Health & Safety Policy and Safety Management System Version Paula Coward Health & Safety Manager

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1 Health & Safety Policy and Safety Management System Version 3.00 Lead executive Name / title of author: Chief Nurse Paula Coward Health & Safety Manager Date reviewed: 22/12/2014 Date ratified: 28/01/2015 Ratifying Committee: Health, Safety & Wellbeing Sub- Committee Target audience: All UHSM staff, partner staff, volunteers, contractors Policy Summary: Equality Impact Statement: Training impact and plan summary: Outline plan for dissemination: Dissemination lead: name / title / ext n o UHSM follows an integrated approach to managing health and safety, based on the Health and Safety Executives guidance HSG65 Managing health and safety. This approach follows the steps Plan; Do; Check; Act and includes the implementation of safe working practices, a risk assessment process, an incident management and investigation process, and an audit process. Employees also have a duty to ensure their own health and safety, and the safety of others, under the Health and Safety at Work etc Act 1974, and must behave in a safe and responsible manner at all times. University Hospital of South Manchester NHS Foundation Trust ( UHSM ) strives to ensure equality of opportunity for all service users, local people and the workforce. As an employer and a provider of health care, UHSM aims to ensure that none are placed at a disadvantage as a result of its policies and procedures. This document has therefore had an initial assessment, in accordance with the equality impact proforma incorporated in the Checklist for Review and Ratification of UHSM-wide Documents, to ensure fairness and consistency for all those covered by it regardless of their individuality. This initial impact assessment indicated that the potential discriminatory impact is low, and therefore no further assessment was necessary On-line health & safety mandatory training for all UHSM staff. Moving & handling mandatory training; Infection Prevention mandatory training; Fire Safety mandatory training; Display Screen Equipment mandatory training: specific health & safety related training relative to work area / job role Mandatory training is a mixture of e-training and face to face training completed every 1-3 years. Face to face training provided by the specialist Advisor / qualified person at a frequency specified in the relevant policy. Disseminated by Paula Coward, Health & Safety Manager, following ratification by UHSM s Health, Safety & Wellbeing Committee. Communication on UHSMs weekly bulletin. Dissemination to Directorate Managers, Clinical Leads and Matrons via Paula Coward, Health & Safety Manager This version n o V3.00 Date published: 04/02/2015 1

2 Version number V1 V2 Issue Date Sept 2011 V3.00 Feb 2015 Version Control Schedule Revisions from previous issue Health & Safety Policy new policy Complete review Complete review and rewrite of V2.00 Health & Safety Policy. New template. Rename to Health & Safety Policy and Safety Management Plan Date of ratification by Committee 21 st Sept th January 2015 Summary of consultation process Control arrangements Document Control Consultation, via from H&S manager, with: Health, Safety & Wellbeing Sub Committee Union Appointed Safety Representatives Joint Chaired Negotiation Committee Human Resource & Organisational Development Employee Health & Wellbeing Estates & Facilities Specialist Advisors South Manchester Healthcare Limited Sodexo All Staff (UHSM Consultation procedure) Review every 3 years or more frequently if required. Review by UHSM s Health & Safety Manager Associated documents UHSM s Safety Strategy UHSM s Risk Management Policy and Strategy References Health and Safety at Work etc Act 1974 Management of Health and Safety at Work Regulations 1999 Management of Health and Safety at Work (Amendment) Regulations 2006 Workplace (Health, Safety and Welfare) Regulations 1993 HSG65 (Third edition, 2013) Managing for health & Safety Document Compliance Monitoring Arrangements Process for monitoring Policy will be monitored by an audit of KPIs listed in section 5.4 Responsible individual / group/ committee Frequency of monitoring Role responsible for preparation / approval of report and action plan Committee responsible for review of results / approval of action plan Individual / group / committee that is responsible for monitoring of action plan Health & Safety Manager Annually Health & Safety Manager / Health, Safety & Wellbeing Sub- Committee Health, Safety & Wellbeing Sub Health, Safety & Wellbeing Sub 2

3 Contents Section Page 1 Introduction and purpose 4 2 Policy statement 4 3 Scope and exclusions 5 4 Definitions 5 5 Process for health and safety management Plan Do Risk Assessment Safe Practices Organising Health & Safety Incident Management Health Assessments & Health Surveillance Check (Measuring Performance) Active Performance Monitoring Reactive Performance Monitoring Act (Audit & Review) 12 6 Duties and responsibilities of key relevant groups and individuals- summary 13 Appendices A HSG65 Plan; Do; Check; Act Cycle 15 B Detailed duties and responsibilities of key relevant individuals 16 3

