Airedale NHS Foundation Trust
Trust Board: October 2013
Title: Health and Safety policy
Author: Stacey Hunter
Background
The Health and Safety at Work Act requires that the Board of Directors formally
approve the Health and Safety (H&S) Policy to ensure that aall Board decisions
reflect the Foundation Trust’s health and safety intentions, as expressed in the
health and safety policy
Introduction
The Board has delegated management for all issues relating to H&S to the Joint
Health and Safety Committee which oversees the H&S strategy to ensure it meets
the standards required by the Health and Safety Executive and statutory
regulation. The responsible Director and chair of the Joint Health and Safety
Committee is the Director of Operations. The policy has been reviewed and
approved by the Health and Safety Operational Group, and the Joint Health and
Safety Committee and been ratified by the Procedural Documents Approval
Group. This provides the Board with assurance that it has been through the
appropriate governance groups and deemed fit for purpose by the Joint Health
and Safety Committee within the remit of their delegated authorities.
Key Points of the policy
•
•
•
•
Describes the roles and responsibilities for Health and Safety within the
Trust
How ANHSFT acts to protect the Health and Safety of its Employees and
other affected by its undertakings
Describes how the Trust will meet it’s legal requirements for Health and
Safety
Defines how Health and Safety arrangements will be monitored to ensure
compliance with policy and ensure any issues are promptly identified
Changes since the last version
It should be noted that it has not been necessary to make material changes to the
policy as the law and guidance that govern H&S in the NHS has not changed
since the last policy update. Therefore the changes are minor and relate to
changes in job titles and names of management groups/committees e.g.
Executive Assurance Group and the Procedural Documents approval group.
Board Actions:
The Board are asked to approve this updated version of the Health and Safety
Policy for Airedale NHS Foundation Trust.
Stacey Hunter
Director of Operations
October 2013
1
Health and Safety Policy
Document
Reference:
Automatically
allocated on
Sharepoint
Version:
6.2
Document
Owner:
Director of Operations
Document
Author:
Compliance Manager
Date
Approved:
August 2013
Date Ratified:
September 2013
Review date:
Dec 2015
Accountable
Committee:
Ratified by:
Date issued:
Target
audience:
Health and Safety
Operational Group
and Joint Health and
Safety Committee
Policy Approval and
Ratification Group
Date this document is
posted on the intranet
All staff and people
working at ANHSFT
premises
Equality Impact
Yes
Assessment:
Key points
•
•
•
How ANHSFT acts to protect the Health and Safety of its Employees and
other affected by its undertakings
Defines responsibilities for achieving Health and Safety
Describes how the Trust will meet it’s legal requirements for Health and
Safety
The most recent version of this document is held on the Sharepoint Policies
page.
Uncontrolled if Printed
1
CONTENTS
1.0
ASSOCIATED DOCUMENTS ....................................................................... 4
2.0
INTRODUCTION ........................................................................................... 4
2.1 Trust Statement of Intent....................................................................... 4
2.2 Sustainable Development - EcoAwaire ................................................ 5
2.3 Purpose .................................................................................................. 5
2.4 Scope ...................................................................................................... 6
3.0
DEFINITION OF TERMS USED WITHIN THIS DOCUMENT ........................ 6
4.0
DUTIES ......................................................................................................... 7
4.1
Structure for the Management of Health and Safety...................... 7
4.1.1 Trust Board .............................................................................. 7
4.1.2 The Executive Assurance Group (EAG)................................. 8
4.1.3 Policy, Guidance and SOP s Approval Group ....................... 8
4.1.4 The Joint Health and Safety Committee ................................ 8
4.1.5 The Health and Safety Operational Group ............................. 8
4.2
General Roles and Responsibilities................................................ 9
4.2.1 Chief Executive........................................................................ 9
4.2.2 Directors / General Managers / Heads of Service /
Department Managers...................................................................... 9
4.2.3 Line manager’s responsibilities ........................................... 10
4.2.4 Employees responsibilities .................................................. 11
4.3
Specialist Health and Safety Responsibilities.............................. 12
4.3.1 Designated Executive Director ............................................. 12
4.3.2 Compliance manager ............................................................ 12
4.3.3 Health and Safety Co-ordinator ............................................ 12
4.3.4 Head of Employee Health and Wellbeing............................. 13
4.3.5 Fire Safety Advisor ................................................................ 13
4.3.6 Manual Handling Coordinator .............................................. 14
4.3.7 Assistant Director Estates and Facilities / Nominated
Building Custodians ...................................................................... 14
4.3.8 Other Specialist Health and Safety Advisors ...................... 15
4.3.9 Communication Manager ...................................................... 15
4.3.10 Training and Education Department .................................. 15
5.0
PRINCIPLES OF HEALTH AND SAFETY .................................................. 15
7.0
DISSEMINATION AND IMPLEMENTATION ............................................... 16
7.1 Dissemination ...................................................................................... 16
7.2 Implementation .................................................................................... 17
7.3 Training/Awareness ............................................................................. 17
8.0
PROCESS FOR MONITORING EFFECTIVE COMPLIANCE...................... 17
9.0
RECORD KEEPING .................................................................................... 17
10.0
EQUALITY & DIVERSITY ........................................................................... 18
11.0
REFERENCES ............................................................................................ 18
12.0
VERSION CONTROL SHEET ..................................................................... 20
12. APPENDICES ................................................................................................... 21
APPENDIX A CONSULTATION ............................................................................. 21
2
APPENDIX B EQUALITY IMPACT ASSESSMENT – INITIAL ASSESSMENT FORM
................................................................................................................................ 23
3
1.0 ASSOCIATED DOCUMENTS
This policy to be read in conjunction with other health and safety related
policies and procedures as follows:•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Risk Management Policy Risk Management Strategy
Risk Assessment Procedure
Adverse Event Reporting Procedure
Adverse Event Investigation Procedure
Serious Incidents Requiring Investigation (SIRI) Policy
MAJAX Plan
Complaints Management Policy
Claims Management Policy
Management of Occupational Stress Policy
Contamination Injuries Prevention and Management Policy
COSHH (Control of Substances Hazardous to Health) Policy
Asbestos Management Plan
Manual Handling Policy
Slips, Trips and Falls Policy for Staff, Visitors and Others
Security Policy
Display Screen Equipment Policy
Fire Safety Policy
Latex Policy
Maternity Risk Management Strategy
Resuscitation Policy
Being Open Policy
Medical Devices Policy
Waste Disposal Policy
All policies including the Trust’s compliance with the requirements of health and
safety are available on the SharePoint site under Trust Policies.
