HEALTH & SAFETY POLICY

Transcription

1 HEALTH & SAFETY POLICY Document Reference Ratifying Committee / Group Status of policy Document Reference No Safety Manager Executive Board Final TW/00050/15-18a Signed: Claire Murdoch, Chief Executive Approved date: February 2015 Essential reading for the following staff groups: 1 - Executive Board 2 - Associate Director of Quality 3 - Head of Safety 4 - Health and Safety Manager 5 - Divisional Health and Safety Managers 6 - All Local Managers of Health and Safety 7 - Estates and Facilities 8 - Infection Control 9 - Occupational Health POLICY IMPLEMENTATION DATE: Feburary 2015 DATE POLICY TO BE REVIEWED: January 2018 Following staff groups should be aware exists for reference purposes: 1 All staff Page 1 of 32

2 HEALTH & SAFETY POLICY Contents 1. KEY POINTS STATEMENT OF INTENT PURPOSE AND SCOPE RESPONSIBILITIES DEFINITIONS USED POLICY MONITORING COMPLIANCE & EFFECTIVENESS REACTIVE MONITORING PROACTIVE MONITORING REFERENCES... 7 APPENDICES Appendix A Appendix B Appendix C Appendix D Appendix E Health and Safety Objectives Responsibilities Corporate Risk/Health and Safety Group Terms of Reference Monitoring Compliance & Effectiveness Equality, Human Rights and Privacy Impact Assessment Page 2 of 32

3 1.0 Key points This document contains information pertaining to the Trusts commitment to: 1. Ensuring the Health, Safety and Welfare of all employees. 2. Ensuring the Health and Safety of service users, visitors and members of the public. 3. Setting out the Health and Safety auditable standards to measure how well Health and Safety is being managed in the Trust. 4. Identifying roles and responsibilities for the management of Health and Safety within the Trust and the duty of care held by all employees. 5. Setting out the health and safety objectives which are detailed commitments on how Health and Safety will be managed. 6. Listing the associated policies and procedures to manage Health and Safety risks. 7. This policy also contains the Terms of Reference for Corporate Risk/Health and Safety Group. Page 3 of 32

4 2.0 General statement of intent It is the policy of the Trust to comply with the requirements of the Health and Safety at Work etc. Act 1974 and other relevant Health and Safety legislation. We recognise that high standards of health, safety and welfare are an integral element of efficient management of objectives and contribute to the overall operational success of the Trust. We are committed to the continuous improvement in occupational safety, health and environmental matters that may affect employees, service users, volunteers, contractors and members of the public. For such standards to be achieved, adequate financial and physical resources shall, so far as is reasonably practicable, be made available thereby ensuring continuing development of the competence of employees and the provision of any necessary expert advice. Health and Safety is a management responsibility of equal importance to all other objectives, thus the Board, Divisional Directors and Managers shall pursue progressive improvements in health and safety performance. This will be achieved by establishing and maintaining control, communicating the necessary information, encouraging co-operation between individuals and groups to ensure that a positive Health and Safety culture is promoted and developed. Equally, it is recognised that all employees have a duty of care to themselves and others by avoiding hazards, preventing accidents and co-operating with the Trust by complying with all instructions and recommendations on Health and Safety. So far as is reasonably practicable, we shall ensure that: Safe work methods and conditions are provided and adopted Statutory requirements are complied with and accepted as the minimum standards in all work areas and activities Employees are made aware of potential hazards and the precautions to be adopted, by providing information, instruction, training, supervision and appropriate safety equipment Steps are taken to identify immediate and underlying causes of work related injuries and ill health and implement any preventative action necessary Employees are actively encouraged to participate in Health and Safety arrangements and submit ideas and suggestions for improving standards This policy will be reviewed every two years or when procedural, legislation or best practice changes occur to ensure it remains effective, and any necessary amendments will be communicated to all employees. Signed:.. Claire Murdoch, Chief Executive Page 4 of 32

