2015 – 2016
Annual Health & Safety
Board Report
IncorporatingAnnual
Health & Safety Committee
Security and Occupational Health Reports
Prepared by
Rod Dewar
Health & Safety Advisor / EPRR Lead
Executive Lead
Bronwen Bishop
Director of Strategic Development
Table of Contents
2015 – 2016Annual Health & Safety Board Report
1.Executive Summary
1.1Format
1.2Health & Safety Resource
1.3Health & Safety Responsibilities
1.4Radiation Protection
1.5Estates Department
2.Purpose of the Report
2.1Purpose
3.Legislative Framework for Health & Safety
3.1Legislative Framework
3.2Statutory Duties
Table-1: Key Regulations – Oversight Responsibility:
4.Key Health & Safety Regulatory Areas
4.1Health & Safety Executive (HSE)
5.Trust Health & Safety Management System
5.1HSG-65 Health & Safety Management Model
6.Responsibilities
7.Safety Alerts
Table-2: Safety Alerts received by Type and Qty
8.Health & Safety Training
8.1Health & Safety Training Arrangements
Table-3: Health & Safety Essential Training – 2015/16 Uptakes
9.The Health & Safety Committee
10.Datix Incident Reporting
Table-4: Specific Datix Reported Incidents - Data by Financial Quarter 2015-16
Table-5: Detail for Staff RIDDOR Reported Incidents
Table-6: Detail for ‘Patient RIDDOR’ Reported Incidents
Table-7: Detail for ‘Visitor RIDDORs’ Reported Incidents
Table-8: Detail for Contractor RIDDOR Reported Incidents
Table-9: Personal Injury Claims - 01st April 15 to 31st March 2016
10.10Radiation Safety
10.11Datix Reported – Unintended Exposure to Radiation Incidents
Table-10: Datix Reported Unintended Exposure to Radiation - Detail by Quarter 2015/16
10.12Datix Reported - Fire Safety Incidents
10.13Datix Reported – Pathology Incidents
10.14Datix Reported - Abuse Incidents
10.15Datix Reported – Control of Substances Hazardous to Health Incidents (CoSHH)
10.16Datix Reported - Manual Handling Incidents
Table-11: Detail for Datix Reported Manual Handling Incidents - by Quarter 2015-16
10.17Datix Reported – Contamination and Sharps Incidents
Table-12: Contamination SHARPS Incidents 2015-16
Table-13: Contamination Splash Incidents:
11.Key Developments during the Year
11.1Memorandum of Understanding (MoU) - Health and Safety Executive (HSE) and Care Quality Commission (CQC).
11.2RIDDORs in health and social care
11.3Trust Updated Core HEALTH & SAFETY Policies Uploaded to Document Management System.
11.4Trust Health & Safety Policies Due Review by June 2016
11.5Trust E&FM New Issue Policies - Ratified and on DMS 2015
11.6Trust E&FM Reviewed HEALTH & SAFETY Related Policies - Ratified and on DMS 2015.
11.7Trust Changes to Responsibilities 2015-16
11.8Trust Estates Department Reconfiguration
12.Summary of Health & Safety Priorities 2016-17
12.1Estates Department
12.2Training
12.3Health & Safety Audit Programme
13.Appendix-1: Annual Security Report 2015-16
14.Appendix-2: Annual Occupational Health Service Report April 2015 to March 2016
15.Appendix-3: Annual Health and Safety Work Plan 2016-2017
- Executive Summary
- Format
This Annual Health & Safety Report details a number of Health and Safety metrics, in a format agreed by the Executive Lead for Health & Safety and the Health & Safety Committee.
1.2Health & Safety Resource
For the reporting period 2015/16, the Trust had in post one professionally qualified and experienced Health & Safety ‘Competent Person’ as required by Regulation-5; of the Management of Health & Safety at Work Regulations–1999. For the whole reporting period this post was resourced at 0.6 WTE (3-days per week).
1.3Health & Safety Responsibilities
The Trust Health & Safety Policy details specific responsibilities for the implementation of Health & Safety within the Trust, including responsibilities for the Chief Executive Officer, nominated Executive Director for Health & Safety, Executive Directors and Senior Managers / Heads of Departments.
The Trust Health & Safety Advisor provides advice and guidance to the Trust on Health & Safety matters and maintains a watching brief on Health & Safety Legislation changes which will, or may, affect trust compliance with Health & Safety Legislation.
The Health & Safety Advisor is also responsible for reporting on Health and Safety matters to the Health & Safety Committee, Risk Management Committee, Quality & Governance Committee and the Trust Board.
1.4Radiation Protection
For Radiation Incidents reported via the Datix Incident Reporting System, the Radiology department has specific processes and procedures in place to ensure that rapid local investigation takes place and where an incident meets set criteria; all external reporting requirements are met.