2.0 INTRODUCTION
2.1 Trust Statement of Intent
The minimisation of injury to human costs in terms of injury, pain and incapacity to
our staff and visitors is paramount to our Trust. This policy aims to ensure adequate
controls are in place to address the Health and Safety risks arising from the Trust’s
work activities and that staff are appropriately consulted on matters affecting their
health and safety in order that a health and safety culture may be developed that
permeates into all areas and activities of the Trust.
Effective health and safety requires cooperation at all levels of the organisation. This
policy outlines roles and responsibilities and focuses on how to reduce risks through
effective control of activities and the environment. The Trust considers this
responsibility equal to that of any other management function.
The Health and Safety Policy has been developed in accordance with the relevant
overaching Health and Safety at Work Act 1974 (HASWA) which requires employers
to ensure as far as is reasonably practicable, the health and safety of their
employees and others who may be affected by their work activity. In addition,
4
employees must not endanger themselves or others and must use any safety
equipment provided.
Other relevant Health and Safety related Laws and Regulations are listed below:NB: this list is not exhaustive
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Health and Safety at Work Act 1974
Workplace (Health, Safety and Welfare) Regulations 2002
Management of Health and Safety at Work Regulations 1999
Manual Handling Operations Regulations 1992
Personal Protective Equipment at Work Regulation 1992
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations
(RIDDOR) 1995
Display Screen Equipment Regulations 1992
Consultation with Employee regulations 1996
Disability Discrimination Act 1995
Healthcare commission core standards
Human Rights Act 1998
LOLER Regulations 1998
Mental Capacity Act 2005
Provision and use of work equipment regulations 1998
Safer Patient initiative
Safety Representative and Safety Committee Regulations 1977
The Trust complies with the Employers Liability (Compulsory Insurance)
Regulations 1999 through its memberships of the NHS Litigation Authority
(Liabilities to third Parties Scheme {LTPS})- more details can be found in
the Claims Policy
Occupiers liability Act 1957 and Occupiers Liability Act 1984
Defective Premises Act 1972
2.2 Sustainable Development - EcoAwaire
As part of its development, this policy was reviewed in line with the Trust’s
sustainability ideals. As a result, the document is designed to be used electronically
in order to reduce any associated printing costs.
2.3 Purpose
This Policy has been written to ensure compliance with Section 2 (3) of the Health
and Safety at Work Act 1974 that requires organisations to have a written Health and
Safety Policy. The Trust recognises its responsibilities as the Employer as specified
in the Health & Safety at Work Act (1974) and in all subsequent Health & Safety
legislation relevant to the activities of the Trust, including the European Community
directives on Health and Safety at Work.
This Policy is compliant with the requirements of the NHSLA Acute Risk
Management Standards and complements the Trust’s Risk Management Strategy,
Risk Assessment Policy, Risk Assessment procedure, Adverse Event reporting
procedure and Adverse Event Investigation procedure that can be found on
Sharepoint. It provides guidance to management and employees in the fulfilment of
their duties.
It is the policy of the Trust to provide a safe and healthy environment for all
employees, trainees, patients, visitors, contractors, members of the public and users
of our services, and to enlist the active support of all employees to achieve this.
5
Good health and safety benefits the Trust by:
• seeking to protect staff from injury or illness as a result of work
• minimising the financial losses arising from avoidable unplanned events and
learning lessons from claims made against the Trust to prevent recurrence
events.
• ensuring compliance with health and safety related legislative and regulatory
requirements
• ensuring a systematic approach to the identification of health and safety risks and
the allocation of resources to control them and that a robust escalation process is
in place.
• ensuring compliance with external audits eg NHSLA by evidencing that robust
health and safety processes are in place.
• enhancing and protecting the reputation of the Trust
2.4 Scope
This Health and Safety Policy is created in compliance with common law and
statutory duties relating to health and safety. It is supported by specific policies
arising from health and safety legislation where required, for example, the COSHH
Regulations 1999. It applies to all employees and those who work on behalf of the
Trust (including volunteers) and is supplemented by appropriate departmental policy
and other specialised policies (see 1.0 of this policy)
3.0 DEFINITION OF TERMS USED WITHIN THIS DOCUMENT
Accident
Includes any undesired circumstances which give rise to ill health
or injury, damage to property, plant, products or the environment,
increased liabilities
Danger
A liability or exposure to harm, a thing that causes peril
Dangerous
Occurrence
Environmental
Protection
Hazard
A “near miss” which could have lead to serious injury or loss of
life and which is reportable to the enforcing authorities
Arrangements to protect the environment from the effects of
workplace activities
The potential of a substance, activity or process to cause harm
Health
Health
Surveillance
The protection of the bodies and minds of people from illness
Monitoring of employee health to detect signs or symptoms of
work related ill health so that steps can be taken to eliminate or
reduce the probability of further harm
Includes acute / chronic ill health caused by physical, chemical or
biological agents as well as adverse effects on mental health
Ill health
Incident
Includes all undesired circumstances and near misses which
have the potential to cause accidents
Near miss
Occupational ill
health
Policy
An incident which could have resulted in an accident
Illness or physical and mental disorders caused or triggered by
workplace activities
Is used in relation to health and safety and other functional
management areas to convey the general intentions, approach
and objectives of an organisation. Written policy statements is
used to describe the documents which record the policy of the
organisation
6
Risk
Definitions relating to risk can be found in the Trust’s Risk
Assessment procedure which is available on SharePoint here
Safety
Suitable and
Sufficient
Welfare
• Acceptable Risk
• Residual Risk
• Risk
• Risk Acceptance
• Risk Analysis
• Risk Assessment
• Risk Avoidance
• Risk Control
• Risk Evaluation
• Risk Identification
• Risk Management
• Risk Reduction
• Risk Transfer
• Risk Treatment
• System Failure
The protection of people from physical injury
A set criteria that has to be met to fulfil a duty.
