Documentation Control Reference HS/SP/015 Date approved 23 Approving body Directors Group Implementation date 23 Supersedes Version 2 (March 2010) Consultation undertaken Trust Health and Safety Committee Target Audience Date of Completion of Equality Impact Assessment Date of Completion of We Are Here For You Assessment Date of Environmental Impact Assessment All managers and staff 15 May 2012 15 May 2012 Not Applicable Review Date October 2015 Lead Executive(s): Author Further guidance/information from Medical Director Health and Safety Manager Health, Safety & Ergonomics Department Ext 62316 (QMC) / 59629 (City) 1
CONTENTS Paragraph Title Page 1 Introduction 3 2 Policy Statement 3 3 Causative Factors 4 4 Process for Managing Risks 5 5 Risk Assessment 6 Roles and Responsibilities 5 7 Training 7 8 Equality and Diversity Statement 8 9 Here For You Standards 8 10 Environmental Impact Assessment 11 Process for Monitoring & Audit 8 12 Supporting Information 9 8 Appendix 1 Equality Impact Assessment 10 Appendix 2 Certificate of Employee Awareness 15 2
1. Introduction Employers have a responsibility to ensure that their employees and anyone else who could be affected by their work (such as visitors, members of the public, patients etc) are kept safe from harm and that their health and safety is not affected. This means slip and trip risks must be identified and controlled to ensure that people do not slip, trip and fall. This policy concentrates on environmental risks of slips, trips and falls, a separate Adult In- Patient Falls (incorporating the use of bedrails) Policy looks at the risks of in-patient falls. Slips and trips nationally are on average, responsible for: Over a third of all reported injuries 25% of all reported major incidents in the Health Service in 2010/11 (HSE) The human cost of slip and trip accidents is usually easy to see. But not always so apparent is the price the NHS pays, both as an organisation and as an employer. Treatment costs currently stand at 133m per year and with 90 per cent of major accidents resulting in a broken bone, the NHS also has the expense of longterm staff absences. (HSE 2011) 2. Policy Statement This policy outlines the Trust s requirement to assess the risks to employees and others who may be affected by their work, e.g., visitors, patients and members of the public associated with slips, trips and falls on its premises and to make provision for suitable controls designed to remove or reduce the risk of harm occurring. The Trust is committed to preventing or minimising the risk of slips, trips and falls to staff, patients and other stakeholders who visit or use Trust premises. It aims to do this by: Providing a safe working environment which, as far as is reasonably practicable, is free from hazards that contribute to slips, trips and falls. 3
Ensuring any slip and trip hazards in the workplace are identified, reported and rectified. Ensuring, where deficiencies are identified, appropriate risk assessments and risk reduction action plans are in place to reduce risks and ensure the best practice principles are applied Ensuring hazard awareness training is provided as part of mandatory health and safety training to all staff 3. Causative Factors Research undertaken by the HSE has fed into the development of the model below which captures the main causative factors of Slips, Trips and Falls. Almost all slips occur when floors are wet or dirty ie. contaminated with water, body fluids, food debris, dust, paper, packaging etc. Trips and falls usually occur on damaged, uneven floors, floors in a poor state of repair or where obstacles have been left where people do not expect to find them. 4
Flooring - should be even, well maintained, suitable for the activity taking place on it, fitted correctly Contamination spillages must be cleared up immediately Obstacles all waste and unwanted items must be disposed of and all items must be stored correctly, vigilant housekeeping Cleaning floors must be kept clean, report any hazards People/human factors do not leave things lying around, clean up your own spillages or report it, be aware of distractions when walking around, have a positive attitude towards cleaning Environment too much light may cause glare and prevent hazards being seen, too little light may also prevent hazards being seen, weather conditions make create contamination Footwear staff must conform to Trust Policy, ensure footwear is suitable for the environment, wear PPE where this has been identified by a risk assessment eg. safety footwear Working at height correct use of ladders/scaffolding/edge protection, ensure appropriate training for staff Alighting from vehicles correct footwear /risk assessed ascent/descent 4. Process for Managing Risks A good management system will help identify problem areas and should involve: Planning - identify key areas of risk, review work activities and undertake a risk assessment Organisation - involve staff and Health and Safety Trade Union Representatives in the risk assessment process and communicate with them regarding risks, ensure arrangements are in place for implementing the policy Control check that staff are following safe working practices and wearing appropriate footwear in line with any training given Monitoring and reviewing check accident reports and safety inspection data, follow up and investigate all slip, trip and fall incidents, review the risk assessment annually or 5