4 1. Introduction and purpose The Health and Safety Executive 2013/14 statistics state: 1.2 million working people are suffering from a work-related illness 133 workers were killed at work 80,000 injuries to employees were reported by employers under RIDDOR 629,000 self-reported injury 28.2 million working days were lost due to work-related illness and workplace injury This document sets out UHSM s policy and framework for health and safety management to ensure, as far as reasonably practicable, that UHSM is a safe place of work that will not cause an injury or illness. It supports UHSM s Safety Strategy and aims to prevent UHSM s staff and visitors from being harmed whilst working at or visiting the Trust. UHSM s Health & Safety Management Plan is based upon the Health and Safety Executive s guidance Managing for health and safety (HSG65 third edition) Plan, Do, Check, Act approach (illustrated in Appendix A). UHSM will endeavour, by following a systematic integrated approach, to eliminate health and safety hazards, as far as reasonably practicable, to ensure that the workplace and work environment is free of health and safety hazards, and where elimination cannot be achieved, minimize the risks associated with health and safety hazards to as low as reasonably practicable. 2. Policy Statement UHSM recognizes the risk to its staff, patients, visitors, partners and contractors from health and safety related hazards, and acknowledges Its statutory duties as an employer under the Health and Safety at Work etc. Act 1974 to provide, so far as is reasonably practicable, a healthy and safe workplace for its employees, and those who come onto UHSM premises; Its moral duties to provide a healthy and safe workplace; and Its objectives set out in UHSM s Safety Strategy UHSM also recognises the responsibilities of all staff to ensure a safe and healthy workplace, and reinforces the view of the Health and Safety Executive that all staff have a duty of care to: Look after their own safety and work in a way that promotes this Take care of persons affected by their work Share information about hazards by ensuring incidents and near misses are reported promptly. UHSM will endeavour to provide a safe and healthy work place and place to visit by following a systematic integrated approach. UHSM aims to provide this through: Being compliant with current legislation, guidance and best practice Effective and appropriate risk identification, assessment and control Having effective Health & Safety related policies and safe working procedures 4

5 Having effective systems in place to report and investigate health and safety related incidents Training and Education of staff 3. Scope and exclusions This policy applies to all employees who work at or visit UHSM including: those who may work off the premises; all service providers; partner s; volunteers; contractors and other persons who carry out work on behalf of UHSM. 4. Definitions HSE Health and Safety Executive HSWA1974 Health and Safety at Work etc Act 1974 RIDDOR Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 HSG Health and Safety Guidance HBN Health Building Note HTM Health Building & Technical Memorandum HSWSC Health, Safety & Wellbeing Sub-Committee SMHL South Manchester Healthcare Limited PFI Private Funded Initiative PPM Planned Preventative Maintenance 5. Process for health and safety management This process is based upon the HSE s Plan; Do; Check; Act approach detailed in health and safety management system guidance HSG65 (2013, 3 rd edition) 5.1 Plan Effective planning is essential for the implementation of a health and safety management, and requires an integrated framework to enable s to plan to control risks; react to changing demands; and sustain positive health and safety attitudes and behaviours. UHSM s has a systematic approach in place to effectively manage health and safety which includes this document, and in addition: Health & Safety Strategy UHSM s Corporate Health & Safety Strategy sets out UHSM s vision to enable patients, colleagues and UHSM to benefit from effective safety management and a sensible health and safety culture. It sets out key Health and Safety objectives and actions to achieve this strategy over a 2 year period. UHSM s Health & Safety Strategy will be reviewed and updated at the end of the 2 year period. 5

6 Risk Management Policy & Strategy this strategy sets out UHSM s approach to ensuring adequate work precautions are provided and maintained to control the risks associated with health and safety hazards across the. The process of risk assessment and control at UHSM is detailed in the Risk Management Policy & Strategy. Estates Strategy this strategy sets out UHSM s approach in managing the Trust estate, to ensure that the estate supports patient care, and UHSM provides a safe, secure and warm environment for patients, visitors, staff and others. Strategic Major Incident Plan sets out UHSM s approach for the management, response, coordination and control of resources in order to support local teams in carrying out their work in the event of a major incident. Incident Reporting and Investigating process UHSM has a incident reporting process in place for employees to report health and safety related incidents (include near misses and harm events). Further information on the incident reporting policy can be found in UHSM s Incident Reporting Policy. Following an incident a process of investigation is in place at UHSM, depending on the level of the incident, and further information of this process is included in UHSM s Investigation of Incidents Policy. Both policies can be found on UHSM s intranet policy webpage. Audit Programme UHSM has in place a programme of clinical audit to support and evaluate the effectiveness of national and trust objectives for safety, quality and patient experience 5.2 Do To deliver an effective safety management system the must implement processes for managing and controlling health and safety related risks. This is delivered through: Risk Assessment The process of assessing health and safety-related risks for staff and others includes: All staff following UHSM s Risk Management Strategy and Policy UHSM s Health & Safety Manager assessing the corporate level health and safety risk and identifying appropriate controls Directorate Leads assessing and managing health and safety risk, identifying appropriate controls, and maintaining and updating their risk assessments Ward and Department Managers assessing and managing health and safety risks by ensuring implementation of effective controls locally, and maintaining and updating their risk assessments Staff Side Union Safety Representatives available to assist in assessing managers in their risk assessments Safe Practices This document adopts an integrated approach to assess, train, raise awareness, monitor and manage health and safety hazards throughout UHSM. Safe Working Practices adopted include: 6