The provisions of facilities to maintain health and well-being of
individuals
4.0 DUTIES
Health and safety requires an active lead from managers at all levels to ensure that it
is a fundamental part of the Trust’s total approach to quality improvement, integrated
governance and assurance. It is recognised that although ultimate responsibility for
health and safety rests with the Board, all staff are required to play a positive role to
improve health and safety. Operational responsibility lies with management and the
individual employee.
Any employee, including managers, department heads, clinical and executive
directors and general managers may be found criminally liable if he/she has not
fulfilled their duties under the Health and Safety at Work Act 1974 and related
regulations.
4.1
Structure for the Management of Health and Safety
4.1.1 Trust Board
The Trust Board has overall accountability for health and safety and is responsible
for collectively and individually providing health and safety leadership at the Trust,
and the development and implementation of this policy. This includes;
•
•
•
delegating responsibility to the Chief Executive for ensuring this policy is
implemented
designating an Executive Director to have overall responsibility, on behalf of the
Chief Executive, for co-ordinating risk management and health and safety work
within the Trust
ensuring all board decisions reflect the trust’s health and safety intentions and
policy
7
•
•
•
•
•
•
•
acting to engage all staff in health and safety and promoting a positive health
and safety culture
ensuring they are kept informed and alerted to relevant health and safety issues
and that when decisions are being made the health and safety implications are
considered
ensuring that appropriate resources are allocated to allow implementation of this
policy
ensuring that effective management systems are in place for monitoring and
reporting on health and safety performance, including health and safety audits
and an annual review of health and safety performance
ensuring liability is covered by adequate insurance
reviewing and approving the health and safety policy, at least annually
receives risk assessments with a score of 12 and above.
4.1.2 The Executive Assurance Group (EAG)
This Group provides the Trust Board with assurances that risks are properly
managed and controlled and reviews the management of corporate risks (rated 9 and
above).
It supports the Trust Board in developing an integrated approach to risk management
by ensuring implementation of robust systems that enable the Trust to achieve its
objectives.
It provides the Trust Board with the information it needs to understand progress
against its objectives and highlights serious risks (with a score of 12 and above) to its
principal objectives (Assurance Framework).
It promotes local level responsibility and accountability by developing capability and
effective monitoring and control mechanisms.
4.1.3 Policy, Guidance and SOP s Approval Group
Is responsible for ratifying all Trust policies, its terms of reference can be found here.
4.1.4 The Joint Health and Safety Committee
This committee, which meets quarterly, reports to EAG in the month following the
quarter-end and by exception.
It oversees implementation of the health and safety policy; reviews, monitors and
makes recommendations with regard to health and safety risks to individuals working
for, contracted to or visiting the Trust and also to the Trust’s non-clinical structures,
systems and processes.
Is chaired by the Designated Executive Director with responsibility for health and
safety .
Ensures the Trust is compliant with relevant legislative and NHS standards, e.g.
Health and Safety at Work Act 1974, NHSLA and consults with staff as described in
Appendix C.
Detailed responsibilities are covered in the terms of reference, available here.
4.1.5 The Health and Safety Operational Group
This committee, which meets bi-monthly, reports to the Joint Health and Safety
Committee
8
It oversees operational implementation of the health and safety policy; reviews,
monitors and makes recommendations with regard to health and safety risks to
individuals working for, contracted to or visiting the Trust and also to the Trust’s nonclinical structures, systems and processes.
Is chaired by the Assistant Director Estates and Facilities.
Supports the Joint Health and Safety Committee to ensure the Trust is compliant with
relevant legislative and NHS standards, e.g. Health and Safety at Work Act 1974,
NHSLA.
Detailed responsibilities are covered in the terms of reference, available here
4.2
General Roles and Responsibilities
4.2.1 Chief Executive
The Chief Executive has overall responsibility for health and safety in the Trust.
Through delegation to the designated Executive Director, the Chief Executive will
ensure the following:
•
•
•
•
•
•
•
the Health and Safety Policy is understood and implemented
the Trust complies with all health and safety legislation
corporate health and safety objectives are created, and a plan developed for their
implementation (this may include the development of directorate policies,
procedures and objectives)
adequate resources, including competent health and safety advice are available
to allow the Trust to comply with this policy and legislative requirements
processes are in place to provide the Trust Board with the assurance that health
and safety risks are appropriately assessed and controlled
the Trust Board has the reports necessary to show whether or not this policy is
being implemented or where improvements need to be made
a positive health and safety culture is promoted
The Chief Executive’s overall responsibility for health and safety is discharged
through the normal management structure with managers’ job descriptions containing
health and safety responsibilities. The Chief Executive will ensure that the
effectiveness of the Health and Safety Policy is continually reviewed.
4.2.2 Directors / General Managers / Heads of Service / Department Managers
The responsibility for allocating roles and responsibilities for health and safety, for
the overall achievement of the Trust’s policy and for the completion of risk
assessments rests with the appropriate Directors / General Managers / Heads of
Service / Department Managers (Senior Manager).