following an incident, change in working practice or change in personnel 5. Risk Assessment The Trust will ensure that any risk identified is adequately assessed in accordance with the Trust s Risk Management Policy and that appropriate action is taken to reduce the risk so far as is reasonably practicable. It is a manager s responsibility to ensure that the necessary risk assessments are carried out for any workplace under his/her control and that appropriate action is taken to eliminate or control the risks identified. The assessments must be recorded on the Trust Risk Assessment Tool. The assessments should be reviewed on an annual basis or after any significant changes, i.e. an incident or a change in working practice, to ensure that standards are maintained and that new or additional hazards have not been introduced or become apparent since the previous assessment. The practical measures that can be taken will vary in different situations. Each situation needs to be assessed to identify what factors cause slips, trips and falls and then to match practical control measures to these factors. 6 Roles & Responsibilities 6.1 Chief Executive As the person ultimately accountable for Health & Safety matters, the Chief Executive will ensure that this policy is implemented across the Trust. In discharging that responsibility, the Chief Executive delegates the actual implementation of the policy through the Medical Director, Clinical Directorates and Corporate Heads of Service. 6.2 Clinical Directors and Heads of Service 6
Although the Trust Board accepts that overall responsibility for compliance with this policy rests with them, Directorate and Corporate management teams carry prime responsibility for implementing this policy and will be responsible for ensuring that local arrangements exist for the identification of slip/trip hazards. 6.3 Managers Managers must ensure that risk assessments are carried out in accordance with section 5 above and any proactive measures to eliminate or control the risks are implemented and monitored. Any risks that cannot be adequately controlled must be dealt with in accordance with the Trust s Risk Management Policy and the Health and Safety Compliance Review. Slips, Trips and falls hazards must be covered at local induction. Managers must investigate all incidents reported by staff and take measures to learn from this. Managers should provide feedback to staff and adjust the risk assessment accordingly. 6.4 All Staff are required to: co-operate with the Trust in implementing this policy report spillages immediately to Ext 55900 City; Ext 62111QMC report maintenance defects to Ext 55900 City; Ext 62111 QMC report other trip hazards to your line manager or the manager of the area you are in complete an incident form in the event of a slip, trip or fall incident Wear appropriate footwear for the work area and the task being performed 7
adhere to any training given 6.5 Trust Health & Safety Committee & Health, Safety & Ergonomics Department The Trust Health and Safety Committee and the Health, Safety & Ergonomics Department will ensure that staff, are aware of how to raise awareness should an issue arise regarding slips, trips and falls. Methods by which this will be achieved include clear signing, themed posters, information for staff via their Health & Safety Link Person and ad-hoc displays/events. The Trust Health and Safety Committee will monitor this and the Health, Safety & Ergonomic Department will keep the Committee abreast of developments within the slips, trips and falls domain. 6.6 Estates and Facilities Ensure that assessments of all internal floor surfaces are made with respect to the condition and potential for slip / trip incidents. Ensure that floors are maintained in a safe condition. Ensure that appropriate floor covering is assessed in all for refurbishment or new build projects. Ensure that flooring is cleaned effectively to prevent slip / trip hazards. Liaise with infection control to ensure that cleaning can be carried out to required standards. Provide support to ensure that slip/trip hazards are dealt with effectively. 7. Training Training is undertaken as identified in the Training Needs Analysis. 8. Equality and Diversity Statement All patients, employees and members of the public should be treated fairly and with respect, regardless of age, disability, gender, 8
marital status, membership or non-membership of a trade union, race, religion, domestic circumstances, sexual orientation, ethnic or national origin, social & employment status, HIV status, or gender re-assignment. 9. We Are Here for You Mission Statement This Trust is committed to providing the highest quality of care to our patients, so we can pledge to them that we are here for you. This Trust supports a patient centred culture of continuous improvement delivered by our staff. The Trust established the Values and Behaviours programme to enable Nottingham University Hospitals to continue to improve patient safety, outcomes and experiences. The set of twelve agreed values and behaviours explicitly describe to employees the required way of working and behaving, both to patients and each other, which would enable patients to have clear expectations as to their experience of our services 10. Environmental Impact Assessment The environmental impact of this policy has been considered and no further action is required at this time. 11. Process for Monitoring and Audit The implementation and effectiveness of this policy will be monitored through the Trust s Health & Safety Committee and any significant risk issues will be escalated to the Quality Operational Group as per the Risk Management Policy. The NUH Workplace Safety Strategy Compliance Reviews and local inspections / audits will seek to measure compliance with this policy. The Trust Health and Safety Committee will monitor accidents and incidents on a quarterly basis as part of the Incident Report. Directorate and Corporate risk assessments will be monitored as part of the Health and Safety Compliance Review. 12. Supporting Information Health and Safety at Work etc Act 1974 9
