Health and Safety Annual Report

Transcription

1 Health and Safety Annual Report Page 1

2 CWHHE Collaborative of Clinical Commissioning Group Health & Safety Annual Report Contents 1 Introduction 3 2 Accountability for Health and Safety 4 3 Health and Safety Policies 5 4 Review of 2014/ Priorities for 2015/ Building and Landlord Requirements 9 Page 2

3 CWHHE Collaborative of Clinical Commissioning Group Health & Safety Annual Report Introduction 1.1 This annual report covers the period 1 st April 2014 to 31 st March 2015 for the five Clinical Commissioning Groups (CCG) within the CWHHE Collaborative, namely: Central London CCG West London CCG Hammersmith & Fulham CCG Hounslow CCG Ealing CCG 1.2 This report has been produced to identify and document health and safety performance against the overarching health and safety objective: to minimise the number of instances of occupational accidents and illnesses and ultimately achieve an accident-free workplace. 1.3 In October 2014, the CWHEE Collaborative took on responsibility for the operational management of Health & Safety from the North West London Commissioning Support Unit. As such, the Health and Safety management system is evolving, and the Health and Safety Committee has approved an action plan which includes the health and safety objectives for 2015/ There are many examples of good practice highlighted in this report and, in broad terms, many property management aspects are compliant with current legislation. During 2015/2016, the focus will be on reshaping and redirecting the Health & Safety management system, as well as commissioning, analysing and implementing the findings of a full Health and Safety audit. Page 3

4 2. Accountability for Health and Safety 2.1 Each staff member has responsibility for supporting a safe and healthy working environment, and staff are encouraged to report issues in a variety of ways, including via formal reporting mechanisms, providing feedback at training, as well as at staff meetings. 2.2 Figure 1, below, provides an overview of the CWHHE Collaborative accountability structure for Health & Safety. Governing Body CLCCG Governing Body WLCCG Governing Body H&FCLCCG Governing Body Hounslow CLCCG Governing Body Ealing CLCCG Quality & Safety Committee (Meets H&S Committee concurrently) Building User Group Figure 1: CWHHE Collaborative Accountability Structure for Health & Safety 2.3 The Health & Safety Committee is responsible for agreeing the Annual Health and Safety Plan, for seeking assurance on delivery and for offering an opinion to the CCG Governing Bodies on Health and safety compliance. 2.4 The Building User Group s (BUG) primary purpose is to oversee the successful delivery of the Health and Safety Plan. The Group meets once a month, and also discusses any building, health and safety, incidents and risks that have been identified across the five CCGs. 2.5 Management responsibilities for Health & Safety are as follows: Director Lead: Ben Westmancott, Director of, CWHHE Management Lead: Helen Christodoulou, Facilities Manager, CWHHE Site Leads: - Marylebone Road: Helen Christodoulou - Sovereign Court: Tandeep Fairman, Head of Quality and Governance, Hounslow CCG - Perceval House: Beryl Bevan, Assistant Director of Operations & Governance, Ealing CCG Page 4

5 3. Health and safety policies 3.1 A suite of Health and Safety policies were approved in March 2014, as follows: Display Screen Equipment Fire Safety First Aid Health and Safety Manual Handling Personal Safety Slips and Trips Work Equipment 3.2 The following policies have been reviewed or drafted, and are due for approval during 2015/2016: Safe use of Display Screen Equipment Display Screen Equipment CWHHE Building and H&S Incident & Accident Reporting form Building and Facility Incident & Accident Health & Safety 3.3 A security policy will also be drafted for approval during 2015/ Review of 2014/ Advice and Support Health and safety law requires organisations to ensure that they have access to competent Health and Safety advice. During 2014/2015, this advice was provided to the CWHHE Collaborative by the Director of, the Facilities Manager, Site Leads as well as NHS Property Services In addition to the above, a procurement is being undertaken to secure additional bespoke Health and Safety advice and support across the CWHHE Collaborative into 2015/ Health and Safety Training The Human Resource (HR) and Communications teams continue to monitor and review compliance with mandatory training against the organisations target of 100%. Staff receive statutory fire safety, health, safety and welfare and moving and handling training via e-learning. Page 5

6 4.2.2 Table 1, below, reports the 2014/2015 training compliance and completion figures, as provided by HR. CLCCG WLCCG H&FCCG Hounslow CCG Ealing CCG Headcount 161 Headcount 48 Headcount 53 Headcount 58 Headcount 83 Rate (%) Completion Rate (No. of staff) Rate (%) Completion Rate (No. of staff) Rate (%) Completion Rate (No. of staff) Rate (%) Completion Rate (No. of staff) Rate (%) Completio n Rate (No. of staff) Fire Safety Health, Safety and Welfare Moving and Handling Table 1: CWHHE Collaborative Mandatory Training The low levels of staff mandatory training compliance can be attributed to: A not-fit-for-purpose mandatory training recording and reporting system and poor data quality i.e. lack of assurance that all staff undertaking mandatory training are being recorded Lack of staff awareness regarding the requirement to undertake training, as well as where and how to access training Poor management of staff compliance Mandatory training is currently not incorporated into staff induction programmes Clearly, achieving acceptable levels of staff mandatory training compliance is a key priority for 2015/ Accidents and Incidents Table 2, below, reports accidents and incidents during 2014/ There is a duty to report specified workplace incidents (RIDDOR - Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013) and no incidents were reported to the Health and Safety Executive during 2014/ During the 12 months, only one First Aid incident was reported, relating to a trip / fall. The incident was managed by internal First Aiders, followed by a local A&E department visit There were no reported security incidents at Marylebone Road, however, the building is potentially vulnerable, given its public access as well as the rear car park. There were two security incidents at Ealing and none reported at Hounslow Page 6

