Code of Practice. for. Risk Assessment

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1 Code of Practice for Risk Assessment July 2004 Royal Free Hampstead NHS Trust & Royal Free & University College Medical School (Hampstead campus)

2 Contents 1. Introduction 2. Managerial Duties 3. Guidance on the Risk Assessment Process 3.1 General Principles 3.2 Steps in carrying out a Risk Assessment 4. References Appendices Appendix 1: Common hazards covered by specific policies Appendix 2: General Risk Assessment Form RACoP Page 2 of 10

3 SCOPE This code is concerned with risk assessment as required by health and safety legislation. It seeks to explain the duties placed on managers and other employees by the trust s health and safety policy and to provide guidance on how to discharge those duties. 1. INTRODUCTION Risk assessment is required by several health and safety regulations. The majority of the regulations deal with a specific subject (eg manual handling, display screen equipment, chemicals) and trust guidance is available for many of them. The Management of Health and Safety at Work Regulations 1999 extend the requirements of the Health and Safety at Work Act (HSWA) 1974 and require a suitable and sufficient assessment of the risks to the health and safety of employees whilst they are at work. There is also a requirement to assess the risks to non-employees e.g. patients, visitors, contractors etc. The assessments made under these regulations are often referred to as general risk assessments to distinguish them from the assessments made for specific subjects. Appendix 1 lists common hazards requiring specific risk assessments, together with the relevant Trust Health and Safety Policy. Policies with their own assessment proformas are indicated. Once the assessment has been carried out, suitable control measures need to be implemented to reduce the risk to the lowest level reasonably practicable. Where significant risks exist, risk assessments must be recorded. Recording risk assessments also provides documentary evidence of legislative compliance should the Health and Safety Executive (HSE) carry out an inspection. Recorded assessments may also provide essential evidence in defending a civil claim. Risk assessments may already be incorporated into existing policies and procedures or into method statements, for example, an assessment of suitable personal protective equipment may be covered in an instruction manual, manufacturer s guidelines or Trust local policies. Risk assessment is a means to an end, and not an end in itself. 2. MANAGERIAL DUTIES Managers have various health and safety management responsibilities as detailed in the Trust s Health and Safety Policy Organisation and Arrangements for Implementation. Their key duties in the management of safety are to ensure that: suitable and sufficient risk assessments are carried out risk assessments are kept up to date the risk assessors are competent, have been adequately trained, and are given sufficient time to carry out their risk assessment duties timely completion of the corrective actions that were shown to be necessary by the assessment. If, as a result of a risk assessment, risks cannot be reduced to acceptable levels, then this needs to be brought to the attention of senior management. Significant risks that cannot be reduced to acceptable levels in a short period of time should be placed on the risk register. 3. GUIDANCE ON THE RISK ASSESSMENT PROCESS 3.1 GENERAL PRINCIPLES approaches to risk assessment There are many ways of carrying out a risk assessment. Largely, it will depend on the nature of the work and the types of hazards and risks present. Although the aims are the same, each subject needs its own set of questions and, therefore its own assessment proforma (this is discussed in step 4 below). RACoP Page 3 of 10

4 The trust general risk assessment proforma is designed to provide a general template that can be used, or extended, in almost all situations. competent persons The Management Regulations require that competent persons should carry out the risk assessment. In effect this means that only persons who have received the appropriate training (e.g. risk assessment training), or who have the relevant experience or technical knowledge in relation to the risk(s) can carry out the assessment. Therefore, risk assessments can be carried out by the manager or this task can be delegated to a member of staff who meets the above criteria. consultation with staff The risk assessment needs to be carried out in conjunction with employees who may be more directly involved with the work and also with their safety representatives. This is more likely to give a true reflection of risk. shared workplaces Where employees of different employers work in the same workplace, the employers involved have duties under the Management Regulations to co-operate and co-ordinate their activities. This means that the respective employers need to co-operate to produce an overall risk assessment. This needs to be communicated to all employees so that they will be aware of all the risks that may be present. This also applies to Trust staff working on another site. definitions of hazard and risk A hazard is something which has the potential to cause harm. Risk is the likelihood or probability of harm actually occurring, and the severity or consequences of the harm if it does. 3.2 STEPS IN CARRYING OUT A RISK ASSESSMENT The HSE has published guides to risk assessment in which it identified 5 steps in the process: Step 1: look for the hazards Step 2: decide who might be harmed and how Step 3: evaluate the risks and decide whether existing precautions are adequate, or whether more work needs to be done Step 4: record the findings Step 5: review the assessment and revise if necessary. It should be noted that the steps are not all of the same length or degree of difficulty. The HSE model assumes that the assessor already has a clear idea of what is to be assessed. This is not always the case and so we suggest there is a preliminary step, called Step 0 here, which is to clearly identify the activity that is being assessed and all the component job steps that make up that activity. The following discussion applies to all types of risk assessment. However, the reader may find it helpful to refer to the general risk assessment proforma in Appendix 2 whilst reading the discussion. STEP 0: THE ACTIVITY AND JOB STEPS This is not as simple as it might first appear. Although the overall job or activity might be obvious, most jobs can be broken down into a number of stages job steps and these are not RACoP Page 4 of 10