The Management of Health and Safety at Work Regulations 1999 The Workplace (Health, Safety and Welfare) Regulations 1992 HSE information sheet no. 2 Slips and trips in the health services Equality Impact Assessment Report Outline 1. Name of Policy or Service Slips, Trip and Falls Policy 2. Responsible Manager Heather Churchill Health and Safety Manager 3. Name of Person Completing Assessment Heather Churchill Health and Safety Manager Appendix 1 10
4. Date EIA Completed 15 th May 2012 5. Description and Aims of Policy/Service (including relevance to equalities) Employers have a responsibility to ensure that their employees and anyone else who could be affected by their work (such as visitors, members of the public, patients etc) are kept safe from harm and that their health and safety is not affected. This means slip and trip risks must be identified and controlled to ensure that people do not slip, trip and fall. 6. Brief Summary of Research and Relevant Data DATIX Incident Statistics 7. Methods and Outcome of Consultation THSC 29 th May 2012 8. Results of Initial Screening or Full Equality Impact Assessment: Equality Group Age Gender Race Sexual Orientation Religion or belief Disability Dignity and Human Rights Working Patterns Assessment of Impact 11
Social Deprivation 9. Decisions and/or Recommendations (including supporting rationale) Policy has been written giving due consideration to all aspects of equality and diversity. There is no evidence to suggest that this policy impacts on these groups. 10. Equality Action Plan (if required) N/A 11. Monitoring and Review Arrangements (including date of next full review) Incident reported on DATIX Incidents reported to THSC Next Full Review: August 2014 12
Screening Grid Equality Key Equalities Area Legislation / Policy (See summary sheet) Is this policy or service RELEVANT to this equality area? YES / NO Assessment of Potential Impact: HIGH MEDIUM LOW NOT KNOWN positive (+) negative (-) Age Equality Act 2010 No N/A N/A Gender Equality Act 2010 No N/A N/A Reasons for Assessment impacts adversely on any Equality Groups impacts adversely on any Equality Groups Equality Area Key Equalities Legislation / Policy (See summary sheet) Is this policy or service RELEVANT to this equality area? YES / NO Assessment of Potential Impact: HIGH MEDIUM LOW NOT KNOWN positive (+) negative (-) Race Equality Act 2010 No N/A N/A Sexual orientation Equality Act 2010 No N/A N/A Reasons for Assessment impacts adversely on any Equality Groups impacts adversely on any Equality Groups 13
Religion and beliefs Equality Act 2010 No N/A N/A impacts adversely on any Equality Groups Equality Area Key Equalities Legislation / Policy (See summary sheet) Is this policy or service RELEVANT to this equality area? YES / NO Assessment of Potential Impact: HIGH MEDIUM LOW NOT KNOWN positive (+) negative (-) Disability Equality Act 2010 No N/A N/A Dignity and Human Rights Working Patterns Human Rights Act 1998 (relevant articles) The Part-time Workers (Prevention of Less Favourable Treatment) Regulations 2000 No N/A N/A No N/A N/A Reasons for Assessment impacts adversely on any Equality Groups impacts adversely on any Equality Groups impacts adversely on any Equality Groups 14
Equality Area Social Deprivation Key Equalities Legislation / Policy (See summary sheet) Neighbourhood Renewal Strategy Tackling Health Inequalities Local Area Agreement Is this policy or service RELEVANT to this equality area? YES / NO Assessment of Potential Impact: HIGH MEDIUM LOW NOT KNOWN positive (+) negative (-) No N/A N/A Reasons for Assessment impacts adversely on any Equality Groups 15
Appendix 2 CERTIFICATION OF EMPLOYEE AWARENESS Document Title Version (number) 3 Version (date) 23 I hereby certify that I have: Identified (by reference to the document control sheet of the above policy/ procedure) the staff groups within my area of responsibility to whom this policy / procedure applies. Made arrangements to ensure that such members of staff have the opportunity to be aware of the existence of this document and have the means to access, read and understand it. Signature Print name Date Directorate/ Department The manager completing this certification should retain it for audit and/or other purposes for a period of six years (even if subsequent versions of the document are implemented). The suggested level of certification is; Clinical directorates - general manager Non clinical directorates - deputy director or equivalent. The manager may, at their discretion, also require that subordinate levels of their directorate / department utilise this form in a similar way, but this would always be an additional (not replacement) action. 16