7 Safe Design the design and development for new Trust buildings and the renewal and/or repair of current Trust buildings must be compliant with current legislation, regulations, best practice, and the specifications of relevant HBN s or HTMs followed, as far as is reasonably practicable. Where it is unavoidable that current legislation, regulation, HBN s or HTM s cannot be followed then a fully evidenced risk-based assessment must be completed and agreed with the Health and Safety Manager, and Head of Risk, Compliance and Assurance which justifies the course of action taken. Maintenance and Repair Programme UHSM s Estates & Facilities has in place a programme of maintenance undertaken in conjunction with UHSM s PFI Partner and Service Provider. This includes an assurance programme for Estates & Facilities health and safety related hazards, a programme of Estates & Facilities capital improvement schemes which includes resources for health and safety related hazards and fire safety; and a defect reporting procedure through UHSM s Service Provider to enable staff to report defects. Policies UHSM will have a suite of health and safety related policies in place to provide information on specific health and safety hazards. These policies will be developed by the Health and Safety team and/or relevant Specialist Advisor. A list of health and safety related policies is available on UHSM s Risk and Governance intranet page and UHSM s policy page. Safe Working Procedures safe working procedures which relate to a local departmental task will be developed by the local department, in conjunction with the Directorate Governance Managers; Health & Safety team; Specialist Advisors; Union Safety Representatives or local sub-committees/groups where required. Local safe working procedures must be displayed in the local area. Safe working procedures which relate to the wider trust will be located on UHSM s intranet site. Emergency Planning Arrangements UHSM s Emergency Planning Department works closely with other local responders (e.g. Police; Fire Service; Ambulance Trust; Local Authority; and Health Economy Partners) to plan for and respond to emergencies and a local and national level. The department also provides training and practical exercises in emergency preparedness Organising health & safety This is the collective label given to activities that promote positive health and safety outcomes. These are: Responsibilities roles and responsibilities for health and safety management are detailed in section 6 of this document Cooperation/worker involvement It is a legal requirement for all employees in United Kingdom to be consulted about health and safety issues in the workplace that affect them. UHSM actively encourages and supports employee consultation, and acknowledges the importance of worker involvement (more than consultation alone) in promoting a positive safety culture. Involvement of the workforce and cooperation of the workforce is key to an effective safety management system and a healthy and safe workplace. This also includes cooperation from partner s; service providers and contractors. UHSM encourages cooperation and worker involvement through: - Consultation (using UHSM s intranet and HSWSC) 7

8 - Union-appointed Safety Representatives - Safety Champions - Fire Wardens - Moving & Handling Link Workers - Contractor pre-start meetings - Joint Health & Safety arrangements between UHSM and partner s (e.g. University of Manchester) - Joint meetings between UHSM, PFI Partner SMHL and PFI Service Provider Sodexo Communication - At UHSM, Health and Safety issues are communicated to employees through: - Leaders Forum - Safety Newsletters (e.g. Patient Safety One-Liners) - Weekly Update - Pop-up Screen Savers - Executive/Directorate/Department meetings - Events and awareness campaigns - Safety Alert system - Posters and leaflets At UHSM, Health and Safety issues are communicated to external s through: - Benchmarking and peer review - Reporting of accident and ill health information to enforcing authorities - Health & Safety Manager attending relevant Health & Safety external groups Competency & Training - UHSM has appointed a team of competent persons to assist with the management of health and safety, and to implement measures to comply with the s legal requirements. This team of competent persons includes: - Health & Safety Manager - Health & Safety Advisor - Specialist Advisors (including Fire Safety Advisor; Moving & Handling Advisor; Directorate Governance Managers; Falls Nurse Facilitator) - Employee Health & Wellbeing Nurse Advisor; Physician; Physiotherapist In addition to the above, UHSM acknowledges that effective health and safety management requires competency across every level of the to ensure that responsibilities are and activities in relation to health and safety. UHSM must ensure all employees are competent, and have the relevant experience, skills and knowledge to carry out their work safely and healthily. At UHSM competency is assessed by recruitment procedures; UHSM s appraisal process and supervision 8

9 In addition to assessing competency, UHSM provides a series of health and safety-related training. The programme of training includes: - Health & Safety and Patient Safety included in UHSM corporate induction - Health & Safety Mandatory training provided as e-learning training. - Health & Safety e-learning training as identified in the Training Needs Analysis for specific job roles - Emergency Preparedness training (annual exercises; internal training and external training events) - Local training in safe working practices and procedures - Use of Safeguard to report and access the Hospital Incident Reporting System (HIRS) and UHSM s Risk Register Further information on UHSM s training can be found on UHSM s intranet Learning and Development web page ( Incident Management UHSM has an incident reporting process in place for employees, (and others with assistance from a UHSM employee) to report health and safety-related incidents, including near misses and harm events. Health and safety-related incidents are managed through: Taking immediate action following an incident to control the risk Reporting and investigating incidents in accordance with UHSM s Incident and Investigation Policy Reporting of incidents which come under RIDDOR to the Health and Safety Executive, coordinated by UHSM s Health & Safety Manager Sharing the outcomes of incident investigations to learn from, feedback into local areas, Trust-wide and into corporate policy, and to raise awareness Health Assessment and Health Surveillance UHSM acknowledges that work is good for physical and psychological health, and has an internal based Employee Health & Wellbeing Service which provides services to support and promote a safe and healthy working environment. Work Health Assessment Process this assessment is required for all employees prior to them commencing a new role or position within the to determine fitness for role and if any adjustments are required for the proposed role. As part of this process the recruiting line manager is required to complete a risk assessment to identify any potential risks associated with the role, and the candidate completes a confidential work health assessment form which is sent to the Employee Health & Wellbeing Service. Attendance Case Management the aim of this service is to provide a specialist clinical opinion and advice in relation to an employee s fitness for work, which is based on a work-focused approach to a health issue that is or could be impacting on work. 9