5 always as obvious. It is common to find that the hazards and risks are not the same in every job step and so different control measures (precautions) may be needed. Steps 1 to 5 need to be followed for each job step. STEP 1: HAZARD IDENTIFICATION The first step in the risk assessment process is to identify all the hazards associated with a particular activity/task. You can identify hazards in your workplace by one or more of the following methods: Walking around your workplace and looking at what could reasonably be expected to cause harm; Talking to people who actually carry out the work i.e. employees and also to safety representatives, supervisors and managers; Consulting legislation, Approved Codes of Practice and guidance some hazards will have specific legal requirements pertaining to them; Looking at in-house policies, arrangements and guidance. Table 1, Appendix 1 comprises a list of common hazards in the trust that are covered by specific policies. A more detailed list of hazards can be found in Appendix E of the trust health & safety policy. Consulting accident/ill-health and other incident records; Information from manufacturers/suppliers including, for example, safety data sheets and hazard warning labels; STEP 2: IDENTIFYING WHO MIGHT BE HARMED AND HOW In deciding who is at risk you will need to consider: The number of people likely to be exposed to the hazard; The type of persons likely to be exposed; The duration of exposure; Those who may be particularly at risk, for example: - Young/inexperienced workers - trainees, volunteers - students - visitors, members of the public - new and expectant mothers - contractors, cleaners, maintenance workers In deciding how persons may be harmed, you will need to look at/consider: - methods of work and other work-related factors e.g. lone working, workload etc. - provision and/or level of training - experience/technical knowledge - any disabilities the person may have. STEP 3: EVALUATE THE RISK This involves looking at what risk control measures are currently in place and deciding whether they adequately control the risk. Existing precautions: i) what is being done now? This question should be asked of each of the hazards. Record here if there are any other risk assessments (eg COSHH, DSE) RACoP Page 5 of 10

6 ii) how effective are the present precautions? If the analysis is not clear-cut, then it is advisable to add here a discussion on the pros and cons so that in the future it will be possible to understand how the final decision was reached. Action required: what else needs to be done? This question follows on from (ii) above. The following hierarchy of control measures will help you to identify what additional control measures will need to be taken to reduce the risk to an acceptable level. It is important to remember that some corrective measures are better than others and some are very ineffective as controls. The table below shows control measures in descending order of effectiveness. HIERARCHY OF CONTROL MEASURES HAZARD ELIMINATION e.g. use of alternatives, design improvements, change of process. SUBSTITUTION e.g. replacing a hazardous chemical with one with less risk. USE OF BARRIERS e.g. isolation/segregation; guarding. USE OF PROCEDURES USE OF WARNINGS USE OF PERSONAL PROTECTIVE EQUIPMENT (PPE) e.g. safe systems of work, limiting exposure time. e.g. signs and labels, audible alarms. To be used only as a last resort. STEP 4: RECORDING THE RISK ASSESSMENT The significant findings of the risk assessment must be recorded. Risk assessments or copies of risk assessments should be available to people working with particular hazards. There is no general consensus on how a risk assessment form should be laid out or what it should contain. However, the following information should be recorded as a minimum: Details of the risk assessor name and job title Date of the risk assessment Details of what was assessed location, task, plant or equipment Hazards identified and associated level of risk Details of persons likely to be at risk Description of any existing precautions, with an assessment of their effectiveness Description of further action/control measures required Recommended date for review Several risk assessment forms are available for download from the Health and Safety folder on Freenet. Step 5: Reviewing the Risk Assessment The risk assessment should be reviewed when it is no longer valid. This may be due to changes within the organisation, for example, changes in work procedures, change of personnel etc. It may also be due to external changes, for example, new legislation, new hazards identified with RACoP Page 6 of 10