The Trust employs the services of a qualified Radiation Protection Advisor (RPA) based at the Bristol Royal Infirmary and on site Radiation Protection Supervisors (RPS). All Radiation incidents are fully investigated by the Radiology Manager and Trust RPS, with advice and guidance provided by the RPA, all Radiation Incidents are also reviewed by the Radiation Protection Committee.
1.5Estates Department
The ‘Director of Strategic Development’tookover executive responsibility for the Estates Department from 1st June 2015 and took steps toimplement Health & Safety recommendations to ensure the department has in place the required, policies, risk assessments, safe systems of work, documentation and training required, in order to fulfil its Health & Safety Statutory Duties.
Work to ensure the Estates Department has in place all statutory competencies required was ongoing throughout the reporting period. Subject to delivery of an agreedtraining plan designed to ensure that members of Estates Staff undertake required competency training and are formally appointed.
Throughout the reporting period, the Trust Health & Safety Advisor supported Estates Managers in the delivery of required Health & Safety policies and procedures.
- Purpose of the Report
- Purpose
- The purpose of this report is to provide assurance to the Board regarding the Trusts Health & Safety Systems and Processes for the year1April 2015 to 31March 2016.
2.1.2This report enables the Trust Board to demonstrate effective, active leadership and commitment, detailing the ‘downward’ communication systems and management structures in place to enable integration of positive health and safety management.
- Legislative Framework for Health & Safety
- Legislative Framework
- The‘Health and Safety at Work Act -1974’ provides the legislative framework for the Health, Safety and Welfare of persons at work. The Act is an ‘enabling act’detailing the Health and Safety requirements for people at work, in all occupations. It also details protection forthe wider public where they may be affected by the activities of people at work.
3.1.2The ‘Act’ includes; Health & Safety Regulations, Approved Codes of Practice, Guidance Notes and Directives. The Trust is required to comply with all elements of the act and non-compliance may result in an offence being committed under the Act and may constitute a criminal offence leading to prosecution, resulting in a fine and/or a term of imprisonment.
3.1.3Under the Corporate Manslaughter and Corporate Homicide Act - 2007; an offence will be committed where failings by an Organisation’s Senior Management, are a substantial element in any gross breach of the duty of care owed to the organisation’s employees or members of the public, which results in death.
3.1.4The maximum penalty is an unlimited fine and the court can make a publicity order, requiring the organisation to publish details of its conviction and fine.
3.2Statutory Duties
3.2.1Whilst the Trust is ‘vicariously liable’ for the acts and omissions of its staff, trust employees also have a duty under the ‘Health & Safety at Work Act – 1974’;
‘To take reasonable care to avoid injury to themselves and others and to co-operate with the Trust as their employer and others, in meeting the statutory requirements’
3.2.2Failure to comply with any Health & Safety Regulations that apply to the Trust, may lead to Enforcement Actionby the Health & Safety Executive in the form of Improvement or Prohibition Notices, the Fire Authorities are also empowered for enforcement action, under the Fire Safety Order.
3.2.3The Trust has a statutory duty to ensure compliance with a significant number of current Health & Safety Regulations, as detailed at Table-1 below.
Table-1: Key Regulations – Oversight Responsibility:
Regulation / Oversight1.The Health and Safety at Work Act - 1974 / H&SCommittee
2.The Management of Health and Safety at Work Regulations – 1999 (MHSWR) / H&S Committee
3.The Workplace (Health, Safety and Welfare) Regulations – 1992 (WHSWR) / H&S Committee
4.The Manual Handling Operations Regulations - 1992 (amended – 2002) / H&S Committee
5.The Provision and Use of Work Equipment Regulations -1998 (PUWER) / H&S Committee
6.Health and Safety (First Aid) Regulations -1981 / H&S Committee
7.Reporting of Injuries, Diseases & Dangerous occurrences Regulations - 1985 (RIDDOR) / H&S Committee
8.The Control of Substances Hazardous to Health Regulations - 2002 / H&S Committee
9.Health and Safety (Display Screen Equipment) Regulations - 1992 / H&S Committee
10.The Personal Protective Equipment Regulations - 2002 / H&S Committee
11.Health and Safety (Sharp Instruments in Healthcare) Regulations - 2013 / H&S Committee
12.Control of Noise at Work Regulations - 2005 / H&S Committee
13.The Ionising Radiation (Medical Exposure) Regulations - 2000 / H&S Committee
14.Ionising Radiations Regulations - 1999 / H&S Committee
