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MINUTE of MEETING of the HEALTH and SAFETY COMMITTEE
Board Room, Assynt House /14 February 2008 – 10.30 am
Present
/ Ms Elaine Mead, Chief Operating Officer (Joint Chair)Ms Diane Fraser, RCN, New Craigs (Joint Chair)
Ms Pauline Craw, North Highland CHP (videoconference)
positMr Stephen Don, MSF, RaigmoreHospital
Mrs Anne Gent, Director of Human Resources
Ms Anne MacKenzie, SE Highland CHP
Ms Susan MacLellan, Dental Services
Ms Janette McQuiston, UNISON, RossMemorialHospital
Mr Peter Rudkin, Mental Health & Learning Disabilities, New Craigs
Ms Nichola Summers, Cancer Services
In attendance / Mr Fraser Brunton, Radiation Protection
Mr Tony Cowan-Martin, General Manager, Occupational Health
Mrs Lynda Davidson, Infection Control (deputising for Alison MacLean)
Ms Linda Rawlinson, Nurse Manager, Occupational Health
Mr Colin Shields, Health and Safety Team Leader
Dr Lesley Anne Smith, Head of Clinical Governance & Risk
Management
Miss Irene Robertson, Board Committee Administrator
1 WELCOME AND APOLOGIES
Apologies were received from Trevor Bell, Marilyn Davidson, Stephen Davison, Alison MacLean, Gill McVicar, Fiona Murdoch, James O’Kane, Caroline Parr, and John Swatman.
2MINUTE OF MEETING HELD ON 22 NOVEMBER 2007
The minute of meeting held on 22/11/07 was approved subject to the following amendment:
Page 8, item 7.6 Radiation Protection, fourth bullet point, second line, ’Radiation Safety Committee’ to read “Radiation Safety Sub Group’.
3MATTERS ARISING
3.1HSE Management Inspections Report Action Plan
The Committee considered the updated action plan detailing high and medium priority areas and progress made against them to date. It was noted that designated leads had now been identified. It was agreed that an additional column should be inserted in the document indicating the timeframe for implementation, and that the dates of the audits from which the recommendations for action arose should be noted on the document.
For the next meeting, the Committee agreed to review the action plan and timescales for delivery, and identify any areas where implementation by the agreed timescale might be challenging.
The Committee:
aNoted the updated action plan.
bAgreed that the action plan and timescales for delivery should be reviewed, and identifyingany areas where implementation by the agreed timescale might be challenging.
3.2Moving & Handling and Violence & AggressionTraining
The Committee received an update from Colin Shields who drew the Committee’s attention to the following issues:
Interviews had been held for the Violence & Aggression Manager’s post but no appointment was made. The job had since been re-advertised with interviews planned for early April. The resignations of two part-time trainers were noted.
Progress was being made towards instituting the initial Key Worker pilot in the Raigmore Theatres. A role and remit for this post had been drafted, a copy of which would be shared with Diane Fraser who emphasised the need to ensure Staffside involvement in this and other such developments.
Priority was currently being given to induction training with the aim of ensuring that all staff received this before commencing in post. As start dates were variable, it was suggested that there should be just one or two intakes of staff at specified dates to facilitate the planning and delivery of induction training and associated HR issues, and Occupational Health clearance. The HR Sub Group would be considering this proposal. Ongoing support for staffin the workplace was also a key issue. Mr Shields advised that a three year rolling programme was being developed encompassing induction training, on site support and competency assessment. The intention would be to move over time, to a competency based approach that would deliver a sustainable model which would be more effective and efficient. However, to progress this change of approach there would be some resource implications and it was suggested that in addition to utilising existing training resources some funding might also be sought from KSF monies.
Mr Shields reported briefly on issues around fire safety training which he and John Swatman were pursuing. These were discussed in more detail at item 7.4.
The Committee:
aNoted the issues identified and the actions being taken to address them.
3.3Health and Safety Review
The recent Health and Safety Review had highlighted a number of services which were provided or had been inherited by the Health and Safety Department which could appropriately be transferred to other areas and departments. The services identified were:
- Prevention and Management of Stress
It had been agreed that the Health and Safety Adviser who currently provided stress management services as part of his work load, would be assigned to the Occupational Health Department, to undertake stress prevention management provision on a full time basis.
- Incident Reporting
The reporting process had been shared between the Health and Safety and Clinical Governance and Risk Management Departments. It had been agreed that responsibility for this service would now lie with Clinical Governance and Risk Management.
- Occupational Road Risk
All new starts whose posts involved driving on behalf of the organisation, were required to complete an Occupational Road Risk form. This was essentially an administrative function which it was felt could appropriately be integrated into the recruitment process.
- First Aid Provision
The provision of first aid training administration had been inherited by the Health and Safety Department. A number of options for its future provision were put forward. It was proposed that a short life working group be established to consider the options and report back to the next meeting of the Committee with recommendations as to the way forward. The membership of the working group to comprise of representatives from each of the operational units, Occupational Health and Partnership.