7 the process or more effective/cheaper methods of risk control measures been developed. Risk assessments also need to be reviewed if the manager is aware that controls are not working. Changes often occur gradually over a period of time and so are not noticed; however, when considered together, they may well represent a significant change. It is good practice, therefore, to review risk assessments on an annual basis. REFERENCES & FURTHER READING Organisation & Arrangements for Implementation Trust Health & Safety Policy, Management of Health & Safety at Work Regulations Approved Code of Practice & Guidance. L21; HSE Books. Successful Health & Safety Management HS(G)65; HSE Books,1998 Five Steps to Risk Assessment IND(G)163; HSE Books, 2000 Management of Health & Safety in the Health Services 1994; HSE Books RACoP Page 7 of 10

8 Appendix 1: Common hazards covered by specific Trust policies HAZARDS POLICIES ISSUES Asbestos Blood & Body Fluids Building Work Short Form Policy on Asbestos Works/Projects Policy Infection Control Policy & COSHH Policy Covered by Works/Projects Department Health & Safety Policy Control of exposure to respirable fibres Prevention of infection Building work to be carried out safely and without risk of injury Chemicals* COSHH Policy Requirements to prevent or control exposure to hazardous chemicals Display Screen Equipment* DSE Policy Requirements for workstations to meet minimum requirements Electricity * Portable Electrical Appliances Equipment to be safe Policy Fire Fire Policy Fire Precautions, Arrangements for Fire Evacuation & Fire Training Genetic Modification (GM Work)* Local Rules on Genetic Modification Prevention of infection Protection of the Lighting Health, Safety & Welfare Policy Environment Requirement to ensure that lighting is suitable and sufficient Manual Handling* Manual Handling Policy To prevent the risk of manual handling injuries at work Noise Radiation* Slipping & Tripping Hazards Stress Vehicles Workplace, Health Safety & Welfare Policy Local Rules for Radiation Safety & Handbook Workplace Health Safety & Welfare Policy Psychological Well-Being at Work Workplace, Health Safety & Welfare Policy To prevent/control exposure to noisy work environments To ensure that work with radiation is carried out safely and without risks to staff and patients To ensure the work environment is safe in order to prevent slipping & tripping accidents To prevent vehicle-related accidents RACoP Page 8 of 10

9 Appendix 1 (continued) HAZARDS POLICIES ISSUES Ventilation/Heating Workplace, Health Safety & Welfare Policy Requirement to ensure that work rooms are sufficiently ventilated with a supply of fresh air. Violence* Violence Prevention Policy Requirement to safeguard staff from violent incidents Work Equipment* Provision & Use of Work Equipment Requirement to ensure that work equipment is maintained in good working order to safeguard staff and patients Working Time Human Resources Guidance To ensure that excessive working hours will not significantly increase risk of accident/ill-health. * Denotes policies with their own assessment forms also: Personal Protective Equipment policy RACoP Page 9 of 10

10 Appendix 2: general risk assessment proforma Department/Area: Date of Assessment: Assessment No: DESCRIPTION OF ACTIVITY HAZARD IDENTIFICATION PERSONS AT RISK (who might be harmed and how? Are there any groups especially at risk?) EXISTING PRECAUTIONS (what controls are currently in place?) other risk assessments ANALYSIS OF EXISTING PRECAUTIONS (are the precautions effective; if not, why not?) ACTION REQUIRED (what further action needs to be taken to control/reduce the risk?) Action By whom Target date Date completed REVIEW DATE PERSON(S) CARRYING OUT THE ASSESSMENT Print: Signature: Date: Note. An on-line version of this form is available separately on Freenet RACoP Page 10 of 10

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