NHS Commissioning Board: Health and safety policy. NHS Commissioning. Health and Safety Policy

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1 NHS Commissioning Board: Health and safety policy NHS Commissioning Board: Health and Safety Policy

2 DOCUMENT STATUS: Approved DOCUMENT RATIFIED BY: NHS CB Board DATE ISSUED: October 2012 DATE TO BE REVIEWED: April

3 AMENDMENT HISTORY: VERSION DATE AMENDMENT HISTORY /03/2013 Section on Disabled Persons (S.8) added REVIEWERS: This document has been reviewed by: NAME TITLE / RESPONSIBILITY DATE VERSION APPROVALS: This document has been approved by: NAME SIGNATURE TITLE / RESPONSIBILITY DATE VERSION Bill McCarthy National Director: Policy 1 October NB. The version of the policy posted on the intranet must be a PDF copy of the signed approved version. DOCUMENT STATUS: This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of the document are not controlled. RELATED DOCUMENTS: These documents will provide additional information. REF NO DOC REFERENCE NUMBER TITLE VERSION GLOSSARY OF TERMS: TERM ACRONYM DEFINITION 3

4 Contents Contents Introduction Scope Purpose Strategic context How health and safety will be delivered Organisation and responsibilities General arrangements Disabled Persons Incident reporting Fire and emergency evacuation Building maintenance Manual handling Mobile telephones General safety and environment Monitoring and review

5 1. Introduction 1.1. The role of the NHS Commissioning Board (NHS CB) is to commission healthcare, both directly and indirectly, so that valuable public resources secure the best possible outcomes for patients. In doing so, the NHS CB will seek to meet the objectives prescribed in the mandate and to uphold the NHS Constitution. This policy is important because it will help the NHS CB to take care of the people who work for it and make sure that their working environment is the best it can be The NHS CB is fully committed to promoting the health, safety and welfare of all its staff. The Board of the NHS CB will provide the leadership to ensure that exemplary health and safety practices are firmly embedded throughout the organisation to provide a secure and healthy environment in which to work There is an obligation upon every line manager to ensure that staff are informed and instructed with regards to health and safety training, instruction and that such activities are properly recorded and records maintained As an employee of the NHS CB, you are required to attend all health and safety training relevant to you and to read this policy document carefully and raise any queries that you may have with your line manager or the Corporate Development Team. 2. Scope 2.1. This policy applies to those members of staff that are directly employed by the NHS CB and for whom the NHS CB has legal responsibility. For those staff covered by a letter of authority/honorary contract or work experience the organisations policies are also applicable whilst undertaking duties for or on behalf of the NHS CB. Further, this policy applies to all third parties and others authorised to undertake work on behalf of the NHS CB. 3. Purpose 3.1. The purpose of this policy is to: ensure, as far as is reasonably practicable, the health, safety and welfare of NHS CB staff; ensure, as far as is reasonably practicable, the health, safety and welfare of other people, for example contractors, visitors, general public who may be affected by NHS CB s activities; and satisfy the requirements of the relevant regulations. 4. Strategic context 4.1. The NHS CB attaches great importance to the health and safety of its staff, and recognises its legal obligations under the Health and Safety at Work Act 1974, to ensure the health, safety and welfare of its staff, so far as is reasonably practicable. The NHS CB also accepts such responsibility for other persons who may be affected by its activities whilst on any site. 5