The Senior Managers’ responsibilities are to protect the health and safety of
themselves, their staff and people who might be affected by their or their staff's
actions and ensure that proper consideration is given to health and safety matters
including:
•
•
allocating health and safety responsibilities to specific people and the
management of these health and safety staff within their management
structure
agreeing with the designated Executive Director the role and priorities for
nominated health and safety staff
9
•
•
•
•
•
•
•
•
•
•
•
acting in compliance with trust health and safety and related policies and
procedures and in a manner that assists in the development of a health and
safety culture
interpreting health and safety policy within their sphere of operations
ensuring all potential risks, including risk of injury, are identified and risk
assessments are undertaken using the trust risk assessment procedure and
bringing the results to the attention of the relevant group as described in the
risk management policy
identifying and carrying out risk assessments of areas under their control
where ongoing monitoring of health hazards, for example noise, dust, fume,
maybe required. Where a requirement is identified, for liaising with the
appropriate specialists to ensure suitable monitoring is in place
ensuring incidents are reported and investigated in compliance with the
Trust’s adverse event reporting and investigation procedures.
ensuring staff receive the appropriate resources, information, instruction,
training and supervision required to enable them to work safely
ensuring local health and safety arrangements and polices are in place,
including effective systems for measuring health and safety performance
ensuring this policy is adhered to and incorporated in all contracts with external
agencies
providing timely feedback to their staff regarding health and safety issues,
incidents, risks, controls and mitigating actions
work with Head of Facilities/Nominated Building Custodians to ensure suitable
signage is in place to warn of hazards
alerting the Health, Safety and Emergency Planning Manger or designated
Executive Director of any health and safety issues they are, or become
aware, of and acting to resolve these issues where appropriate.
4.2.3 Line manager’s responsibilities
Managers are directly responsible for ensuring that rules, regulations, procedures
and codes of practice relating to health and safety of employees, trainees and
others affected by the work of their department, for example contractors,
students, agency and locum staff (staff) are correctly adhered to and
•
•
•
•
•
•
that staff are aware of and comply with the Trust’s health and safety policy
and any local health and safety requirements and arrangements
their staff receive the appropriate information, instruction, training and
supervision to enable them to work safely
staff are aware of, and follow, the process for reporting of incidents and
accidents
ensuring this policy is adhered to by all people working on site under their
responsibility and incorporated in all contracts with external agencies
carrying out, and reviewing at least annually, suitable and sufficient risk
assessments, relevant to their areas
reporting the outcome of all risk assessments pertinent to the management of
health and safety to their local Quality and Safety group and where scored
o 9 or more to relevant sub-groups to be escalated to the Health
and Safety Operational Group and Joint Health and Safety
Committee as required,
o 9 or more escalated to the Executive Assurance Group for
consideration
o 12 or more reported to the Board
These groups are also responsible for ensuring the assessments are entered
onto the local or Trust risk register, approving the actions required to control
10
•
•
•
•
•
•
the risks that fall into their jurisdiction and ensuring assurance is obtained to
confirm implementation of the action
identifying appropriate specialists, for example occupational hygienists to
allow the development safe systems of work to deal with identified hazards
and reduce the risk
monitoring accident and ill-health reports for their areas of responsibility
ensuring that health and safety audits and inspections are completed and
any risks / actions identified are acted upon
ensuring health & safety requirements for first aid provision are met
liaison with trade union representatives, elected employees or directly with
employees regarding health and safety matters
to ensure staff under their remit attend Employee Health and Wellbeing services
for health surveillance if this has been identified through the risk assessment
process
4.2.4 Employees responsibilities
All employees, trainees, contractors, agency and locum staff are required to:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
cooperate with supervisors, managers and other employees on health and safety
matters
not interfere with anything provided to safeguard their health and safety
not enter areas where they do not have authorisation to be
take reasonable care of their own health and safety and that of other persons who
may be affected by their actions
carry out their responsibilities in ways that help to ensure a safe and healthy place of
work
avoid improvisation which may create risks to the health and safety of themselves or
others
maintain awareness of, and act in accordance with, the requirements of the health
and safety policy and other related policies and procedures, including compliance
with the uniform and workwear policy.
cooperate with the trust on the implementation of this policy, supporting policies,
procedures and guidelines and any other change required for health and safety
ensure they attend appropriate health and safety training
make themselves aware of risk assessments and other health and safety information
provided for their benefit
encourage colleagues to adopt a positive attitude to health and safety
comply with the Trust’s incident management and risk policies
bring to the attention of their supervisor or manager, by completing an adverse event
form if appropriate
o
any situation which reasonably could be considered to represent a
serious or immediate danger to the health and safety of any person
o
any matter which reasonably could be considered to represent a
shortcoming in the Trust’s health and safety protection arrangements
o
any other concern related to health and safety
o
any accident or incident occurred (whether or not injury resulted) and
complete an adverse event form.
o
any extremes of environmental conditions, such as temperature,
shadows or glare.
where no trade union representation is in place, employees can elect to liaise with
management, through an elected staff member, or be consulted as a group, on
matters affecting health and safety.
to attend Employee Health and Wellbeing services for health surveillance if this has
been identified through the risk assessment process
11
4.3
Specialist Health and Safety Responsibilities
The following post-holders have additional health and safety duties above the
standard responsibilities outlined above.
4.3.1 Designated Executive Director
The Trust will designate an Executive Director lead on health and safety. Currently
the Director of Operations is designated the lead Director.
The designated Executive Director is responsible for:
• reporting to the Chief Executive, and Trust Board on policy implementation,
achievement of health and safety objectives, any health and safety issues and
areas where improvements need to be made.
• supporting the implementation of the Health and Safety Policy
• ensuring there is a process in place to enable consistent development,
implementation and monitoring of health and safety policies, procedures,
guidance, etc
• working with the Trust’s specialist health and safety staff to agree the health and
safety work-plan and for agreeing roles in conjunction with the relevant manager
• chairing the Trust’s Joint Health and Safety Committee, reviewing health and
safety performance and progress and agreeing plans for improvement
• ensuring the Trust meets its legal requirement to consult with employees fully in
regard to health and safety matters
• ensuring appropriate staff training is in place for health and safety
• ensuring appropriate management arrangements are in place to maintain a safe
environment for all people attending the Trust site or receiving a service provided
by the Trust.