10 Physiotherapy Service this service is provided for all UHSM employees, to help support them at work with acute or chronic musculoskeletal conditions. Immunisation and Vaccination Service in order to meet the Department of Health Guidelines for Health Care Workers (2007) UHSM provides this service for UHSM employees. Post Exposure Incident Support in the event of a sharps injury or contamination incident UHSM employees and partner employees must attend Employee Health & Wellbeing for assessment and follow up treatment. Psychological Support Services UHSM provide an independent and confidential counselling support service for UHSM employees, available 24 hours a day, 7 days a week. 5.3 Check (Measuring Performance) Measuring performance is essential to maintain an effective health and safety management system, and improve health and safety performance. UHSM s undertakes Active and Reactive Performance Monitoring Active Performance Monitoring This type of monitoring provides the with feedback on its performance before an accident, or incident of ill health occurs. At UHSM the following active performance monitoring takes place: Safety Inspections - A number of safety inspections occur at UHSM, these include: Health & Safety Inspections these inspections focus on non-clinical and environmental related hazards, and are coordinated by UHSM s Health & Safety Manager. They are unannounced and take place in external and internal areas; ward, department and communal areas, across the, in accordance with the planned schedule that aims to inspect all areas every year. These safety inspections are led by UHSM s Health & Safety Manager or Health & Safety Advisor, and may include: - Staff Side Representative - Head of Nursing (Infection Prevention) - Moving & Handling Advisor - Trust Falls Coordinator - Estates & Facilities Representative - PFI Service Provider Representatives Non-ward based Patient Safety Walk-rounds these are led by the Executive Directors according to a programme designed to ensure each area is inspected each year. They are an opportunity for board members to speak directly to patients, and to staff regarding patient safety issues in their departments. Immediate feedback is provided to the department manager, and this is followed up in a written report summarising the findings. Patient led Assessments of the Care Environment (PLACE) an inspection team, including Trust Executive Directors, Nursing Staff, Infection Prevention Team, PFI Partners, Estates & Facilities and Patient Assessors, lead the assessments each quarter. The inspections involve the team inspecting and scoring specific aspects of cleanliness and the environment, food service, privacy 10

11 and dignity, and the external environment. Results of inspections are published locally by the Trust. Staff Surveys - Each year UHSM participates in the NHS Staff Survey which is live for a set time period. The survey includes questions on Health & Safety related issues. The results of the staff surveys are disseminated throughout the by Human Resources & Organisational Development. Safety Culture Survey this is for staff to complete and is live during a one-month period each year. The assessment provides employees with the opportunity to give their opinion on health and safety at UHSM, and the results are analysed by the Health & Safety Manager. Review of Policies: A suite of Health & Safety-related policies, each with an individual review by date, is in place at UHSM. The content and effectiveness of each of these policies is reviewed when it becomes due. Each policy review is led by the author or lead named in the policy, with support from the Health & Safety Manager. Review of Risk Register: UHSM s significant risks are reviewed bi-monthly by the Quality & Assurance Committee, along with planned actions to reduce these risks. Directorate and local risks are reviewed periodically by the responsible person, to review population of risks onto UHSM s risk register. Planned Preventative Maintenance (PPM) UHSM s Estates & Facilities, in partnership with its PFI partner and service provider, has in place: a programme of planned repair / replacement of components, elements or systems; a programme for servicing of equipment; and a programme of routine inspections to ensure the Trust provides and maintains a safe and healthy workplace. Training Compliance The Learning & Development team carries out a review of compliance with Health and Safety- related training each month, and reports compliance levels to Directorate Leads, issues on UHSM s Learning & Development intranet site. Health & Safety Observations - UHSM s PFI Partner undergoes monthly health and safety observations with service providers, which are shared with UHSM s Director of Estates and Facilities, and UHSM s Health & Safety Advisor. These observations cover a different health and safety topic each month and identify gaps in safety management, so that actions can be planned for improved risk control Reactive Performance Monitoring This type of monitoring provides the with feedback on its performance following an incident or untoward event. At UHSM the following reactive performance monitoring takes place: Incident and work-related absence data - The following Key Health & Safety Performance Indicators, are monitored monthly across UHSM and reported to UHSM s Health, Safety & Wellbeing Sub-Committee. i. the number of staff harm incidents; ii. the number of RIDDOR reportable incidents to staff and others; iii. the number of lost time days due to a work related incident; Incident Investigations UHSM s Incident Reporting and Investigation Policy sets out UHSM s framework for investigating incidents in relation to their harm rating. Incidents are reviewed 11