5 3.0 PURPOSE AND SCOPE 3.1 This policy recognises that the Trust s responsibility for the health, safety and welfare of its service users and employees, and others who may be affected by the way it conducts its business. This responsibility extends beyond those premises the Trust controls to all places that its employees may be required to work or from which services are provided. 3.2 The purpose of the policy is to provide a clear, positive and proactive approach to the management of Health and Safety and provide a clear practical framework to assist all staff to reduce and control Health and Safety risks to service users, staff and others. This policy aims to achieve compliance with all relevant Health and Safety legislation. 3.3 A range of objectives have been prioritised to minimise Health and Safety risks. They have been agreed by the Corporate Risk/Health and Safety Group and endorsed by the Executive Board. See Appendix A for a full listing. 4.0 RESPONSIBILITIES 4.1 The Health and Safety at Work etc Act 1974 requires that the Trust s Health and Safety policy is underpinned by appropriate organisation and arrangements to enable its implementation. These include clearly defining responsibilities in these regards, especially for those with unique responsibilities. These are listed below: Board of Directors Executive Board Corporate Risk/Health and Safety Group Chief Executive Divisional Directors Associate Director, of Quality Head of Safety Security Manager Health and Safety Manager Divisional Health and Safety Managers Local Managers for Health and Safety All Employees Learning and Development Department Estates and Facilities Department Clinical Safety Manager Trust Fire Safety Advisor Health and Safety Representatives Health and Safety Management Representatives Occupational Health Service Other Parties A detailed schedule of each group and post holders roles and responsibilities are contained within Appendix B. Page 5 of 32

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7 5.0 Definitions used 5.1 The Health and Safety at Work etc Act 1974 is an Act of Parliament within the UK which defines the fundamental structure and authority for the regulation and enforcement of workplace health, safety and welfare within the United Kingdom. 5.2 Risk Assessment is a careful examination of what, within the workplace, could cause harm to people. Once potential hazards have been identified, reasonable steps must be taken to prevent the harm to people or, if it cannot be eliminated to reduce the likelihood of harm to as low as is reasonably practicable. 6.0 Policy 6.1. This policy forms part of an overall approach to managing Health and Safety within the Trust and should be read in conjunction with the other relevant Health and Safety policies and procedures noted in section The Trust remains committed to continually improving the caring and working environment and have therefore, given priority to programmes of work necessary to effect improvements in Health and Safety and to minimise risk. In addition, and where reasonably practicable, it will provide adequate resources in the form of senior management level support and finance, to ensure the promotion and maintenance of the appropriate level of safety performance 7.0 MONITORING THE EFFECTIVENESS OF THIS POLICY Standards are in place to monitor how effectively Health and Safety is being managed across the Trust, this comprises of the following: 7.1 Reactive monitoring The Trust will carry out reactive monitoring through quarterly trend analysis of incident reporting data relating to the following types of incidents: Assaults on staff Manual handling Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) Slips, trips and falls Non-Clinical Security Incidents Workplace Risk Assessment Compliance 7.2 Proactive monitoring Proactive monitoring will also be undertaken in the following areas: Training Reports will be issued to the Corporate Risk/Health and Safety Group summarising compliance levels in Health and Safety training. Workplace Risk Assessments Reports will be issued to the Corporate Risk/Health and Safety Group on Workplace Risk Assessment compliance. Health and Safety audits Page 7 of 32

8 Audits will be undertaken on an annual basis in all in-patients areas, and 3 yearly in all other areas across the Trust using the Health and Safety Audit Checklist. See Appendix D to view the Monitoring Table. This policy will be reviewed every two years, and in the event that significant changes to legislation, work activities, staff or the workplace take place. It will also be reviewed if there is reason to suspect that it is no longer valid. The Health and Safety Manager will disseminate this document throughout the Trust by posting it on Trustnet the Trusts intranet site. Divisional Directors and Local Managers will ensure that the Policy is effectively communicated to and understood by their staff via local mechanisms. Support and guidance in this matter will be provided by the Trust s Health and Safety Managers and Divisonal Health and Safety Managers as appropriate. 8.0 REFERENCES This policy forms part of an overall approach to managing Health and Safety within the Trust and should be read in conjunction with the following relevant Health and Safety legislation, Health and Safety Executives (HSE) documents and Trust policies and procedures. Legislation and HSE documents: Health and Safety at Work etc. Act 1974 Management of Health and Safety at Work Regulations 1999 Revitalising Health and Safety, Health and Safety Executive HSE guidance notes and Approved Codes of Practice (ACoP) Trust policies and procedures: The Working at Height, Steps and Ladders Policy Manual Handling Policy COSHH Policy Stress Management Policy and Procedure Display Screen Equipment Policy Pregnancy Risk Assessment Policy Slips & Trips Policy Inclement Weather Procedure Incident and Serious Incident Reporting Policy and associated procedures Management of Violence and Aggression Policy incorporating Lone-working Personal Alarm Policy Risk Management Policy First Aid Policy Zero Tolerance Policy CCTV policy Security Policy Workplace Risk Assessment Procedure Fire Safety Management Strategy The Dress Code Policy Lone Worker Policy Page 8 of 32