• ensuring appropriate competent persons are appointed to undertake health and
safety work
• working with the Compliance Manager to develop a health and safety culture at
the Trust.
• working with the relevant specialist to ensure liaison with external agencies
occurs promptly and correctly
4.3.2 Compliance manager
The Compliance Manager (is the designated competent person for the trust) reports
to the Assistant Director of Healthcare Governance and is responsible for the
following:
• formulating and developing the health and safety policy and management
structure in line with HSE Best practice ;
• reporting arrangements are in place against key performance indicators to
monitor the Trust’s performance relating to health and safety; including incident
reporting statistics and areas of non-compliance;
• providing advice and guidance to assist managers to meet their duties under
health and safety law;
• ensuring and monitoring compliance with legal and regulatory requirements and
other relevant standards;
• co-ordinating Trust’s systems for maintaining Health and Safety compliance;
• ensuring, through the designated Executive Director, the Board receives an
annual report in regard to the Trust’s status regarding health and safety.
• work with the designated director to plan the trusts approach to health and safety
and support the Trust’s health and safety culture
4.3.3 Health and Safety Co-ordinator
The Health & Safety Co-ordinator reports to the Compliance Manager and is
responsible for the following
12
•
•
•
•
•
•
•
•
•
•
•
supporting the development and review of Health and Safety policies and
guidance;
co-ordinating the reporting and investigation of all RIDDOR accidents and
supporting staff in the investigation of accidents;
delivering appropriate health and safety training to Trust employees and trainees
and feeding into the Mandatory Trainers meetings on quality of training delivered;
assisting Trust employees and managers to carry out risk assessments in
situations to ensure health and safety risks are minimised;
promoting a health and safety culture including effective communication
regarding health and safety to help ensure active participation of Trust staff and
other interested parties;
undertaking routine interrogation of the Adverse Event Reporting database to
highlight patterns and trends to produce quarterly dashboard reports to the
Health and Safety Operational Group. Co-ordination of risk reduction plans from
other health and safety specialist areas to add to reports;
producing quarterly reports for health and safety related groups for further
discussion/identification of hot spot areas. Chair and feed into slip, trip, fall and
contamination injuries working group subgroups. Also input into manual handling
subgroup;
Responsibility for the self inspection audit system and ensuring that all areas
complete this annually to ensure all areas are health and safety compliant. Coordination and support given to all areas with Trust and community based staff;
Providing assurance for agreed, specified areas (including slips, trips and falls
and COSHH) under the SIA that the responses received are valid
working with other health and safety specialists within the Trust to ensure safety
of Trust staff.
co-ordination with estates maintenance with regards to health and safety
operational group agenda planning and escalation of appropriate issues to the
joint health and safety group as required.
4.3.4 Head of Employee Health and Wellbeing
The Head of Employee Health and Wellbeing reports to the Head of and is
responsible for:
• providing an Employee Health and Wellbeing service
• pre-employment and health screening
• secure storage and maintenance of staff health records
• providing a staff counselling service, including following an incident
• supporting managers with the rehabilitation and resettlement of employees
returning after accidents or illness.
• advising on and helping the Trust to develop relevant policies and guidance
• advising managers of problems which may affect the health and safety of
employees and trainees
• maintaining the immunisation service as required
• keeping up-to-date with changes in legislation, standards and good practice
• supporting managers in delivering a safe working environment for staff
• where appropriate, arranging for and keeping records for health surveillance
4.3.5 Fire Safety Advisor
The Fire Safety Advisor will be accountable to the Head of Facilities (Fire Safety
Manager) for matters of fire safety in line with HTM 05-01. They provide competent
fire safety advice and will be responsible for:
• undertaking, recording and reporting fire risk assessments;
• providing expert advice on fire legislation
• providing expert technical advice on the application and interpretation of fire
safety guidance, including DH’s Firecode;
13
•
•
•
•
•
•
•
•
•
•
assisting with the review of the content of the Trust’s fire safety policy;
assisting with the development and delivery of a suitable and sufficient training
programme for staff;
the assessment of fire risks within premises owned, occupied or under the control
of the Trust;
the preparation of fire prevention and emergency action plans;
the investigation of all fire-related incidents and fire alarm actuation;
liaison with the enforcing authorities on technical issues;
liaison with managers and staff on fire safety issues;
liaison with the authorising engineer (fire).
giving advice regarding fire safety measures, recommending the order of
priorities of fire safety work and undertaking fire risk assessments
ensuring compliance with relevant fire legislation
4.3.6 Manual Handling Coordinator
The Moving and Handling Co-ordinator reports to the Training and Development
Manager and is responsible for:
• advising and assisting mangers in the implementation of the moving and handling
policy;
• providing specialist manual handling advice to staff to ensure they develop and
maintain their manual handling knowledge and skills;
• delivering training for key trainers, new staff, and updates for remaining staff in
the absence of a key trainer;
• reporting on training, provision and uptake quarterly to the manual handling
assurance group, health and safety operational group and quality and safety
assurance group
• assisting with manual handling risk assessments in complex handling situations
or where the manager feels they are unable to do so;
• assisting with the development of local guidelines for manual handling tasks and
reporting these to the manual handling assurance group;
• supplying information to all wards/departments on all aspects of manual handling
as required via the manual handling sharepoint site;
• providing specialist advice and guidance on all aspects of manual handling;
• reporting on changes to the Manual Handling Operations Regulations and other
relevant regulations and guidelines;
• assisting with review of health and safety incident reports;
• providing assistance to Employee Health and Wellbeing in the assessment of
staff with appropriate complex handling needs via a robust referral system;
• reporting, reviewing and providing assurance on the results of the aspects of the
Self Inspection Audit process relating to manual handling.