6 5. How health and safety will be delivered 5.1. Principles: good practices will be adopted to manage health and safety, and the NHS CB will endeavour to secure the co-operation of all staff in matters of health and safety and encourage their active participation through consultation; the NHS CB will provide adequate safety training and the necessary safety devices at each site, as well as ensuring sufficient resources are available; the NHS CB will make necessary provisions to ensure all health and safety policies and procedures are regularly monitored and reviewed; the NHS CB will take all necessary precautions to safeguard its staff from exposure to harm including stress at work, violence, harassment and bullying; and The NHS CB s ways of working will be guided by: o CRAMM (Risk Assessment and Management Methodology); o Published organisational values; and o Health and Safety Executive guidance It is the policy of the NHS CB to: provide and maintain standards of health, safety and welfare, which comply fully with the Health and Safety at Work Act 1974 (HASAWA 1974) and any other statutory provisions, or codes of practice relevant to the nature of the business; provide and maintain plant, equipment and systems of work that are suitable, safe and without risk to health; provide all staff with sufficient instruction, information and supervision to develop and encourage safety awareness in order to work in a safe manner; provide a safe place of work; establish joint consultation on matters of health and safety in order to help identify risks and to assist in the prevention of accidents; and ensure as far as is reasonably practicable, that the operations of NHS CB are safe and without risk to the health and safety of visitors and the local community. 6. Organisation and responsibilities 6.1. The National Director: Policy has delegated responsibility for all aspects of health and safety. At an operational level, the duties will fall to the Corporate Development Team of the NHS CB Line managers are responsible for ensuring their staff receive all necessary health and safety training, instruction and information and that such activities are properly recorded and records maintained. They must: organise the department, section or workplace so that operations or work carried out is to a satisfactory standard of safety, resulting in minimal risk to people, equipment and materials; plan and maintain good house-keeping; 6

7 make sure the control measures in place are at all times operable and not interfered with and that personal protective clothing, where appropriate, is available and is used; co-operate with safety advisors as necessary; review operating and work instructions and specific related hazards to staff transferred into the department and/or new staff; ensure all accidents are reported to the relevant person so that they may be recorded; ensure all staff are aware of health and safety procedures; and encourage the good behaviours required by staff by setting a good example with respect to health and safety All staff whilst at work have a legal duty to take reasonable care for the health and safety of themselves and others who may be affected by their acts or omissions. They also need to co-operate fully with the arrangements made by management to meet its legal responsibilities for health and safety as in Section 7 of HASAWA Staff have a responsibility for bringing to the immediate attention of their manager or the Corporate Development Team, any failings that could be detrimental to themselves and others, including visitors. Specific responsibilities of staff are: to comply with local fire procedures; to comply with local first aid procedures; not to attempt to repair any item of electrical equipment (unless properly authorised to do so) but to report it to their manager or the Corporate Development Team; not to bring personal mains electrical equipment into work; to report to the Corporate Development Team, any obstructions to any walkways, entrances and exit areas and avoid creating such obstacles; not to move any equipment without relevant training; to report any building and/or equipment defects and/or shortfalls in cleanliness to the local competent person; and to set a good personal example with respect to health and safety. 7. General arrangements 7.1. The NHS CB has the following policy statements 7.2. Violence/bullying and harassment: the NHS CB as an employer has a duty of care to provide both a safe place and safe system of work. Consequently, a policy to cover this issue is being drafted. In the meantime any violence, bullying and/or harassment of NHS CB staff that is reported will be investigated in order to comply with this duty of care Third party contractors - people undertaking work, for example, building maintenance: 7

8 third party contractors (not management contractors) will be required to submit a copy of their safety documentation such as, THE Safety Policy, liability insurance and risk assessments/method statements along with their tender, in order for the NHS CB to ensure the contract includes appropriate measures of health and safety. Where possible, contractors who have recognised quality systems in place such as ISO 9000 will be chosen to carry out work; third party contractors will be supplied with a copy of the NHS CB s health and safety policy and will be expected to abide by the policy unless a variation has been explicitly agreed; and all contractors that attend an NHS CB site will be provided with information on local health and safety arrangements and will be issued with permits for work where applicable Control of substances hazardous to health (COSHH): risk assessments will be undertaken to ensure staff do not become harmed in any way from exposure to hazardous substances in the workplace. any potentially hazardous substances identified will be suitably stored and labelled correctly. Appropriate information will be readily available relating to the natural characteristics of a particular substance, and suitable control measures and contingency plans will be in place to ensure appropriate action is taken in the event of an accident or injury. full training and information will be given to all staff who are required to handle such substances; and protective personal equipment will be provided where appropriate, and a full review of substances will be carried out at regular intervals Work station assessment: all staff who are dependent on the daily and prolonged use of display screen equipment are classed as essential users, and the NHS CB will ensure that risk assessments are carried out annually (or whenever circumstances change) to identify any workstation hazards and risks to which an essential user may be exposed; and risk assessments will cover the whole working environment including IT equipment, workstations, work patterns, and lighting. 8. Disabled Persons NHS Commissioning Board aims to provide full and fair opportunity for employment for disabled applicants and to ensure, through training and practical assistance where required, their continued employment and promotion. Employees who become disabled will be accorded every possible opportunity for maintaining their position or for retraining if appropriate. Arrangements will be made to ensure that visitors who have a disability will be welcome and not disadvantaged by our equipment, premises or facilities. 8