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10 HEALTH AND SAFETY OBJECTIVES Appendix A 1. Ensure that the Trust receives advice from appropriately qualified / experienced persons in matters pertaining to Health and Safety and fire safety. 2. Ensure that management, at all levels, fulfils its obligations for health, safety and welfare in areas under its control. 3. Ensure compliance with relevant Health and Safety legislation and drive performance towards levels of good practice. 4. Provide training for staff in Health and Safety at induction and on an ongoing basis in accordance with the mandatory and statutory training schedule. 5. Carry out structured, regular and documented risk assessments (Workplace Risk Assessments) of all environments in which staff work to ensure they are safe and secure. 6. Ensure that there are adequate and effective security systems in place, which are periodically monitored and reviewed. 7. Review the Security Strategy and develop local policies and procedures as necessary to reduce risk to personal safety and damage / loss of Trust property. 8. Invest in the security of its assets and premises from the planning stage through to completion. 9. Training is provided to all Local Managers of Health and Safety to ensure that they have the adequate knowledge and ability to manage Health and Safety within their area of responsibility. 10. Ensure that the audit system designed to audit the management of Health and Safety across the Trust is effective. Page 10 of 32

11 Appendix B RESPONSIBILITIES OF KEY GROUPS AND STAFF Party/person Board of Directors Executive Board Corporate Risk/Health and Safety Group Key responsibilities In the context of effective governance arrangements, managing Health and Safety risk is a key issue for the Board, who have a collective role in providing committed leadership in the continuous improvement in Health and Safety The Board is responsible for committing resources as an investment to improve staff health, safety and welfare and subsequently monitoring the impact of committing resources. Board decisions and actions will support the Trust s Health and Safety responsibilities. The Executive Board has delegated responsibility from the Board of Directors for ensuring there are adequate Health and Safety risk management arrangements operating in the Trust. It will ensure its actions and decisions reinforce this commitment and will review the effectiveness of the Health and Safety management system and performance, at least annually. The Health and Safety Group is responsible for reviewing and approving Health and Safety policies and procedures, monitoring Health and Safety compliance and performance and promoting with others, a positive Health and Safety culture throughout the Trust. The Terms of Reference of the Group are attached at Appendix C. Chief Executive The Chief Executive has overall and final responsibility for Health and Safety. Specific Health and Safety duties include: Provision of an organisation which has clearly defined responsibilities leading to effective and comprehensive Health and Safety management Allocation of resources to comply with Health and Safety legislation and best practice so far as is reasonably practicable Ensuring that systems are in place so that all employees are fully aware of their statutory responsibilities by the inclusion of Health and Safety in all job descriptions and through Trust Induction Appointing an individual(s) with special responsibility for Health and Safety who is responsible for the overall coordination of health safety and welfare issues within the Page 11 of 32

12 Trust and for monitoring the implementation and upkeep of Health and Safety policies Reviewing the health and safety performance of the Trust through annual Health and Safety reports and ensuring appropriate action plans are developed to facilitate continuous improvement Director of Nursing and Quality Divisional Directors In accordance with the Secretary of State s instructions the Trust has in place an Executive Director who assumes the role of Safety Management Director. In CNWL this is the Executive Director of Nursing and Quality who is responsible for Health and Safety management matters. Divisional Directors are responsible for: Implementing Trust policies and procedures, developing and delivering local protocols Ensuring appropriate and relevant performance targets are met and monitored Taking appropriate corrective actions identified through incident investigation. The implementation and monitoring of Health and Safety policies within their Division, ensuring responsibilities are clearly assigned. Identifying persons of appropriate competence and seniority as Local Managers (a role as described in this policy). Ensuring risk assessments are undertaken, appropriate action taken and results are included in the local risk register. Providing effective support for their Local Managers decisions and recommendations and providing appropriate resources where available. Ensuring that staff have adequate information, instruction and training to undertake their work safely. Ensuring that Health and Safety management and awareness is included in performance appraisal. Promoting a positive Health and Safety culture within their Division. Ensuring that all accidents and incidents are managed in accordance with relevant policies and procedures. Associate Director of Quality The Associate Director of Quality is responsible for: Ensuring the acquisition and retention of competent support, guidance and advice on all Health and Safety matters Ensuring that policies and procedures are in place to facilitate safe workplaces and safe systems of work Managing the Trust s Head of Safety Ensuring the Trust s Health and Safety Policy is monitored and reviewed Page 12 of 32