4.3.7 Assistant Director Estates and Facilities / Nominated Building Custodians
Are responsible for the fabric of the Trust, they have a duty to:
• carry out the operational health and safety management of the Trust’s buildings
and fabrics, including ensuring safe access and egress
• assist managers and safety representatives to ensure that staff working
environment is in a safe and healthy condition
• when selecting flooring ensuring slip resistance has been assessed and taken
into account
• make arrangements for the communication, co-operation and co-ordination of
health and safety arrangements with others in shared premises
• make repairs and carry out maintenance to ensure a safe working environment
for staff, visitors and others
• ensure specialists are consulted during all phases of construction and
refurbishment projects,
14
•
•
advising the designated Director and Compliance Manager of areas for concern
and improvement regarding health and safety
work with senior managers to ensure suitable signage is in place to warn of
hazards
4.3.8 Other Specialist Health and Safety Advisors
The Trust employs or has access to other health and safety advisors including:
• Director of Infection, Prevention and Control
• Infection Control Manager
• Assistant Director Estates and Facilities (also the Local Security Management
Specialist and Fire Safety Manager)
• Resuscitation Officer
• Head of Capital Corporate Services (for Legionella and Asbestos advice)
• Radiation Protection Advisor, Medical Physics BRI
Their individual responsibilities are defined within the relevant policies located on the
Trust Policies page on Sharepoint
4.3.9 Communication Manager
The Trust‘s Communication Manager is responsible for managing all contacts with
the media regarding health and safety issues.
4.3.10 Training and Education Department
On joining the Trust all staff will receive health and safety induction training including,
risk assessment, incident investigation, fire and manual handling training. They will
also receive local induction that includes local health and safety arrangements. This
training will be repeated at defined intervals, depending on the type of job held.
Advice and support on health and safety and the risk management process is
provided by the Quality and Safety Team, including how to grade and classify risks.
Additional health and safety training can be provided for leads and department
managers as identified through their personal development plans. The training
needs analysis for the trust identifies which training and how frequently that training
takes place and is available at:
http://www.learnonline.nhs.uk/Trust+Training/Airedale+NHS+Trust/General+Training/
Training+Prospectus
5.0 PRINCIPLES OF HEALTH AND SAFETY
The Trust has responsibilities under health and safety legislation and will
•
•
•
•
•
•
Provide adequate control of the health and safety risks arising from our work
activities by: carrying out appropriate risk assessments; ensuring accidents and
incidents are reported via the Trust Adverse Event Reporting Process;
investigation and lessons learnt to prevent recurrence.
Proactively review health and safety arrangements to ensure continuous
improvement in health and safety practice
Conduct our work activities in such a way as to ensure, so far as is reasonably
practicable, that people not employed by the Trust, but who may be affected by
the Trust’s activities are not exposed to health and safety risks.
Recognise that accidents, ill health and incidents result from the failure of
management control and are not necessarily the fault of individual employees
Ensure safe means of access and egress Trust Wide.
Maintain safe and healthy working conditions (including the provision of adequate
welfare facilities), safe systems and methods of work and seek to protect
15
•
•
•
•
•
•
•
•
•
•
employees, trainees, contractors, patients, visitors, members of the public and
users of our services from hazards.
Provide suitable and sufficient information, instruction, training and supervision to
ensure all employees are competent to carry out their jobs safely and efficiently
Use the best possible means to prevent the emission of noxious or offensive
substances and to render these substances harmless and inoffensive
Provide and maintain safe plant, equipment, machinery and systems of work (this
is covered in detail within the Estates Maintenance Health and Safety (Policy)
Ensure safe handling, storage, transportation and use of substances (this is
covered in detail within the COSHH policy)
Encourage a supportive health and safety and risk culture that allows adequate
control measures in regard to health and safety risks and ensures staff are
actively encouraged to report any safety issue.
Acknowledge that people are a key resource to the Trust and act to promote the
general health, safety and wellbeing of its staff
Promote standards of health, safety and welfare in order to comply with, at
minimum, the provisions and requirements of the Health and Safety at Work Act
1974 and all other statutory provisions, guidance and where applicable codes of
practice.
Ensure adequate meeting arrangements are in place (Health and Safety
Operational Group and Joint Health and Safety Committee) to consult with
employees in regard to health and safety issues and arrangements and to
provide a mechanism for raising health and safety concerns. (see Appendix C for
more information on the requirement to consult staff).
Provide adequate and appropriate resources to implement this policy, including
access to specialist advice when required.
Review and revise this policy as necessary, but not less than annually.
Breaches of this policy which would constitute a failure to comply with the Health and
Safety at Work Act 1974 and its associated regulations may lead to the prosecution
of the organisation/individual involved. Breaches of this policy could potentially result
in disciplinary action being taken under the Trust’s disciplinary policy whether or not a
prosecution takes place.
The Trust is aware the Corporate Manslaughter Act 2007 has removed the ‘directing
mind’ and placed greater responsibility for health and safety on all senior staff whose
duty it is to ensure all relevant policies and procedures are known to, and observed,
by staff under their control and that premises and plant are maintained in a safe
condition and that any risks to health and safety are identified and assessed. The
Trust will support managers and supervisors, as far as is reasonably practicable, to
achieve and comply with their duties of care.
6.0
CONSULTATION PROCESS
This policy has been developed and reviewed by the Health and Safety Co-ordinator,
Compliance Manager, Assistant Director of Healthcare Governance, Health and
Safety Operational Group, Joint Health and Safety Committee, Policy, Guidance and
SOPs Approval Group and all staff with specialist responsibilities identified within this
policy.