- Eye Care Vouchers
Noting that different arrangements applied in the Argyll and Bute CHP area, the Committee remitted to Colin Shields to pursue the issues with the CHP with a view to ensuring consistency and equity for staff across the whole of NHS Highland. Further clarity would be sought in respect of DSE criteria.
Acknowledging the increasing devolution of generic health and safety responsibilities to the operational units, the Committee agreed that further debate needed to take place around the functions that should be organised centrally and those which could appropriately be transferred to the localities.
The Committee:
aNoted the re-alignment of stress prevention/management provision to the Occupational Health Department and that the Clinical Governance and Risk Management Department now had sole responsibility for the Reporting Incidents process.
bAgreed to recommend that the Occupational Road Risk procedure be integrated into the recruitment process.
cAgreed that a short life working group be established which would be a sub group of the Health and Safety Committee, to consider options for the provision of first aid training administration and bring recommendations to the next meeting for consideration.
dAgreed that the eye care voucher arrangements in Argyll and Bute should be reviewed with the aim of standardising the process across the area, and that further clarity would be sought on eligibility for DSE support.
eAcknowledged that further debate was required on the issues around centralisation/devolution of functions relating to health and safety.
3.4Car Parking Safety
In John Swatman’s absence this item was deferred to the next meeting.
3.5Fire Safety
This issue was covered in the Estate Manager’s report (item 7.4).
3.6Scottish Patient Safety Programme
Lesley Anne Smith updated the Committee on the implementation of the Scottish Patient Safety Programme. A three day learning session had been held in Glasgow in January which over 30 NHS Highland delegates attended. RaigmoreHospital had four front line teams currently participating in the first phase of the work: Critical Care (ITU), Medicines Management (Ward 7C), General (Ward 6A) and Perioperative (Theatres and Ward 5C). Feedback from Raigmore on the impact of the programme on patient care and safety was positive. The programme would continue in these pilot areas for some six – twelve months. The three Rural General Hospitals involved (Caithness General, BelfordHospital and Lorn & Islands) were at present completing the required pre-work.
The Committee:
aNoted progress made with the implementation of the Scottish Patient Safety Programme within RaigmoreHospital and the work ongoing to roll out the Programme to the other sites.
3.7Incident Management Report
In her circulated report, Lesley Anne Smith confirmed that the new IR1 Form had been finalised and pads of forms distributed in December 2007. Training sessions on the new form had been held across operational units and would continue to be held over the next few months to ensure that all relevant staff were appropriately trained in the use of the form.
The report provided an analysis of incidents by operational unit, main cause, those which were Riddor reportable, and groups affected by incidents. It was noted that the main causes of incidents during the period April – December 2007 were ‘Disruptive, violent, aggressive behaviour’ and ‘Slips, Trips and Falls’. With regard to ‘Personal Accident’, it was suggested that this needed to be re-categorised, as some incidents could appear under other categories such as ‘Slips, Trips and Falls’. There were a number of incidents under the ‘Radiation’ heading which Fraser Brunton would follow up with Dr Smith to clarify the circumstances and ensure that any necessary action was taken. Anne MacKenzie requested that the figures relating to Mental Health and Dentistry be disaggregated from the South East Highland CHP data. It was agreed that for the purposes of local reports, the figures would be disaggregated. It was suggested that a category for ‘Telephone Abuse’ should be included in the form. In response to a query, Dr Smith explained that it had been decided not to code information, however the form would be reviewed in the light of experience and amended as necessary.
Discussions were ongoing with eHealth to consider options for the integration of the two computer systems used to record incidents. A tender document had been issued and responses were expected by the end of February 2008. Depending on the outcome of this process, the inputting procedure may be revisited. The Clinical Governance Team was also looking at the possibility of establishing a quality control post to ensure consistency of inputting across the area.
A Critical Incident Resource Pack had been developed to assist managers in carrying out critical incident reviews. It contained report and action plan templates, procedures to be followed and tools to assist with investigations, including the IR2 Form. This form would be available on the Intranet for staff to download and use as required. If there was sufficient demand consideration would be given to having the forms printed.
The report also provided specific examples of lessons learned and changes implemented. Detailed analysis and interpretation of the incidents was key in terms of using the data to inform management action and targeting resources appropriately and effectively. Dr Smith indicated that the intention would be to review the position in six months’ time to confirm that agreed changes had been carried out.
The Committee:
aNoted the report and the issues identified for action.
bAgreed the amendments to the IR1 Form as discussed above.
4TOPIC SPECIFIC ITEMS
4.1Annual Report
Anne Gent explained that the Health and Safety Committee, as one of the Board’s Governance Committees, was required to produce an annual report for submission to NHS Highland’s Audit Committee, to satisfy the requirements of NHS Highland’s Statement of Internal Control. A draft report for 2007-2008 was circulated for the Committee’s consideration. It was intended that the 2007-08 Annual Reports of the Health and Safety Team and the Occupational Health Services would be incorporated in the document as appendices.