13 Providing the Corporate Risk / Health and Safety Group, Executive Board and the Board of Directors, with an annual report showing Health and Safety performance across the Trust. Head of Safety The Head of Safety manages the Trust s Health and Safety Team and ensures that policies and procedures are developed and reviewed as required. The Head of Safety is also responsible for monitoring the effectiveness of the policy. Security Manager The Trust s Security Manager undertakes the duties of the Local Security Management Specialist (LSMS). This is in accordance with Secretary of State Directions to health bodies on measures to tackle violence and security management. As part of the Safety Team, the Security Manager reports to the Head of Safety on all matters relating to security management. Health and Safety Manager and Divisional Helath and Safety Managers The Health and Safety Manager and The Divisional Health and Safety Managers are the Trust s nominated competent persons in relation to health and safety. Their role ensures the provision of competent, authorised and appointed persons who provide or commission relevant training for staff. Responsibilities include: Monitoring the effectiveness of Health and Safety-related processes and activities Ensuring that robust arrangements are in place in line with national policy and relevant legislation and creating an environment of continuous quality improvement and development. To achieve this, the Managers will: Co-ordinate the implementation of the Trust Health & Safety Policy across the organisation and review the policy when indicated (i.e. annually or when circumstances change significantly) Advise the Chief Executive, Executive Directors, Divisional Directors, and Trust employees of their statutory obligations under the HASAWA and subordinate Health and Safety legislation Provide specialist advice to all levels of Trust staff in relation to health, safety and welfare Monitor compliance with Health and Safety responsibilities, including via audit, to identify problems and areas for improvement Keep up-to-date with developments in legislation and best practice Liaise with staff on problems and areas for improvement, Page 13 of 32

14 and provide information, instruction and training as appropriate Ensure that problems and areas for improvement are communicated to local managers, Health and Safety Representatives, the Corporate Risk / Health and Safety Group and the Board as appropriate Ensure the appropriate distribution of Health and Safety information to relevant personnel Monitor, review and where necessary investigate accidents, incidents and near misses to identify causes and corrective action, and to ensure that measures are put in place to prevent recurrence Receive reports of adverse incidents and report specific categories of adverse incidents to the Health and Safety Executive (HSE) in accordance with the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995 Act as the liaison officer for the Trust with external bodies regarding Health and Safety matters Page 14 of 32

15 Local Managers for Health and Safety Local Managers for Health and Safety will preferably be no lower than at Band 5 level will be identified by relevant Service Managers. Local Managers have a responsibility for day-today Health and Safety operations commensurate with their level of management responsibility within the Trust. To meet their responsibility, Local Managers for Health and Safety will: Ensure new staff receive local induction training on Health and Safety matters to enable them to carry out their roles appropriately and safely Ensure that local Health and Safety arrangements are adequate, or problems are being addressed, and that any concerns that have not been resolved locally are discussed with their line managers and/or the Corporate Risk/Health and Safety Group, as appropriate Ensure programmes of risk assessment are undertaken within the specified timetable Where unacceptable risks are identified by risk assessment, implement adequate control measures to eliminate or reduce the risk using the Hierarchy of Control Methods as detailed in the Trust Workplace Risk Assessment Procedure Where residual risks remain, communicate relevant information to those who may be affected Identify to Divisional Directors any areas where the organisation needs to commit additional resources to ensure Health and Safety is maintained or improved Ensure all staff report all accidents, incidents and near misses occurring to staff, patients and visitors To monitor accidents and near misses and report any incidents to the Health and Safety Manager(s) Take corrective action whenever this is required to prevent recurrence of incidents and absence from work Monitor that all applicable Health and Safety policies/procedures are being adhered to To ensure that staff without access to Trustnet are able to view the policy in an alternative way Ensure good housekeeping to remove possible hazards and obstructions and to designate employees responsible for the housekeeping for certain areas Ensure that suitable clothing and footwear is worn. Further information can be found in The Dress Code Policy Ensure staff receives appropriate training, including attendance at the Trust induction and departmental induction programmes for all new staff. In addition, relevant, specialist Health and Safety training must be provided as appropriate. Update training must be provided Page 15 of 32

16 on a regular basis as indicated. Records of all training must be maintained by the manager and must be available when required Consult with employees on all Health and Safety matters, either via the ward(s)/department safety representative or directly with employees Ensure that staff Health and Safety Representatives are given adequate time during working hours or time in lieu to undertake his/her Health and Safety duties Staff Health and Safety Representatives duties include: Health and Safety training Attendance at respective Health & Safety meetings Assisting the Local Manager when carrying out inspections Assisting the Local Manager when carrying out Health and Safety assessments Representing staff on ward/team/department Health and Safety matters Local Managers must update the Health & Safety Manager(s) of any personnel changes regarding Staff Health & Safety Representatives. All Employees All individuals within the Trust have a responsibility to adhere to the Health and Safety Policy. In meeting this legal duty all employees are expected to: Read, understand and comply with Trust Health and Safety policies. Employees have a duty to keep themselves updated with regard to relevant policies and procedures Co-operate with their managers on Health and Safety issues, including complying with the Trust s Health and Safety arrangements To comply with any procedures and safe systems of work and to make proper use of any equipment provided Use all items of equipment correctly, and in accordance with instruction and training. Also, to report any loss or defect in equipment to the appropriate Local Manager and/or Health and Safety Representative To wear any special clothing or personal protective equipment given to them by the Trust for the purpose of protecting their health, safety and welfare Inform the Local Manager and/or Health and Safety Representative of any concerns about Health and Safety arrangements (even when no immediate danger exists) so that they can take remedial action where necessary Inform the Local Manager and/or Health and Safety Representative of the need for a risk assessment in respect of specific risks, where needed Attend the mandatory Health and Safety training, and any other training needed appropriate to the respective job role Report immediately any incident, accident or near miss in Page 16 of 32