15.Lifting Operations and Lifting Equipment Regulations -1998 / H&S Committee
16.Health and Safety (Consultation with Employees) Regulations - 1999 / H&S Committee
17.Safety Representatives and Safety Committees Regulations - 1977 / H&S Committee
18.The Work at Height Regulations - 2005 / H&S Committee
19.The Health and Safety (Training for Employment) Regulations - 1990 / H&S Committee
20.The Health and Safety (Safety Signs and Signals) Regulations - 1996 / H&S Committee
21.The Regulatory Reform (Fire Safety) Order - 2005 / H&S Committee
22.Liability (Compulsory Insurance) Act - 1969 / H&S Committee
23.Electricity at Work Regulations - 1989 / H&S Committee
24.Chemicals (Hazard Information and Packaging for Supply) Regulations - 2002 / H&S Committee
25.Construction (Design and Management) Regulations - 2007 / H&S Committee
26.Gas Safety (Installation and Use) Regulations - 1994 / H&S Committee
27.Dangerous Substances and Explosive Atmospheres Regulations - 2002 / H&S Committee
28.Disability Discrimination Act (DDA) - 2005 / H&S Committee
29.The Health and Safety (Offences) Act - 2008 / Trust Board Secretary
30.The Corporate Manslaughter and Corporate Homicide Act - 2007 / Trust Board Secretary
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- Key Health & Safety Regulatory Areas
Table-3
Asbestos Management
(Control of Asbestos Regulations 2012) / Medical Gas
Systems
EU Pharmacopeia Regulations / Ventilation - LEV Testing
- HTM
- Control of Substances Hazardous to Health Regulations 2013
- EH40/2005
Construction Design Management (CDM) Regulations 2015
MHSW Regulations / Diathermy & Surgical Smoke
- Control of Substances Hazardous to Health Regulations 2012
- HSE Guidance
- Controlled Waste (England and Wales) Regulations 2012
- HSE Guidance
High Voltage Systems Authorisation Process
- HTM 06-03
- HTM 02-01 A & B
- Lifting Operations and Lifting Equipment Regs 1998 (LOLER)
- (HSE Info 5) Falls from windows or balconies in health and social care
- MHRA Safety Alert
- EFA/2012/001
- Provision & Use of Work Equipment Regs 1998 (PUWER)
- Lifting Operations and Lifting Equipment Regulations (LOLER)
- EU Directive HSE
- Management of Health And Safety @Work Regs 1999
- Local Security Management Services
Low Voltage Systems (Electrical)
- HTM-06-03 Elec.
- HTM 02
- Compliance and Authorisation of Processes
- MHRA
- Pressure Systems Safety Regulations -2000
- Manual Handling Operations Regulation -1992
- Regulatory Reform (Fire Safety) Order- 2005
- HTM05-01
- Safe Site
- Pedestrians
- Car Parks
- Road Speed Limits
PAT Testing
- HTM 06 Electricity at Work-1989
- Control of Legionella -2012 (L8.)
- Implementation of Premises Assurance Model (PAM)
- Control of Substances Hazardous to Health Regs -2013
- DoH Infection Prevention Guidelines
- Personal Protective equipment Regulations 2002
- Regulatory Reform (Fire Safety) Order -2005
- HTM 05-01
Air Conditioning Plant.
- Control of Legionella -2012 (L8.)
- HSE Guidance INDG225
- COSHH
- HSE Guidance Safe Handling of Cytotoxic Drugs in the Workplace
- EU Directive compliance
- Health and Safety (Sharp Instruments in Healthcare) Regulations -2013
- Health and safety (First Aid) Regulations -2013
- The Health & Safety At Work Act 1974
- The Management of Health & Safety at Work Regulations -1997
- Safety Representatives and Safety Committees Regulations - 1977
- The Health and Safety (Consultation with Employees) Regulations 1996Health and Safety (Training for Employment) Regulations - 1990
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4.1Health & Safety Executive (HSE)
4.1.1Under the ‘Health and Safety (Fees) Regulations - 2012’, a breach of Health & Safety Law now results in liability for costs submitted by the HSE; including inspection, investigation and enforcement action; the intervention fee hourly ratefor 2016 is set at £129.
4.1.2The HSE continues to implement measures aimed at reducing the burden of unnecessary regulation upon organisations, while maintaining the UK’s health and safety performance.
- Trust Health & Safety Management System
- HSG-65 Health & Safety Management Model
- The Trust currently uses the Health & Safety Executive (HSE) -HSG-65 guidance ‘Managing for Health and Safety’ model to manage the delivery of Health and Safety.
- Responsibilities
- Trust Health & Safety Policy - Responsibilities
Full details of responsibilities for the management of Health & Safety within Weston Area Health NHS Trust, are detailed in the Trust Health & Safety Policy.
6.1.1Trust Chief Executive
The Chief Executive is responsible for the establishment and maintenance of an effective policy for Health & Safety at Work.
6.1.2Trust Executive Lead for Health & Safety
A nominated Executive Directorholds delegated responsibility for overseeing the management of Health & Safety.
- The Director of Strategic Developmentfulfilled this role from June 2015.