9 The NHS Commissioning Boards Health and Safety Policy has been prepared to ensure a safe and healthy working environment for all employees. It recognises that those employees who require extra equipment, facility or assistance, both routinely and in an emergency, will have such needs met. NHS Commissioning Board will keep a record of all personnel who, by reason of disability, are thought to have particular requirements relating to the NHS Commissioning Board s Health and Safety practices. The record will be regularly reviewed in terms of; o The nature of the disability and any limitations it places on either and individuals physical and/or intellectual function. o The extent to which the individual requires change (if at all) in the work environment or workplace practices. o The nature of any routine practical assistance or supervision required of other people arising from the disability. o Any implications that would arise on an emergency basis, either as a consequence of the disability (such as an epileptic fit) or in the workplace (such as emergency evacuation of the premises) o What action has been taken on the basis of the above factors. 8.1 Information & Training Newly appointed disabled employees and employees who become disabled will receive specific information and training on all relevant matters of Health and Safety. The NHS Commissioning Board will ensure that the information is presented in such a way as to be readily understood by each individual. Any Health and Safety bulletins will also be issued in such a way that disabled employees can readily access and understand them. If the NHS Commissioning Board requires the services (supervisory or otherwise) of other employees to assist a disabled person in the course either of their work or to expedite Health and Safety procedures, these employees will be trained by the NHS Commissioning Board and will receive specific notice of the duties required of them, and the disabled employee will be advised of the arrangement. As a matter of good practice, the NHS Commissioning Board will ensure that the workforce is generally advised of any relevant Health and Safety issue that affects an individual disabled employee. 8.2 Record Keeping NHS Commissioning Board will ensure that records are kept of disabled persons in the workforce and records of any special equipment provided or workplace adaptations made for the benefit of disabled persons. Any training provided to disabled persons will also be recorded. 9

10 9. Incident reporting 9.1. The definition of an incident varies according to a particular policy or procedure. An incident can range from the reporting of an accident that occurs in work to raising concerns about fraud being committed by staff For some incidents or situations, making a report is a legal requirement. The NHS CB must report the following types of incidents: work-related accidents that result in: o death; o major injury; or o more than three days off work; work-related diseases; and dangerous occurrences Legal and regulatory reporting requirements: the main reporting requirements placed upon the NHS CB are encompassed in the following regulations: o Management of Health and Safety at Work Regulations. These regulations place a duty on staff to report issues affecting health and safety within the workplace. In most instances this will involve staff alerting facilities management to a problem, for example, a faulty electrical socket. Details of these reporting mechanisms can be found later in this section. o Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995, commonly referred to as RIDDOR 95. The NHS CB needs to report the following types of incidents and occurrences to the appropriate enforcing authority, usually a local authority or the Health and Safety Executive Death or major injury: if an accident occurs, either at the NHS CB s offices or in connection with the NHS CB s work, to a member of staff that results in their death or serious injury, including as a result of physical violence, then this must be reported by the National Director: Policy. Accidents that result in the death or serious injury to a member of the public must also be reported. Such accidents need to be reported immediately, by telephone for example, to the enforcing authority (see below) The National Director: Policy will be responsible for reporting the accident, disease or occurrence to the appropriate enforcement authority via the Incident Contact Centre which is contactable by: o telephone (8.30am-5pm); o (any time); o completing the relevant form on the Incident Contact Centre s website at (any time); 10