17 Learning and Development Department accordance as described in the Incidents and Accidents Procedure Not to intentionally or recklessly interfere with or misuse anything provided in the interest of promoting Health and Safety at work. Any person who is found to do so may be subject to disciplinary action Comply with instructions in relation to emergency procedures, including fire, resuscitation psychiatric emergencies, major incident procedures, as well as procedures for hazardous substance spillage, where relevant The Trust will ensure that appropriate information, instruction and training is provided to enable employees to undertake their duties safely. This includes the provision of supervision and support as appropriate, until employees are competent to work safely unsupervised. All new employees are required to attend an induction programme provided by the Trust upon commencement of employment, which includes fire safety training, manual handling training regarding inanimate loads and an introduction to Health and Safety in the Trust. The training department is responsible for providing information, instruction and training to all staff to help the Trust meet its Health and Safety responsibilities. To achieve this, training department will: Ensure that the range and quality of information, instruction and training from the training department covers the range and quality of Health and Safety information needed by staff Keep a record of attendance at training courses, and report non-attendance of mandatory courses to relevant Local Managers Estates and Facilities Department Accredited safety representatives will receive appropriate training through their staff organisation, as well as relevant update training. Non-accredited representatives will receive training from the Trust s Health & Safety Manager(s). Estates and Facilities Department is responsible for the condition of buildings and the engineering services contained therein. The responsibilities include: The design for new and refurbished buildings to meet all relevant statutory duties, including Health and Safety duties, and to maintain the condition of the buildings Involving the Trust s Health and Safety Team initially in all matters relating to Health and Safety requirements for works and activities Maintaining essential services such as water services, and electricity for lighting and power, lifts, heating, air conditioning and protection systems such as fire alarms Inspections and maintenance of engineering services, Page 17 of 32

18 including electric testing, gas safety certification, portable appliance testing, and Legionella risk assessments as well as Fire Risk Assessments and Fire Safety Training Clinical Safety Manager The Clinical Safety Manager is responsible for co-ordinating the Trust s approach to clinical risk management. The responsibilities include: Monitoring and investigating clinical risk incidents to identify trends and the need for generic solutions Communicating with staff across the Trust on clinical risk problems and issues, including wider NHS initiatives Developing strategies and projects to tackle problems and implement best practice solutions Page 18 of 32

19 Fire Safety Advisor The Trust Fire Safety Advisor is responsible for providing technical advice on fire safety, and monitoring and reporting on the current state of fire precautions within the Trust premises. The responsibilities include: Advising on the fire precautions needed in new and existing buildings, including the provision, siting and maintenance of fire-fighting equipment, fire safety signs, notices etc Assisting with fire audits and fire risk assessments, and recommending remedial action where necessary Provide fire safety training to staff Health and Safety Representatives Health and Safety Representatives are members of staff who have been accredited in this role. They have the right to inspect an area following a change of circumstance or within 24 hours of an adverse incident occurring, or when reasonably requested (in accordance with the Safety Representatives & Safety Committees Regulations 1977 and the Health & Safety (Consultation with Employees) Regulations 1996). Health and Safety Representatives are entitled to adequate time off work and resources to enable them to carry out their role. Health and Safety Representatives are entitled to support the Trust with monitoring and assisting with the implementation of Health and Safety arrangements in their designated work areas. To achieve this, Health and Safety Representatives can: Provide staff and local managers with advice, as necessary, including helping local managers to develop local procedures Investigate potential hazards and causes of accidents at the workplace Investigate employee complaints concerning Health and Safety Inspect their local workplace, when necessary, and after notifying their Local Manager that they intend to do so, particularly for the purpose of risk assessment Assist the Local Manager with carrying out inspections and assessments Make representations, where necessary, to Local Managers, the Health and Safety Manager(s), and/or the Corporate Risk / Health and Safety Group as a result of the above investigations, or on general matters affecting Health and Safety Health and Safety Representatives are not required to accept responsibility for delivering Health and Safety procedures in respect of their designated work areas, but may choose to accept that responsibility. Health and Safety Representatives in each service or directorate will agree which among them will represent the Page 19 of 32