7 4.3.5 As can be concluded from the table, there are inadequacies in the system and quality of accident and incident reporting and these will be addressed, as a priority, in 2015/2016. CWHHE Number reported Event Type (2013/2014) Marylebone Road Perceval Sovereign Court Central London CCG House Hounslow CCG West London CCG Ealing CCG Hammersmith & Fulham CCG RIDDOR - Fatal Accident RIDDOR - Major injury (over 7day) Minor accident via accident report book/system Possible dangerous exposure Incident Near miss low risk 0 Figures not available Facility/Building 2 Figures not available Figures not available Figures not available Table 2: CWHHE Collaborative Accidents and Incidents Reported during 2014/ Fire Safety Fire Risk Assessments have been conducted at all three sites and actions have been carried out to address issues arising. Any outstanding risks or items are recorded in the relevant risk registers As highlighted at 4.2.3, above, take up of fire safety training has been a lot lower than expected and this will be addressed in 2015/2016. The number of Fire Marshalls available at each site has been reviewed and shortfalls are being addressed. 4.5 Risk Assessments Risk Assessments have been conducted at all sites by NHS Property Services, however, there is a need for a coherent approach to risk assessment to ensure actions are addressed and that compliance is adhered to Computer workstation assessments were carried out as and when requested. These health-related assessments mostly related to musculoskeletal pain and discomfort in the lower back and/or neck and arms. No on-going issues were disclosed. The Display Screen Equipment (DSE) policy will be reviewed in 2015/2015 (see 3.2 above) and processes are required to ensure that health related workstation assessments are systematically conducted, logged and reviewed. 5. Priorities for 2015/ The health and safety leads have agreed a Health & Safety Action Plan for 2015/2016 to address the key Health and Safety priorities, as follows: All staff to be compliant with mandatory training requirements. The HR team will lead the development, implementation, monitoring and reporting for a robust and effective mandatory training system. This will be supported by a communication plan to ensure both managers and staff are aware of their responsibilities. Page 7

8 5.1.2 Complete the procurement of bespoke Health and Safety advice and support across the CWHHE Collaborative Undertake a Health and Safety audit to measure compliance and progress, as well as identify issues to be addressed Implement a standardised and effective health and safety and building incident reporting system across all CWHHE sites The Display Screen Equipment policy and process need to be implemented as one uniformed system across all sites Improve the security of staff and visitors at all sites by undertaking security reviews, as necessary, as well as through a thorough investigation and re-visiting of the security card issuing process. Page 8

9 6. Building and Landlord Assessments Requirement. Elements Next due (Landlord - Lazari) Next due (MBR/NHSPS) Next due Date- Dandi) Next due. (Hounslow) Next due- Local Authority) Next due (Ealing) Fire Risk Assessment (FRA) Asbestos Survey Electrical Installation Condition Report Actions logged on risk register. (Every 5yrs) Landlord not willing to provide up to date report. letter sent to Tom Williams by NHSPS to chase this. Electrical Tests Conducted awaiting certificate (3 yearly assessments) all actions addressed. Awaiting advice from NHSPS if any requirement/acti on from us as tenants (chasing up NHSPS for this) Review to be carried out after move to new premises. We are confirming with the landlord that the compliance checks cover all areas within the building. 14/08/2019 (5 yearly) October 2015 Started 03/04.15 inspection on-going. Gas Natural Annual Gas Safety Certificate N/A 29/07/2015 Water Quality Water/Legio nella Risk Assessment Quarterly checks conducted on LUO (Low Use Outlets) 07/11/2015 Page 9

10 Elements Next due (Landlord - Lazari) Next due (MBR/NHSPS) Next due Date- Dandi) Next due. (Hounslow) Next due- Local Authority) Next due (Ealing) Lifts LOLER Thorough Examination Report N/A 09/03/2016 Generators Maintenanc e & Testing No Generators on site for NHS- MBR use. 23/01/2016 Pressure System of Examination N/A 29/07/2015 Piped Medical Gases Scheme of Examination Report N/A N/A Hot Surfaces Risk Assessment Hot Works Risk Assessments and Plans are requested and conducted as and when required. 13/10/2015 Lightning Protection Lightning Conductor Certificate Assessment next due no issues raised N/A (This is landlord responsibility). 09/02/2016 Page 10

11 Elements Next due (Landlord - Lazari) Next due (MBR/NHSPS) Next due Date- Dandi) Next due. (Hounslow) Next due- Local Authority) Next due (Ealing) Window Restrictor Risk Assessment or Survey Report Not required but windows with locks have been locked and TBar Key is kept securely by Building Manager- Compliant PAT Testing Next due (Completed also included reception area). All non-compliant items removed. In the process of sourcing contractor. Currently all windows are locked and security check all windows in the evenings 29/12/15 Fire Extinguisher Testing. Test next due /11/15 Emergency Lighting Test /04/15 Fire Smoke Detector Test. Next due (6 mthly) (Arranged by landlord to test all detectors at MBR as all link into one fire panel). 13/06/15 High Risk- needs addressing A.S.A.P. on Risk register Awaiting report/assessment Fully compliant. **All red items are listed on the risk register in order to manage and monitor actions. Page 11