12 initially by local managers; Health & Safety Team; and Directorate Governance Managers, and escalated to the Head of Patient Safety & Quality, the Head of Risk Compliance & Assurance, and the Director of Governance & Risk as required. Learning from Experience Report this is a quarterly report which analysis incidents, complaints, investigations and claims, with an aim to learn from experience. Within each quarter, themes are identified and discussed in a qualitative and quantitative manner, and learning points are highlighted. Safety Alerts Management - The following Safety Alerts are delivered by the Department of Health s Central Alerting System and/or manufacturer, and overseen by the Health & Safety Team, within Risk and Governance. Alerts include: MHRA Drug Alerts MHRA Device Alerts NHS England Alerts Estates & Facility Alerts Field Safety Notices Dear Dr Alerts The process of managing safety alerts is detailed in UHSM s Central Alert System (CAS) Policy. 5.4 Act (Audit & Review) Auditing and reviewing performance is essential to learn from experience, and to improve its health and safety management system and performance continually through the development of policies, procedures and techniques. UHSM has in place a programme of clinical audit to support and evaluate the effectiveness of national and trust objectives for safety, quality and patient experience Review of Documentation and Procedures: the health and safety audit and reviews carried out at UHSM will include as a minimum: - Annual review of Performance Measurements included in UHSM s Health & Safety Policy - Review of UHSM s Health & Safety Policy & Management System document every 3 years or sooner - Review of UHSM s Health & Safety related policies by relevant author / advisor every 3 years or sooner - Minimum annual review of UHSM s Safety Strategy Action Plan - Estates & Facilities Directorate annual audit of arrangements for managing corporate health and safety hazards. Carried out by an independent - PFI Partner annual audit of health and safety arrangements, carried out by external - Infection Prevention Sharps Audit. Carried out annually by an independent - Clinical Audits The current Clinical Audit programme can be found at the following link: Patient Falls Audits: carried out by Falls Nurse Facilitator and Moving & Handling Advisor on monthly basis to review the Moving & Handling; Falls Risk and Bedrail Assessment documentation on wards. 12

13 5.4.3 Review of staff health & safety performance: Health & safety performance of staff must be included in UHSM s annual appraisals. Failure to observe the requirements of UHSM s Health & Safety Policy & Management System, and follow UHSM s Health & Safety Policies and Procedures may result in disciplinary action. 6. Duties and responsibilities of key relevant groups and individuals This section provides a brief summary of the health and safety duties of key roles within UHSM. More detailed duties and responsibilities for each role are set out within Appendix B. Chief Executive (duty holder) & Trust Board have overall responsibility for ensuring a safe and healthy workplace and environment, so far as is reasonably practicable, within the to ensure compliance with current legislation. In order to ensure an effective and safe system of work at UHSM the Chief Executive and Board of Directors must: recognise the benefits of safe and healthy workforce recognise the benefits of a committed, competent and enthusiastic workforce recognises the link between health and safety and corporate strategy consider a proactive approach to health and safety ensure UHSM is committed to achieving objectives set out in UHSM s Safety Strategy ensure the implementation of UHSM s Health & Safety Policy and Safety Management System ensure suitable and sufficient resources are available to meet statutory duties Chief Nurse: is the designated responsible Executive and Board lead for Health & Safety at UHSM, whose main role is to ensure compliance with UHSM s Health & Safety Policy and Safety Management System. Executive Medical Director must ensure compliance with UHSM s Health & Safety Policy and Safety Management System, and ensure suitable and sufficient resources are in place and provided to achieve a safe working environment in relation to medics. Director of Finance must ensure compliance with UHSM s Health & Safety Policy and Safety Management System, and ensure funds are prioritised and used effectively in order to meet UHSM s statutory duties. Deputy Director of Governance & Risk carries out duties delegated by the Chief Nurse in relation to Health & Safety Management to ensure compliance with UHSM s Health & Safety Policy and Safety Management System, and current legislation. To manage UHSM s Health & Safety Department within Governance & Risk, and to ensure UHSM s Safety Strategy is developed and actions completed. Chief Operating Officer must ensure that suitable and sufficient resources are in place and provided to achieve a safe working environment, and to ensure compliance with UHSM s Health & Safety Policy and Safety Management System Director of Estates & Facilities must ensure all premises owned or leased by UHSM are as safe as reasonably practicable within available resources, ensure systems are in place and provided to achieve a safe working environment, and to comply with UHSM s Health & Safety Policy and Safety Management System. 13

14 Head of Patient Safety & Quality must ensure suitable and sufficient systems are in place and provided to achieve a safe patient environment, including the development of patient safety policies and procedures. Head of Risk, Compliance & Assurance must develop, and ensure compliance with UHSM s Health & Safety Strategy, and oversee compliance with Health & Safety Policy and Safety Management System Health & Safety Manager must develop UHSM s Health & Safety Policy and Safety Management System, and ensure a system is in place to ensure health and safety related policies, procedures and training is in place, and monitored. Specialist Advisors must develop policies, procedures and training to achieve a safe and healthy workplace and environment relating to their specialist topic. Human Resource & Organisational Development / Employee Health & Wellbeing will develop policies, procedures, training, and support to employees to achieve a safe and healthy workplace and environment. Senior Managers (Divisional Medical Directors; Divisional Directors of Operations; Operations Managers; Directorate Managers; Clinical Directors; Specialist Leads; and Heads of Nursing) must ensure suitable and sufficient systems are in place and provided to achieve a safe working environment within the responsible directorate. Matrons / Ward & Department Managers must ensure effective implementation and compliance with UHSM s Health & Safety Policy and Safety Management System; health & safety related policies and procedures and guidance. Staff Representatives must represent employees in the workplace, consult with managers on workplace health, safety and wellbeing matters, and work alongside UHSM s Health & Safety Manager. All UHSM employees (including volunteers) must read, follow and comply with health and safety related policies and procedures, and complete health & safety training, and work in a manner which protects their own health & safety and the health & safety of others. Others (Partner s / contractors) must comply with UHSM s and own s health & safety policies and procedures. Complete own s health & safety training, and UHSM s health & safety training if required in addition, and cooperate with UHSM s Health & Safety Manager and specialist advisors. Health, Safety & Wellbeing Sub-Committee (HSWSC) provides Committee members with the opportunity to review and discuss health and safety issues across UHSM, and allows for the exchange of information and learning from risk assessments and incidents. The individual Advisors provide reports on their specialist areas to the Committee for review and comment. The Committee terms of reference and Committee work plan can be obtained from UHSM s Health & Safety Manager. Minutes from the HSWSC are reported into UHSM s Quality & Assurance Committee. 14