20 others at the Corporate Risk / Health and Safety Group. Health and Safety Management Representatives Relevant Divisional Directors will identify posts that are required to act as Health and Safety Management Representatives. Divisional Directors must inform the Health & Safety Manager(s) of those Health and Safety Management Representatives so identified and to subsequently update the Health & Safety manager(s) of any personnel changes to that particular role. There will be Management Representatives for each Division within the Trust, as follows: Acute Inpatient Services Addictions Assessment and Brief Treatment Camden Provider Service Child and Adolescent Mental Health Services Community Recovery Eating Disorders Hillingdon Community Health Learning Disabilities Offender Care Older People and Health Ageing Psychological Medicine Rehabilitation Health and Safety Management Representatives will represent their Division at meetings of the Corporate Risk/Health and Safety Group. They will be responsible for ensuring information and decisions made at the Group are properly communicated to managers and other staff within in their division. Occupational Health Service Health and Safety Management Representatives will be responsible for ensuring that draft policies and other health and safety related documents are made available to staff for consideration prior to their approval by the Corporate Risk/Health and Safety Group. The Occupational Health Service provides confidential advice to staff on a wide range of issues concerning health, safety and well-being at work. The range of services available includes: Advice on any work related Health and Safety issues, including sickness absence and fitness to work support and counselling for a wide range of conditions, both physical and mental, including stress, bereavement, alcohol and other dependency problem. Health surveillance for employees where a risk assessment shows that it is necessary Page 20 of 32

21 Other Parties Where members of staff are working on premises which are owned and/or managed by a third party, the Trust will ensure that the other party understands and accepts the respective responsibilities of the Trust, the employees of the Trust, and the third party in respect of Health and Safety. To ensure this is carried out all risk assessments, whether in the environment, or the assessment of risk in working practices, will be carried out jointly by the Trust and the third party. The manager directly responsible for activity within the premises owned by a third party will therefore be responsible for acting on the findings of the joint risk assessors. Any agreed steps to be undertaken by the third party to ensure a safe system of work should be recorded by the Trust in writing and details of what has been agreed sent to the third party. Specific responsibilities however, are defined as follows: The Trust will ensure that staff are suitably trained in adopting safe systems of work Employees are responsible for practicing safe systems of work as instructed by the Trust, or through their professional training For any work related activities undertaken outside the premises owned/managed by a third party, the Trust, as direct employers of the staff will ultimately be accountable for ensuring those activities are carried out safely through application of safe systems of work, and/or professional standards The third party will be responsible for ensuring the environment in which the employee is working is safe Where the third party is responsible for managing the work, on a day-to-day basis, the Trust and third party are responsible for independently monitoring accidents, jointly assessing risks, and auditing systems of work. The third party will be responsible for taking management action to correct any shortfalls in the first instance, only referring to the Trust if such shortfalls are not adequately addressed within the time specified. Where such management action fails to result in improvements to Health and Safety within a reasonable time period, the third party must inform the Trust, so that the Trust can take whatever action is appropriate, as the employer of the staff, to ensure safe systems of work are practiced and maintained. Page 21 of 32

22 Appendix C Corporate Risk / Health and Safety Group Terms of Reference 1 Membership Director of Business and Estates (Chair) Associate Director of Quality Head of Facilities and Procurement Head of Estates Human Resources Manager Head of Safety Health and Safety Managers Security Manager Occupational Health Representation Clinical Safety Manager Senior Nurse Advisor Infection Control Senior Nurse Advisor Staff Representatives Local Management Representatives (one from each Division ) Union Health and Safety Leads 2 Meetings The Group will meet every quarter (beginning July 2015) to monitor Health and Safety within the Trust to identify any underlying themes and to consider the need for remedial action. The minutes of Group meetings will be available on Trustnet (with any confidential matters removed). The Group will: Consider the need for further information, instruction and training to help staff to meet their Health and Safety responsibilities Ensure that staff are consulted on significant health and safety issues Assess the need to update the Trust s Health and Safety arrangements, and particularly with regards to developments in Health and Safety, such as new regulations, to ensure that the Trust meets its Health and Safety obligations Communicate with all relevant parties, particularly staff, on Health and Safety issues, initiatives, and developments 3 Quorum The Quorum for a meeting will be 8 people excluding the chair. 4 Attendance Page 22 of 32