7.0 DISSEMINATION AND IMPLEMENTATION
7.1 Dissemination
This Policy will be communicated through the following mechanisms;
16
•
•
•
•
•
•
•
Policy, Guidance and SOPs Approval Group
Joint Health and Safety Committee
Monthly Communication Room Meeting
Weekly Staffing Briefing
Matrons and Sisters Meeting
Clinical Leads
Sharepoint under the Trust Policies Page
7.2 Implementation
To ensure that this procedural document comes to the attention of all Trust staff who
need to adhere to and act upon the requirements contained within it the document
will be posted via the Weekly Brief.
This document will be implemented immediately.
All managers will oversee implementation of this policy within their areas of
responsibility.
Implementation of this policy will be co-ordinated by the policy author.
7.3 Training/Awareness
Delivery of quality and safety training to staff is via the Trust’s corporate induction
and update mandatory training. This training is to be attended on commencement of
employment and to be updated every three years. This training includes reporting of
incidents using an adverse event form and explains the risk assessment process.
8.0 PROCESS FOR MONITORING EFFECTIVE COMPLIANCE
Standard to be
monitored
Process for
monitoring
Frequency
Person
responsible
Committee
accountable
for:
Frequency
of
monitoring
Assessment of Health
and Safety Policy
Compliance
Audit & Review of
implemented health
and safety
arrangements
Health and Safety
data collected is
representative of all
incidents
Report
Annual
Compliance
manager
Joint H&S
Committee
Annual
Self
inspection
audit
Annual
Health and
Safety
Coordinator
Annual
Monitor
reported
Health and
Safety
incidents by;
• Type and
Severity
Investigation
Completed &
Action taken
Health and
Safety
Dashboard
Report
Bimonthly /
Quarterly
Health and
Safety
Coordinator
Operational
H&S Group
Joint H&S
Committee
Operational
H&S Group
Joint H&S
Committee
Bimonthly /
Quarterly
Health and
Safety
Coordinator
Operational
H&S Group
Joint H&S
Committee
Bimonthly /
Quarterly
RIDDOR reports are
notified to the HSE
and have a
completed post
accident risk
assessment
9.0 RECORD KEEPING
17
Bimonthly /
Quarterly
This policy will result in the following classes of records being created, which will
observe the following retention regimes:
Record Type
H&S Annual Report
H&S Audit results
H&S incident data
RIDDOR Reports
Retention period
8 years
8 years
As defined in incident policy
As defined in incident policy
Disposal method
Secure - shredding
Secure - shredding
Secure - shredding
Secure - shredding
10.0 EQUALITY & DIVERSITY
Airedale NHS Foundation Trust is committed to the overarching principles of Equality
and Diversity. As such the organisation values and supports its entire staff. We are
committed to ensuring all forms of prejudicial, unfair basis and/or actions which result
in discriminatory practices are eliminated. The Trust makes this stand based not only
on meeting its legislative duties but also a moral strand on ensuring equitable
outcomes for all of its staff and patients.
The Foundation Trust is continually working towards eradicating all forms of
harassment and discrimination, exclusion, victimisation, harassment and bullying and
working to ensure it meets its legal duties by ensuring that:
•
•
•
unlawful discrimination, harassment and victimisation and other
conduct prohibited by the Equality Act 2010 are eliminated
equality of opportunity between people from different groups; is
advanced and
good relations between people from different groups are fostered.
The Trust treats any complaints it receives very seriously and as such any complaint
received in respect of this policy or associated policies (in terms of application or
adherence) will be investigated by Foundation Trust Staff. The process undertaken
will also ensure that complainants, patients, relatives and carers are not
discriminated against on the grounds of disability, gender, marital status, sexuality,
colour, race, nationality, ethnic origin, religion, belief or age. Additionally, the Trust
will ensure that no individual is treated in a detrimental manner as a result of having
made a complaint.
The policy will be continually reviewed to ensure that there are no elements within
the policy, practice or procedures that are prejudicial on any grounds in respect of the
protected equality characteristics mentioned above. Using the guidance produced
under the auspices of Equality legislation, this document has also been equality
impact assessed and is attached at the end of the document.
An Equality and Diversity Impact Assessment is appended at the end of the
document (See Appendix B).
11.0 REFERENCES
Legislation and other Health related guidance is as follows:• Health and Safety at Work Act 1974
• Workplace (Health, Safety and Welfare) Regulations 2002
• Management of Health and Safety at Work Regulations 1999
• Manual Handling Operations Regulations 1992
• Personal Protective Equipment at Work Regulation 1992
• Reporting of Injuries, Diseases and Dangerous Occurrences Regulations
(RIDDOR) 1995
18
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Display Screen Equipment Regulations 1992
Consultation with Employee regulations 1996
Disability Discrimination Act 1995
Healthcare commission core standards
Human Rights Act 1998
LOLER Regulations 1998
Mental Capacity Act 2005
Provision and use of work equipment regulations 1998
Safer Patient initiative
Safety Representative and Safety Committee Regulations 1977
The Trust complies with the Employers Liability (Compulsory Insurance)
Regulations 1999 through its memberships of the NHS Litigation Authority
(Liabilities to third Parties Scheme {LTPS})- more details can be found in
the Claims Policy
Occupiers liability Act 1957 and Occupiers Liability Act 1984
Defective Premises Act 1972
HSG 65 Successful Health and Safety Management
19
12.0 VERSION CONTROL SHEET
Version Date
Author
6.0
May 2013 Alison Fuller –
AD Healthcare
Governance
6.1
July 2013 Carol Woolgar –
Compliance
Manager
Status
Draft
Comment
Approved
Approved by JH&SC
08/08/2013
20
12. APPENDICES
APPENDIX A CONSULTATION
It is the policy of the Trust to fulfil the requirement to co-operate with representatives
of recognised trade unions or those elected as representatives of employee safety,
so that health and safety can be promoted and controlled effectively.
A.1 Appointed Trade Unions
The Safety Representatives and Safety Committees Regulations gave recognised
trade unions the right to appoint safety representatives amongst employees.