15 APPENDIX A Health & Safety Executive s Plan, Do, Check, Act cycle Taken from HSG65 Managing for health and safety 15

16 APPENDIX B Health & Safety Executive s HSG 65 SAFETY MANAGEMENT SYSTEM CYCLE Plan, Do, Check, Act cycle ROLE CHIEF EXECUTIVE (DUTY HOLDER) & TRUST BOARD Responsible Executive and Board lead for Health & Safety at UHSM (Chief Nurse) Chief Nurse Role Overall responsibility for ensuring a safe and healthy workplace and environment, so far as reasonably practicable, within the, to ensure compliance with current legislation Authorise implementation of UHSM s Health & Safety Management Systems, Health & Safety related policies & procedures, and ensure these are fit for purpose and meet Health & Safety Management needs of the Ensure compliance with UHSM s Health & Safety Management System, related policies and procedures, and current legislation Ensure a system is in place for the provision of competent health & safety advice Ensure suitable and sufficient resources are in place and provided, to achieve a safe working environment in relation to nursing operations PLAN & DO CHECK ACT RESPONSIBILITIES Ensure a systematic integrated framework is in place to effectively plan and implement health & safety management throughout UHSM Ensure clear roles and responsibilities are set out within UHSM for achieving Health & Safety Management. Ensure delegation of responsibility for overseeing and coordinating health and safety across the (delegated to the Chief Nurse) Ensure suitable and sufficient resources are available to meet statutory duties Ensure a process is in place for the delegation of overseeing health and safety management across the Trust (delegated to the Director of Risk & Governance) Ensure clear lines of responsibility are set out to achieve a safe working environment and compliance with policies and safe working procedures Ensure health and safety hazard responsibilities under chief nurse are acknowledged and managed Ensure, so far as reasonably practicable, that effective safe systems of work are operating throughout UHSM Review and agree UHSM s Safety Strategy and other related Health & Safety Strategies throughout the culture throughout UHSM Ensure effective systems are in place to effectively manage UHSM s nursing activities to identify, assess and adequately control operational hazards culture Ensure a programme of performance monitoring is in place to identify health and safety hazards and associated risks, trends in performance and compliance with statutory obligations Receive reports from relevant Directors, Managers and Advisors on health & safety performance, trends and compliance Receive reports on performance, compliance and assurance from relevant Directors, Managers and Advisors associated with Operational activities Review UHSM s Health & Safety Performance, trends and compliance to gain assurance of compliance with current legislation Prioritise actions and resources to enhance UHSM s Health & Safety Management Prioritise actions and resources to enhance UHSM s Health & Safety Management Bring to the attention of the Board actions required to enhance UHSM s Health & Safety Management Review health and safety performance, compliance and assurance in relation to nursing operations, and raise concerns with UHSM s Board. Recommend actions and targets to improve Health and Safety Management across nursing activities of the Deputy Director of Risk & Governance Carry out duties delegated by the Chief Nurse in relation to Health & Safety Management including: Ensure competent Health & Safety advice is available to Ensure clear lines of responsibility are identified for management of health & safety across UHSM Work alongside, and in partnership with Trade Ensure a Safety Strategy is developed for the Ensure an integrated health and safety management system, and related policies Receive reports on health and safety performance, trends, compliance and assurance from relevant Directors, Managers and Advisors Review health and safety performance, trends, compliance and assurance, and raise concerns with the responsible Executive lead for Health & Safety and 16