23 Failure to attend 3 consecutive meetings will result in removal from membership, unless extenuating circumstances apply. This page has been left blank intentionally Page 23 of 32

24 5 Reporting Structure The Group will report to the Executive Board. The Executive Board will receive a report from the Group following each meeting, identifying key issues of importance and decisions taken or required. 6 Duties The overall purpose of the Corporate Risk / Health and Safety Group is to ensure safe working environments exist throughout the Trust, where staff work and patients are treated. In ensuring a safe environment, the Group will consider guidance and proposals and will draw on experience of others, to make recommendations, produce reports and ensure standards are met. The key functional areas which will form the basis of the Group s focus will consist of: Health and Safety To act as a Health and Safety Committee for the Trust and to undertake the duties of such a committee in accordance with relevant Health and Safety legislation. To ensure all relevant Health and Safety information is cascaded from members of group to staff at all levels within their Divisions.. Health and Safety - urgent issues To be a forum for local Health and Safety representatives to raise issues of concern that has not been resolved at a local level. Policies and Procedures To develop, review and approve Health and Safety related policies and procedures as appropriate. To ensure amended or proposed policies and procedures are cascaded to relevant persons within each service line for consultation. Fire Safety Ensuring compliance with Firecode that the Trust eliminates fire backlog maintenance and that regular and appropriate training is given to staff. Accidents, Incidents, Complaints and Legal Claims Receive reports to provide an overview of all incidents in the categories listed below. Identifying areas requiring improvement and consider further actions that will support improvements in the Health and Safety of service users and staff. 1. Slips, trips and falls incidents 2. Manual handling incidents 3. Assaults on staff 4. RIDDOR reportable incidents 5. Non-clinical security incidents 6. Workplace Risk Assessment compliance Review of Risk Register Entries Review the risk register entries regarding any matters that relate to these terms of reference. Page 24 of 32

25 7 Monitoring of effectiveness The Corporate Risk / Health and Safety Group will annually review its terms of reference and its performance. Potential improvements that are identified will be implemented within a time period to be determined by the Group. Page 25 of 32

26 Appendix D Monitoring compliance & effectiveness What key element(s) need(s) monitoring as per local approved policy or guidance? Who will lead on this aspect of monitoring? What tool will be used to monitor/check/ observe/assess/ inspect/ authenticate that everything is working according to this key element from the approved policy? How often is the need to monitor each element? How often is the need complete a report? How often is the need to share the report? Who or what committee will the completed report go to? How will each report be interrogated to identify the required actions and how thoroughly should this be documented in e.g. meeting minutes. Which committee, department or lead will undertake subsequent recommendations and action planning for any or all deficiencies and recommendations within reasonable timeframes? How will system or practice changes be implemented and how will these be shared. Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Re-active monitoring of incidents: Safety Manager / Health & Safety Managers DATIX Quarterly and Annual Reporting Quarterly Report to Corporate Risk / Health and Safety Group Annual Report to the Corporate Risk / Health and Safety Group Safety Manager / Health and Safety Managers Required changes to practice will be identified and actioned within a specific time frame. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders and the Corporate Risk/Health Page 26 of 32

27 and Safety Group. Proactive monitoring includes: Safety Manager / Health & Safety Managers Workplace Risk Assessment Compliance Reports Health and Safety Audit 2 months (except August) Annual Report to Corporate Risk / Health and Safety Group Annual Report to the Corporate Risk / Health and Safety Group Safety Manager / Health and Safety Managers Required changes to practice will be identified and actioned within a specific time frame. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders and the Corporate Risk/Health and Safety Group. Training Learning and Development ATLearning 2 months Annual Report to Corporate Risk / Health and Safety Group Annual Report to the Corporate Risk / Health and Safety Group Safety Manager / Health & Safety Managers / Learning & Development Required changes to practice will be identified and actioned within a specific time frame. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders and the Corporate Risk/Health and Safety Group. Page 27 of 32