11 o completing the relevant form and faxing it (any time); and o completing the relevant form and sending it by post to: Incident Contact Centre Caerphilly Business Park Caerphilly Wales CF83 3GG. the relevant forms, which will be completed by the National Director of Policy are as follows: o death or major injury F2508; o over three day injury F2508; o disease F2508A; and o dangerous occurrence F The Incident Contact Centre forwards details of incidents to the appropriate enforcing authority. This may result in an investigation by the appropriate enforcing authority. Learning points will be produced as a result of this investigation The National Director: Policy will be responsible for ensuring such incidents are reported, together with the learning points from any investigation, to the Health and Safety Group (once established). These matters will then be reported to the Board. The National Director of Policy will also report such incidents to the Executive Team Meeting If the incident has serious consequences for the NHS CB, the National Director of Policy should discuss with the Chair of the Health and Safety Group as to whether an extraordinary meeting of the Health and Safety Group is called to coordinate the NHS CB s response Maintaining records: the National Director: Policy will be responsible for ensuring the maintenance of records of any reportable death, injury, disease or occurrence for a minimum of three years after the incident has taken place. Information to be retained needs to include: o the date, time and place of the event; o personal details of those involved; o the date and way in which the event was reported to the Incident Control Centre; o copies of any reporting forms, s, documents, statements used to record the event; and o a written log recording all the actions taken by the NHS CB. 10. Fire and emergency evacuation Fire: 11

12 the NHS CB will ensure that all persons on site are able to proceed safely along a recognised escape route, to a place of safety regardless of the location of the fire; risk assessment will be carried out to ensure that, as far as is reasonably practicable, all fire hazards and/or risks are eliminated; fire officers and wardens will be appointed at all NHS CB controlled sites to assist with evacuation procedures; assembly points will be clearly identifiable and located in a suitable place away from any other dangers; and staff will be fully informed and trained via evacuations in local evacuation procedures and will receive suitable refresher training as appropriate Other emergency evacuations: emergency evacuations prompted by bomb threats or other events will have the same essential principles for fire evacuation, although may not be signalled by an audible alarm, but via fire wardens as one or more escape routes could be impacted by any suspicious device or gas leak for example. Specific instructions will be issued to staff as the need arises; and staff should read the appropriate evacuation process for any sites that they attend (these can be found on the Intranet under Policies and Procedures). 11. Building maintenance All NHS CB controlled sites will have planned preventative maintenance for all key building services such as air-conditioning, heating, hot and cold water supplies, lighting, cleaning, fire equipment and alarm systems, security systems, sanitary facilities and general decoration Service level agreements will be put in place for such maintenance and appropriate records will be kept of all maintenance, breakdowns and repairs Essential information for use in the event of emergency breakdowns will be available to all designated responsible persons at each site. 12. Manual handling Risk assessments will be carried out for any task where there is a significant risk to a person who is required to move an object through pushing, pulling, carrying or lifting. The assessment will consider the load, the working environment and the physical capability of the individual. Such assessments will be readily available and will be shared amongst staff Consideration is given to the elimination of risky manual handling activities wherever practicable with provision of special equipment where appropriate Training, supervision and information will be given to staff by competent people prior to work being carried out Assessments will be reviewed should conditions change. 12