17 ROLE Chief Operating Officer Executive Medical Director Director of Finance Director of Estates and Facilities UHSM Ensure a process of implementation of UHSM s Health & Safety Management System is in place Ensure suitable and sufficient resources are in place and provided, to achieve a safe working environment. Including the provision of safe estate and facilities at all locations where health care is provided by UHSM Ensure compliance with UHSM s Safety Management System, policy, procedures and current legislation and guidance. Ensure compliance with UHSM s Safety Management System, policy, procedures and current legislation and guidance. Ensure suitable and sufficient resources are in place and provided, to achieve a safe working environment in relation to medics Ensure compliance with UHSM s Safety Management System, policy, procedures and current legislation and guidance. Ensure suitable and sufficient systems are in place and provided, to achieve a safe working environment. Including the provision of safe estate and facilities at all locations where health care is PLAN & DO CHECK ACT RESPONSIBILITIES and procedures are developed for the Chair the HSWSC culture throughout UHSM Union representatives and partner s, to continuously improve health & safety management Ensure clear lines of responsibility are set out to achieve a safe working environment and compliance with policies and safe working procedures Ensure health and safety hazard responsibilities are acknowledged and managed Ensure clear lines of responsibility are set out to achieve a safe working environment and compliance with policies and safe working procedures Ensure health and safety hazard responsibilities under chief nurse are acknowledged and managed Ensure that funds are prioritised and used effectively in order to meet the requirements of UHSM's statutory duties Ensure clear lines of responsibility are set out to achieve a safe working environment and compliance with policies and safe working procedure Ensure own health and Ensure effective systems are in place to effectively manage UHSM s activities to identify, assess and adequately control operational hazards culture Ensure effective systems are in place to effectively manage UHSM s medical team activities to identify, assess and adequately control operational hazards culture Ensure effective systems are in place to effectively manage UHSM s funds across the to meeting UHSM's statutory duties culture Ensure an Estates Strategy is developed for the, which takes into account Health & Safety Issues Provide advice and support to the Risk and Governance Receive reports on performance, compliance and assurance from relevant Directors, Managers and Advisors associated with Operational activities Receive reports on performance, compliance and assurance from relevant Directors, Managers and Advisors associated with Operational activities Receive reports on financial performance, compliance and assurance from relevant Directors, Managers and Advisors associated with meeting UHSM's statutory duties Receive reports on health and safety performance, trends, compliance and assurance in relation to Estates & Facilities health & safety hazards from relevant Managers UHSM s Board Recommend, set and agree actions and targets to improve Health and Safety Management across the Review health and safety performance, compliance and assurance, and raise concerns with UHSM s Board. Recommend actions and targets to improve Health and Safety Management across Operational activities of the Review health and safety performance, compliance and assurance in relation to medics, and raise concerns with UHSM s Board. Recommend actions and targets to improve Health and Safety Management across medics activities within the Review financial performance, compliance and assurance, and raise concerns with UHSM s Board in relation to meeting UHSM's statutory duties. Review health and safety performance, trends, compliance and assurance in relation to Estates & Facilities health & safety hazards. Provide assurance to UHSM's relevant 17

18 ROLE Health & Safety Manager (Health & Safety Advisor to assist and deputise for Health & Safety Manager) provided by UHSM Ensure all premises owned or leased by UHSM are as safe as reasonably practicable within available resources Ensure compliance with UHSM s Safety Management System, policy, procedures and current legislation and guidance. Develop UHSM's Health & Safety Management system to ensure suitable and sufficient systems are in place and provided, to achieve a safe and healthy work place and environment. Ensure a system is in place to liaise with UHSM's Specialist Advisors to ensure policies, procedures and training is in place in relation to each specialist topic PLAN & DO CHECK ACT RESPONSIBILITIES Team with regards to Estates and Facilities related activities culture safety hazard responsibilities identified are acknowledged and managed Ensure a system is in place for contractors to be made aware of, and work to, UHSM s Health & Safety related policies, procedures and current legislation and guidance Ensure clear lines of responsibility are set out with UHSM's Health & Safety Management System to achieve a safe and healthy workplace and environment Develop health & safety training packages (in conjunction with specialist advisors), and provide induction and training when required Work alongside, and in partnership with trade union representatives and partner s to continuously improve health & safety management. Develop and implement UHSM's Safety Strategy Provide competent Health & Safety advice and support to UHSM Interpret legislation and translate into health care settings Ensure a corporate risk register entry is in place for Health & Safety Raise awareness of health & safety issues, and encourage a positive safety culture Liaise with external s in respect of Health & safety issues Maintain own competence/continuing professional development Liaise with UHSM's Directors, Senior Managers and Specialist Advisors to gain assurance of compliance with health & safety legislation within their relevant areas of responsibility Undertake safety inspections and tours of premises and provide feedback to managers and safety representatives Recommend improvement or prohibition notices where necessary Monitor & review health & safety incident data Report incidents which classify under the current RIDDOR regulations to the HSE Maintain an overview of the investigation of nonclinical health & safety incidents Report H&S performance to UHSM's Board Undertake horizon scanning to identify potential threats or lessons for learning that may apply to UHSM committees and raise concerns with the Director of Risk & Governance and responsible Executive lead. Recommend, set and agree actions and targets to improve Estates & Facilities related Health and Safety Management across the Review health and safety performance, trends, compliance and assurance and provide assurance to UHSM's Director of Risk & Governance, and relevant committees. Raise concerns with the Director of Risk & Governance and responsible Executive leads and Managers. Recommend, set and agree actions and targets to improve Health and Safety Management across the 18