During discussion, some amendments to the membership of the Committee were proposed. It was suggested that the Staffside representation should reflect the membership of the Highland Partnership Forum. It was recognised that members had a responsibility to represent the views of the wider constituency and not just their own specific area. It was felt that this should be made more explicit in the document. The final draft document would be circulated to the Committee for approval before its submission to the Audit Committee. It was agreed that the report would need to capture the outputs of the Committee to provide evidence and assurance that it was fulfilling its remit.
The Committee:
aRemitted to its members to forward any further comments/suggested changes to Mrs Gent .
bAgreed that the final draft report would be circulated to the members for approval prior to its submission to the Audit Committee.
4.2COSHH - Floor Cleaning in relation to Slips/Trips/Falls
Colin Shields reported that a short life working group was being set up to review all the COSHH assessments with the aim of developing a list of generic substances for hotel services initially at Raigmore which would thereafter be rolled out on a pan-Highland basis. It was proposed to develop an electronic database of generic substances for which resource would need to be identified.
The Committee supported the proposal in principle. It was suggested that rather than establishing a new working group, WHAG would be the appropriate forum to take this work forward. Colin Shields agreed to discuss this with Dr Stephen Ryder and report back to the next meeting on the outcome.
The Committee:
aSupported the proposed development of an electronic database of generic substances relating to hotel services.
bAgreed to have an update on progress at the next meeting.
4.3Radiation Protection
Fraser Brunton spoke to his circulated report, highlighting the following issues:-
- Radiation Protection advice continued to be provided by colleagues outwith Highland.
- Interviews had been held for the post of Section Head in the Radiation Protection Service but no appointment was made. The post was being re-advertised.
- NHS Highland’s Radiation Safety Committee met on 22/01/08 and was taking forward a number of issues. Further consideration was being given to the membership of the committee.
- Following a review of arrangements for radiation safety in Argyll and Bute, a Sub Group of the Board’s Radiation Safety Committee had been set up to provide a local practical focus for radiation safety. Discussions were ongoing to clarify managerial and administrative support for the Sub Group which met on 24/01/08. It had a significant agenda and would be reporting to the Board Committee.
- The Board’s Radiation Safety Policy was being reviewed. Some work on radiation incident reporting was being taken forward by Mr Brunton and Lesley Anne Smith.
In response to a query, Mr Brunton was able to assure the Committee that the temporary arrangements for the provision of advice by external providers were robust, however routine work was beginning to build up as a result of posts remaining unfilled.
The Committee:
aNoted the position.
4.4Argyll and Bute Issues
As James O’Kane was unable to be present, this item was deferred.
4.5MANAGEMENT OF INCIDENTS AND OUTBREAKS OF HAI, INCLUDING GUIDANCE ON STAFF SCREENING: REPORT OF THE HAI TASK FORCE
Linda Rawlinson spoke to the circulated guidance from the Scottish Government on the management of incidents and outbreaks of healthcare associated infection, including guidance on staff screening. All NHS Boards were required to have policies in place for dealing with incidents and outbreaks of infection. This document was not intended to replace those policies but was intended to identify the guiding principles behind such policies and provide checklists for required policy components. Mrs Rawlinson confirmed that action was being taken on the guidance as required.
The Committee:
aNoted the guidance for information.
4.6STAFF GOVERNANCE ACTION PLAN 2007 – 2008
Tony Cowan-Martin updated the Committee on progress towards achieving Staff Governance Standard Section E – Safe and Improved Working Environment. He advised that the key action in respect of the Review of Health and Safety Policy and Strategy had changed from Green to Amber due to changes in Health and Safety Management. All other key actions were Green. However, due to the condition of some of NHS Highland’s premises, some Disability Discrimination Act issues and the delayed implementation of a NHS Highland Property Strategy, this action was likely to revert to Amber.
The Action Plan would be reviewed and updated again to document further progress as at 31/03/08.
The Committee:
aNoted the progress made against the Action Plan.
5ITEM RAISED BY HEALTH & SAFETY REPRESENTATIVES
5.1First Aid
The Committee agreed that the issues identified should be referred to the short life working that was to be established, as discussed at item 3.3.
5.2Security Issues
Diane Fraserupdated the Committee on the swipe card system for the staff changing rooms at RaigmoreHospital, confirming that costings were now available. There was also tabled for the Committee’s information a health and safety inspection reportidentifying various actions/repairs required to this area.
Discussion followed on how to ensure that this and other such issues were addressed at local level. Lesley Anne Smith advised that a Clinical Governance and Risk Management Group incorporating Health and Safety, had now been established in SSUwhich would be the appropriate forum for addressing these issues. Diane Fraser highlighted the need for Staffside representation on this group. It was agreed that she would seek nominations and notify Dr Smith accordingly. The Committee recalled the work being done by Dr Smith on existing committee structures and reporting arrangementsthroughout NHS Highland with a view to clarifying their function and ensuring appropriate representation. It was proposed that an update on progress with this piece of work be prepared for discussion at the next meeting.