13 12.5. Where a member of staff raises a matter related to health and safety in manual handling the NHS CB will: take all necessary steps to investigate the circumstances; take corrective measures where appropriate; and advise the member of staff of any actions taken. 13. Mobile telephones Staff using mobile phones at work are required to operate them safely and without risk to themselves or others From 1 December 2003, the use of hand-held mobile phones by drivers has been unlawful under new regulations which amended the Road Vehicles (Construction and Use) Regulations It has become a criminal offence for anyone to drive a motor vehicle while using a hand-held telephone or a similar device (other than a two-way radio), which performs an interactive communication function by transmitting and receiving data Since the new offence applies to hand-held devices, a driver will not be liable provided that the phone is operated without being held. Use of hands-free equipment is not prohibited, which means that pushing buttons on a phone while it is in a cradle or on the steering wheel of a car or the handlebars of a motorbike is not covered. Nor will the use of hand-held equipment in a stationary motor vehicle be an offence Those in breach face a 30 fixed penalty or a fine of up to 1,000 on conviction in court. In addition, drivers will continue to risk prosecution for the more serious offence of failure to have proper control of their vehicles if they use hand held phones whilst driving. In the future, the Department of Transport intends to increase the penalty by making those in breach subject to three penalty points and a 60 fixed penalty The use of hand held mobile phones whilst driving is prohibited. It is the advice and strong recommendation of NHS CB that mobile phones, even when legally used, should not be used when driving and preference should be given to only using mobile phones when stationary Consideration must be given to proper rest breaks and staff must not be contacted involuntarily outside normal working hours, mobile phone users are therefore entitled to switch off their phones during rest breaks, whilst driving and when they are not working Mobile phones must not be used in any situation where their use is locally prohibited or where they may cause risk including outside the car whilst on petrol station forecourts, due to the risk of speaking and fuel ignition or in hospitals where their use may affect medical equipment. 14. General safety and environment Pedestrian/traffic routes: 13

14 the NHS CB will work with landlords to ensure that: o control measures are in place to ensure walkways are free from obstructions at all times; o control measures to deal with ice and snow are in place at all sites; and o pedestrians use the path and pavement provided, otherwise walk facing the oncoming traffic; all drivers will be expected to exercise caution whilst on NHS CB premises, particularly where pathways are not provided, and obey and displayed speed limits and warning notices. roadways must not be obstructed and vehicles must only park in designated areas Premises security: appropriate security measures will be in place at each NHS CB site and these will be actively monitored and reviewed to ensure the safety of staff, visitors, equipment and plant; and arrangements will be made for the provision of key holders and suitable training and information will be provided where necessary Physical/environment risk assessment: Utilities: risk assessments will be carried out by competent persons to identify hazards within the workplace; the assessments will state what the hazards are, the risks associated with them, who might be harmed and how; and appropriate control measures will be put in place to reduce risks and regular reviews will be undertaken. utilities such as electricity and water will be provided at each site. Service agreements will be in place to ensure such services are fully maintained and any maintenance work required will only be carried out by qualified professionals Waste disposal: waste will be managed effectively. Thought will be given to waste materials to determine whether they can be reduced, reused or recycled in any way. Where this is not an option, all waste materials will be disposed of safely; and suitable receptacles will be provided at all locations for storing waste until it is disposed of in a suitable manner Working environment: the NHS CB will ensure, so far as is reasonably practicable, that the working environment is a safe and healthy one. Provisions will be made in order to 14

15 14.7. Environment: comply with the Workplace (Health, Safety and Welfare) Regulations. the Environmental Protection Act 1990 has introduced specific guidance through regulations made by the Secretary of State, and deals with the control of industrial waste and pollution; these controls have brought to bear specific responsibilities on companies, the NHS CB aims to meet these standards and therefore, due diligence is necessary by all employees; and the environmental policies at NHS CB have the following intentions for the sites which it controls Statutory nuisances and clean air: all due care will be taken by NHS CB to prevent a statutory nuisance i.e. noise, smell or other effluvium caused by a process or any other matter so deemed to be of nuisance. 15. Monitoring and review Performance against key performance indicators will be reviewed on an annual basis and used to inform the development of future procedural documents This policy will be reviewed on a yearly basis, and in accordance with the following on an as and when required basis: legislative changes; good practice guidance; case law; significant incidents reported; new vulnerabilities; and changes to organisational infrastructure Equality impact assessment The NHS CB aims to design and implement services, policies and measures that are fair and equitable. As part of its development, this policy and its impact on staff, service users and the public have been reviewed in line with the NHS CB's Legal Equality Duties. The purpose of the assessment is to improve service delivery by minimising and if possible removing any disproportionate adverse impact on employees, service users and the public on the grounds of race, socially excluded groups, gender, disability, age, sexual orientation or religion/ belief. The equality impact assessment has been completed and has identified impact or potential impact as no impact The NHS CB will endeavour to make sure that this policy will support the health and wellbeing of a diverse workforce and enable them to work safely. 15

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