19 ROLE Head of Patient Safety & Quality (along with Patient Safety & Quality Managers) Specialist Advisors Ensure suitable and sufficient systems are in place and provided, to achieve a safe patient environment. Including the development of patient safety policies and procedures. Ensure Patient Safety & Quality is included in UHSM's integrated health & safety management system Develop policies and procedures to ensure suitable and sufficient systems are in place and provided, to achieve a safe and healthy work place and environment in relation to specialist topic Ensure a system is in place to liaise with UHSM's Health & Safety Advisor in relation to each specialist topic PLAN & DO CHECK ACT RESPONSIBILITIES Ensure a Patient Safety & Receive reports on Patient Quality Strategy is Safety & Quality developed for the performance, compliance and assurance hazards Chair the Patient Safety & from relevant Managers Quality Board and provide advice and support to the Risk management Committee culture Ensure clear lines of responsibility are set out to achieve a safe patient environment and compliance with policies and safe working procedures Develop health & safety related training packages, and provide inductions and training when required Ensure clear lines of responsibility are set out within relevant policies and procedures Develop health & safety training packages, and provide induction and training when required Work alongside, and in partnership with UHSM's Health & Safety Advisor, trade union representatives and partner s to continuously improve health & safety management Provide competent Health & Safety advice and support to UHSM for the relevant specialist topic Interpret legislation and translate into health care settings Ensure a corporate risk register entry is in place for Health & Safety Raise awareness of the specialist topic and encourage a positive safety culture Maintain own competence/continuing professional development culture Liaise with UHSM's Health & Safety Advisor, Directors, Senior Managers and Specialist Advisors to gain assurance of compliance with health & safety legislation the relevant specialist area Undertake safety inspections and tours of premises and provide feedback to managers and safety representatives Monitor & review health & safety incident data for the specialist topic Support and assist managers in the investigation of health & safety incidents for the specialist topic Report health & safety performance to UHSM's Safety Committee and Risk Management Committee Undertake horizon scanning to identify potential threats or lessons for learning that may apply to UHSM Review Patient Safety & Quality performance, trends, compliance and assurance. Provide assurance to UHSM's relevant committees and raise concerns with the Director of Risk & Governance. Recommend, set and agree actions and targets to improve Patient Safety & Quality Review health and safety performance, trends, compliance and assurance and provide assurance to UHSM's Director of Risk & Governance, and relevant committees. Raise concerns with the Director of Risk & Governance and responsible Executive leads and Managers. Recommend, set and agree actions and targets to improve Health and Safety Management across the 19

20 ROLE Human Resources & Organisational Development / Employee Health & Wellbeing Senior Managers (Divisional Medical Directors /Divisional Directors of Operations /Directorate Managers / Clinical Directors / Speciality Leads / Heads of Nursing Develop policies and procedures to ensure suitable and sufficient systems are in place and provided, to achieve a safe and healthy work place and environment in relation to Human Resource / Organisational Development / Health & Wellbeing Ensure suitable and sufficient systems are in place and provided, to achieve a safe working environment within your responsible Directorates. Ensure effective implementation and compliance with UHSM s Safety Management System, policies, procedures and current legislation and guidance. PLAN & DO CHECK ACT RESPONSIBILITIES Provide Human Resource related Health, Safety & Wellbeing Advice and support to UHSM Attend UHSM s Safety Committee culture Ensure clear lines of responsibility are set out to achieve a safe working environment and compliance with policies and safe working procedure Ensure own health and safety hazard responsibilities identified in UHSM s health & safety hazard matrix are acknowledged Work alongside UHSM's Health & Safety Advisor Ensure clear lines of responsibility are set out to achieve a safe working environment and compliance with policies and safe working procedure Ensure own health and safety hazard responsibilities identified in UHSM s health & safety hazard matrix are acknowledged Work alongside, and cooperate with UHSM's Health & Safety Advisor and Specialist Advisors Ensure that funds are sufficiently allocated prioritised and used effectively to meet Health & Safety requirements Ensure effective systems are in place to effectively identify, assess, adequately control and manage health & safety hazards within Directorates Ensure a process is in place for all staff within Directorates to be briefed on policies, procedures and workplace hazards within the Directorate, and how these hazards are to be managed culture Receive reports on Human Resources health & safety related topics, and Health & Wellbeing from relevant managers & specialist advisor Report health & safety performance for responsible hazards (identified in UHSM's health & safety hazard matrix) to UHSM's Safety Committee and Risk Management Committee Allow Safety Inspections to be undertaken within relevant Directorate Monitor & review health & safety incident performance of staff and health & safety incident data within relevant Directorate Ensure incidents and untoward events are effectively reported, managed and investigated, and appropriate actions are implemented, and lessons learnt are shared throughout the Matrons / Ensure effective Ensure clear lines of Ensure implementation and Ward & implementation and responsibility are set out to supervisor of safe working Departmental compliance with UHSM s achieve a safe working procedures Managers Safety Management System, environment and compliance Ensure all staff are aware of policies, procedures and with policies and safe policies, procedures and current legislation and working procedure workplace hazards within guidance. Work alongside, and the Directorate, and how managed and Ensure incidents and defects are reported within Directorates Ensure incidents and untoward events are effectively reported, Review health and safety performance, trends, compliance and assurance and provide assurance to UHSM's Director of Risk & Governance, and relevant committees. Raise concerns with the Director of Risk & Governance and responsible Executive leads and Managers. Recommend, set and agree actions and targets to improve Health and Safety Management across the Review health and safety performance, trends, compliance and assurance within relevant Directorate and provide assurance to UHSM's Director of Risk & Governance, and relevant committees. Raise concerns with the Director of Risk & Governance Recommend, set and agree actions and targets to improve Health and Safety Management within relevant Directorate Review health and safety performance, trends, compliance and assurance within relevant Directorate and provide assurance to relevant Directorate Manager/Clinical Director 20

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