Employers are also required to consult with safety representatives so that
arrangements are made and maintained allowing effective co-operation. Where
trade unions are recognised, with an appointed safety representative, then
consultation must occur on matters affecting the group or groups of employees they
represent. They are entitled to
• investigate possible dangers at work, the causes of accidents there and
general complaints by employees on health and safety and welfare issues
and to take these matters up with the employer.
• carry out inspections of the workplace particularly following accidents,
diseases or other events.
• represent employees in discussions with health and safety inspectors and
to receive information from those inspectors; and
• go to meetings of safety committees.
A.2 No Trade Union Representation
There is a duty to extend consultation to any employees, who are not members of a
group covered by trade union representatives. Employees who are not covered by
trade union representatives must be consulted either directly or through elected
representatives. The employees should elect a candidate, if this is the method by
which they wish to be consulted. They are entitled to
• take up with employers concerns about possible risks and dangerous
• events in the workplace that may affect the employees they represent.
• take up with the employers general matters affecting the health and safety
• of the employees they represent; and
• represent the employees who elected them in consultations with health
• and safety inspectors.
• In addition, employers may also choose to give elected representatives extra
roles.
A.3 Consultation on Health & Safety
• Consultation involves employers providing information to employees, and also
listening and taking account of what employees have to say, prior to decisions
being made.
• If a decision involving work equipment, process or organisation could affect the
health and safety of employees, the employers must allow time to give the
employees or their representatives information about what is proposed. Time
must be allowed for representatives to express their views, account of which
must be taken prior to a final decision being made.
21
A.4 Areas of Consultation
Consultation with employees must be carried out on matters regarding health and
safety at work, including.
• Changes which may substantially affect health and safety e.g. procedures,
equipment or ways of working.
• Arrangements for getting competent persons to help satisfy health and safety
law.
• Information that employees must be given on the likely risks and dangers arising
from work, measures to reduce/eliminate risk, and action to take to deal with risk
or danger.
• Planning of health and safety training.
• Health and safety consequences of introducing new technologies.
A.5 Help and Training
• Representatives must receive training to allow them to carry out their functions
effectively.
• All representatives must be given time off with pay to take part in any training
they may need.
A.6 Availability of Information
• Employee representatives must be given enough information to allow them to
take full and effective part in consultation.
• Employers are not obliged to provide information that they are not aware of, or if
it:
o Would be against the interest of national security or against the law.
o Is about someone who has not given his or her permission for it to be
given out.
o Would – other than for reasons for its effect on health and safety,
harm
o the Trust;
o If they have obtained the information for the purpose of any legal
proceedings
22
APPENDIX B EQUALITY IMPACT ASSESSMENT – INITIAL ASSESSMENT FORM
Name of Document HEALTH AND SAFETY Policy
Date of Assessment 24/02/09
Assessment undertaken by Carol Woolgar, Kuldip Sohanpal
Department Risk Management,
Please  the appropriate box to
indicate appropriate nature of
document.
Function of the
service
Policy 
Procedure
Strategy
Other (please state)
Please provide brief details of the main aims, objectives and intended outcomes/benefits of the document being assessed
The Trust is required to have a HEALTH AND SAFETY policy to comply with legislative requirements around HEALTH AND SAFETY, to set
out the Trust’s approach to HEALTH AND SAFETY and to provide a structure within which the HEALTH AND SAFETY arrangements at the
Trust will operate.
From the document being assessed who will benefit and in what way
All staff, patients and visitors to the AGH site will benefit from the Trust having a strong and consistent approach to HEALTH AND SAFETY
Please list any stakeholders in relation to the document being assessed.
All employees of the Trust, all employees with specific HEALTH AND SAFETY roles at the Trust. The policy has been presented to all
members of the JHEALTH AND SAFETY Committee for comments (which includes employee representatives) and all staff with specific roles in
the policy.
Initial Assessment Form
Page 23
Please check the document and assess it for any statements, conditions, rules or requirements which could potentially exclude or
when applied, cause an adverse impact against any group of individuals, in respect of race, gender, disability, age, faith and sexual
orientation.
The following information will help ascertain if the Function / Policy / Procedure / Strategy is sensitive in respect of outcomes for
members of the community. This process should also help in identifying improvements required to ensure the process is compliant
with equality legislation.
Please ensure that the comments section lists evidence (either presumed or otherwise, irrespective of “Yes” or “No”)
Please  if there are concerns that the document being assessed could have a differential impact on groups due to:
Yes No Comments

1.Race
The policy applies to all employees of the Trust equally.
2.Gender

The policy applies to all employees of the Trust equally.
3.Disability

The policy applies to all employees of the Trust equally.
4.Sexual Orientation

The policy applies to all employees of the Trust equally.
5.Age

The policy applies to all employees of the Trust equally.
6.Religious Belief

The policy applies to all employees of the Trust equally.
7.Dependants / Caring
Responsibilities
8.Transgendered or
Transsexual

The policy applies to all employees of the Trust equally.

The policy applies to all employees of the Trust equally.
Initial Assessment Form
Page 24
Could the differential impact
identified in the points
above amount to there being
the potential for adverse
impact in the document
being assessed?

Comments (please explain)
The policy applies to all employees of the Trust equally
If you have ticked “Yes” to any of the above statements, the document being assessed may be considered to be discriminatory and
require reviewing / a full impact assessment to ensure compliance with legislation. Please provide details of the action that will be
undertaken to mitigate the risks in order to minimise adverse impact.
Proposed action
When planning training for
HEALTH AND SAFETY issues
around discrimination, for
example age and race will be
considered
Timeframe
As training is planned
Resource implications
None additional
Signed (completing officer) _____
Carol Woolgar__________________________
Lead
Lead trainer
Signed (Lead Officer) ___________Kuldip Sohanpal______________
Initial Assessment Form
Page 25