals with specific needs Ensured information is produced in a range of formats to assist all groups Changes made directly to reflect changes in the user profile. Users consulted prior to planned changes to the service being implemented Staff groups made aware of user groups who may be being Training is given to all at induction at Trust induction and thereafter as required in the following: conflict resolution, fire, health and safety, manual handling and risk management. In addition, Trust mandatory Equality and Diversity training highlights individual need in a broad sense and should help all staff to be aware of equality issues. Staff has full membership of the Health and Safety sub Committee through their union organisation. GOV 30 Health and Safety Strategy 3 Page 22 of 24

23 disadvantaged by existing policy, practice and procedure. Staff being consulted to assess how new policies and procedures may impact on them Step 6 Question 6 Tips Based on the evidence gathered in Steps 2-5, have you identified any potential differential impact for any of the equality groups (Sexual Orientation, Gender, Race, Religion, and Belief & Disability)? If yes, go to Step 7 If No, go to Step 9 In general the law, and therefore the policy, applies equally to all. Though on occasional it may be necessary to place the risk management of Health and Safety above the requirements of anti-discrimination law particularly in relation to Disability. Step 7 Question 7 Tips Is the differential impact as a result of indirect or direct discrimination? If the impact is a result of direct discrimination, this is unlawful and the organisation must decide how to ensure they act lawfully (go to Step 8). If the differential impact is a result of indirect discrimination, is this objectively justifiable or proportionate in meeting a legitimate aim? If yes, provide details here: If no, go to Step 8. Step 8 Consider alternatives (Proposing actions) Step 9 Consult on those likely to be affected by the policy. Follow the organization s consultation process. Alongside the duty under the Disability Discrimination Act (DDA), to make reasonable adjustments and to avoid treating disabled people less favourably, the NHS has duties to safeguard the health and safety of staff patients and the public. It must ensure that the legal rights of the disabled are exercised safely. This may lead to a clash which could therefore lead to direct discrimination. Information The management of Health and Safety is based on a Risk Assessment Process. PCT arrangements should be made in line with the reasonable adjustments under the DDA and where an individual case or circumstance gives rise to H&S concerns these are to be dealt with through an appropriate risk assessment giving consideration to specialist knowledge of the disability. Information Research and consultation with various stake holders, service users and other Trusts has begun and though not specific to H&S the process of feedback will inform how the functions of the Health and Safety Strategy and Policies will be produced to enable equitable accessibility. GOV 30 Health and Safety Strategy 3 Page 23 of 24

24 Step 10 Tips Base your decision on four factors: The aims of the policy The evidence you have collected The results of public involvement and consultations The relative merits of alternative approaches Actions; Question Decide whether to adopt the policy Make monitoring arrangements Complete EIA Summary Form The author is looking for endorsement of the EIA action plan. Collate the actions identified and complete the Equality Impact Assessment Action Plan below; Issues identified Action required to be taken How will the impact be measured Lead/timescales Please forward a copy of the Equality Impact Assessment template to Narinder Kaur, nkaur@nhs.net; GOV 30 Health and Safety Strategy 3 Page 24 of 24