28 APENDIX E Equality, Human Rights and Privacy Impact Assessment This form is protected. You can only complete the fields that are shaded. They will expand as you type so that you are not limited to how much you write. You can move between the fields using the cursor up and down keys. Equality and Human Rights Screening assessment 1.What is the name of the service / policy / procedure / project being assessed Health and Safety Policy 2.Briefly describe the aim of the service /policy /procedure / Trust function that is being Impact Assessed. What needs or duties is it designed to meet? What are its intended outcomes? The purpose of this policy is to enable the Trust to comply with the relevant legislative requirements concerning the Health, Safety and Welfare of employees and members of the public and that it complies with the duty of care towards all staff and those affected by its work activities by providing a safe working environment and the suitable provisions and resources needed to ensure this. 3. If this service /policy /procedure / Trust function has no relevance for Equalities or human rights considerations, please give your reasoning below and sign on page 2. No There is no relevance for equalities or human rights considerations. (Where there is no relevance then the screening section can be signed and countersigned, and there is no need for a full assessments. Where there is relevance, then a full Equality and Human Rights Impact Assessment must be undertaken. Potential Privacy Risk Screening Assessment 4a. Does the project/service development involve any technologies that might have a privacy impact, for example, Smartcards, biometrics, digital imaging, video recording or logging of electronic traffic? No 4b.Does the project/service development involve the use of new personal identifiers or an extension in the use of personal identifiers? No 4c. Does the project/service development involve the handling of a significant amount of new personal data? No Page 28 of 32

29 4d. Does the project/service development involve new or changed data management processes that might be intrusive, insecure, more permissive in terms of access to data, or unclear? No If the answer to any of questions 4a 4d is yes, you are required to contact the Information Governance Team for advice on how to proceed in relation to the privacy issues identified. Manager undertaking the screening assessment Name Designation: Frank Sobande Date 07/04/2015 Health and Safety Risk Manager To be countersigned by the Senior Manager, i.e. Service Head, Line Manager, Director, as appropriate Name Designation: Jack Pooler Head of Safety Date 07/04/2015 * * Full assessment 5. How does the policy / procedure / protocol / service development: Contribute to eliminating unlawful discrimination? Contribute to promoting equality of opportunity? Contribute to promoting good relations between people of different groups? Encourage respect for human rights? The Policy takes into consideration all levels of staff and management. As a result, disabled staff will not be unlawfully discriminated against and equality of opportunity promoted. 6a.Is there any evidence that the service / policy could affect some groups of people (race/ethnicity, disability, gender (including transgender people or people undergoing gender reassignment), age, faith/religion, sexual orientation) disproportionately? Is there reason to believe that the service / policy may have different outcomes for different groups? Is there an adverse impact? What are the reasons for this adverse impact? Please comment under each of the side headings below. Race/ethnicity: No adverse impact Disability: No Adverse impact Page 29 of 32

30 Gender (including transgender and gender reassignment): No adverse impact Religion or Belief No adverse impact Sexual orientation No adverse impact. Age No adverse impact 6b.Is there any evidence that the service / policy is at risk of unlawfully restricting an individual s human rights? No 7. Please describe the evidence you have used to make your judgement in 6a and 6b. What existing data for example (quantitative or qualitative) have you used to form your judgement? Race/ethnicity: N/A Disability: Policy consulted with the Head of Equalities and Diversity and comments were incorporated into the Policy. Gender (including transgender and gender reassignment): N/A Religion or Belief N/A Sexual orientation N/A Age N/A Page 30 of 32

31 Human Rights N/A 8. Have you consulted with the public / staff / service users / carers as part of your assessment? Who have you consulted? What method did you use? What were the results of the consultation and what have you done with them (i.e. how have you used the information gathered as part of the consultation?) This policy has been sent to The Corporate Risk/Health and Safety Group (which is represented by all Directorates), and the Head of Equalities and Diversity for comment. Comments have then taken into consideration and amendments made as required. 9. Have you published results of the consultation? If so, where? The results of the consultation were discussed at The Corporate Risk/Helath and Safety Group. 10. Is there public concern (in the local or national media for example) that this function / policy / service is being operated in a discriminatory manner? How have you taken this into account with regard to consultation, publishing the results of that consultation and in the policy or service development that is subject to this EHRIA? No 11. If, in your judgement, the proposed service /policy / procedure does have an adverse impact or is at risk of unlawfully restricting Human Rights, can that impact be justified? - You need to think whether the proposed service / policy / procedure will have a positive or negative effect on the: Elimination of unlawful discrimination Promotion of equal opportunity Promotion of good relations between people of different groups Ensuring respect for human rights No 12. If the impact cannot be justified, how do you intend to deal with it? N/A 13. Provide information on how you intend to monitor in the future The policy will be reviewed and updated every 2 years. Equality and Human Rights Impact Assessment Action Plan Page 31 of 32

32 The following actions will be undertaken as a result of the Equality and Human Rights Impact Assessment to address identified adverse impact: None identified Adverse impact identified Action to be taken Timescale Responsible Manager To be signed by the Manager undertaking the full assessment Name Designation: Frank Sobande Date 07/04/2015 Health and Safety Risk Manager To be countersigned by the Senior Manager, i.e. Service Head, Line Manager, Director, as appropriate Name Designation: Jack Pooler Head of Safety Date 07/04/2015 Page 32 of 32