6.1.3Trust Executive Lead for Fire Safety
A nominated Executive Directorhas delegated responsibility for overseeing the management of Fire Safety within the Trust.
- The Director of Strategic Developmentfulfilled this responsibility forthe period of this report; 2015-16.
6.1.4Trust Executive Lead for Security
A nominated Executive Directorhas delegated responsibility for overseeing the management of Security within the Trust.
- The Director of Operations fulfilled this responsibility for the period of this report; 2015-16.
6.1.5Trust Executive Directors
All Executive Directors are responsible for effective implementation of the Trust Health & Safety Policy by members of staff for whom they are managerially or professionally accountable.
6.1.6Trust Associate Director of Governance and Patient Experience
Associate Director of Governance and Patient Experience Ensuresthat appropriate governance arrangements for Health & Safety are in place and are a robust part of the Trusts overall governance arrangements.
6.1.7Trust Head of Governance and Patient Experience
Line manages the Trust Health & Safety Advisor.
6.1.8Trust Health & Safety Advisor
Assumes the role of Health & Safety ‘competent person’ for the Trust and provides advice and guidanceto Trust Directors and Managers for implementation of day to day delivery of Health and Safety within the Trust, resourced at 0.6 WTE (3 days per week) during this reporting period.
6.1.9Trust Fire Safety Manager
The Head of Estates and Facilities reports to the Executive Director with responsibility for Health & Safety and has delegated responsibility under ‘HTM05-01: Fire code: Fire Safety in the NHS’ as the nominated Trust Fire Safety Manager, with responsibility for ensuring effective delivery of Fire Safety measures throughout the Trust, by compliance with the requirements of both the Fire Safety Order and HTM05-01.
6.1.10Trust Fire Safety Advisors
Fire Safety Advisors are contracted in to support the Fire Safety Manager and ensureappropriate fire safety guidance is provided to the Trust Fire Safety Manager, including provision of Fire Risk Assessments and Fire Safety / Evacuation Training, currently resourced at 0.4 WTE (2 days per week).
6.1.11Trust Manual Handling / DSE Advisor
Specialist advice for reported Manual Handling and Display Screen Equipment (DSE) issues is provided by a member of the Trust Training Team undertakingTrustwide ‘Health & Safety induction and Statutory Mandatorytraining’.
6.1.12Trust Associate Directors/Senior Managers/Heads of Department/Ward Managers
Senior Managers/Heads of Department/Matrons/Ward Managers (Nursing) are responsible for implementing Health & Safety measures for the areas under their immediate control; e.g. Health and Safety of employees and that contractors and other people (patients and visitors) comply with the Trust’s Health and Safety Policy.
6.1.13Trust Quality & Governance Committee
A Committee of the Trust Board, with responsibility to review all aspects of the Trust’s quality and clinical governance and for ensuring that the Trust meets all its duties and obligations under the NHS Constitution, plus all other statutory, regulatory and best practice requirements. The committee is also responsible for the review of all aspects of the risk management process regarding clinical, quality and safety and obtaining assurance on all aspects of the Trust’s declarations and its registration by the Care Quality Commission.
6.1.14Trust Health & Safety Committee
An essential part of the Trusts governance arrangements for Health & Safety, the committee monitors the delivery within the Trust of Health & Safety, Fire Safety and Security and associated policies and procedures.
6.1.15Health & Safety Representatives
The Trust encourages all departments to have a nominated Health & Safety Representative. Health & Safety Representatives assist management in the promotion and improvement of Health and Safety and their role is clearly defined by the ‘Safety Representatives and Safety Committees Regulations -1977’ and the ‘Health and Safety (Consultation with Employees) Regulations - 1999’
- Safety Alerts
- Safety Alerts are managed by the Head of Governance, appropriate department managers are informed, action due dates are tracked andreporting deadlines are met.
7.2Table-2 below details the type and quantity of safety alerts received by the Trust in the reporting period 2015/16.
Table-2:Safety Alerts received by Type and Qty
Alert Type / Full Title / QtyMDA / Medical Device Alert / 30
EFN / Estates Facilities Notice / 49
EFA / Estates Facilities Alert / 05
DH / Department of Health Notice / 01
NHS/PSA / NHS Patient Safety Alert / 10
Total Alerts Received from 01-04-15 to 31-03-16 / 95
Alerts closed = 19 with actions & 75 no action required / 94
Total Alerts Open - Qty-1 within deadline / 01
Total Alerts Outstanding at 31-03-16 / 0
- Health & Safety Training
- Health & Safety Training Arrangements
- As a key element of the Trusts implementation of its Health and Safety Policy, mandatory training packages are deliveredto members of staff by the Trust Training Team, in order to promote Health & Safety awareness and competency.
8.1.2For2015/16, the Trust continued to deliver induction and refreshermandatory training in: