Health and Safety Policy

Health and Safety Policy Status: Final Next Review Date: Apr 2014 Page 1 of 16

NHS England Health and Safety: Policy & Corporate Procedures Health and Safety Policy Policy & Corporate Procedures Issue Date: December 2013 Document Number: POL_1002 Prepared by: Interim Health and Safety Manager Status: Final Next Review Date: Apr 2014 Page 2 of 16

NHS England Health and Safety: Policy & Corporate Procedures Information Reader Box Directorate Medical Nursing Patients & Information Finance Publications Gateway Reference Document Purpose Document Name Author Operations Commissioning Development Policy Human Resources n/a Policy and High Level Procedures Health and Safety Policy: Policy & Corporate Procedures NHS England, Policy Directorate Publication Date 2013 Target Audience Additional Circulation List Description Cross Reference Superseded Document Action Required Timing/Deadlines Contact Details (for further information) All NHS England Employees n/a Policy for Health and Safety n/a n/a For publication n/a Mark Jamieson Health and Safety Manager 5C22, Quarry House LEEDS Tel: 07918 368419 E-mail: mark.jamieson@nhs.net 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 this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. NB. The version of the policy posted on the intranet must be a PDF copy of the signed approved version. Status: Final Next Review Date: Apr 2014 Page 3 of 16

NHS England Health and Safety: Policy & Corporate Procedures Contents 1 Introduction... 5 2 Policy Statement.. 5 3 Scope. 7 4 Roles and Responsibilities. 8 5 Monitoring and auditing.. 13 6 Equality impact assessment.. 14 7 Associated documentation. 15 Status: Final Next Review Date: Apr 2014 Page 4 of 16

NHS England Health and Safety: Policy & Corporate Procedures 1 Introduction 1.1 This document sets out NHS England s policy on health and safety. This policy will be supported by a set of detailed arrangements documents which will serve as a practical guide to the implementation of this policy. 1.2 NHS England is a large organisation with over 6,000 staff working across more than 60 sites across England. The size and scale of the organisation needs a shared approach in which all NHS England colleagues work together to ensure health and safety is being effectively managed. 1.3 Our staff are our most valuable asset and we are committed to ensuring a safe and healthy working environment for them. To do this we will establish effective organisational arrangements relating to fire, health, safety and welfare. In addition to looking after our staff we will also ensure that we comply with the legal requirements for health, safety and welfare. 1.4 NHS England will also take steps to ensure the health and safety of those we come into contact with through our work is protected, including visitors, members of the public, contractors and those who use our services. 1.5 NHS England will manage health and safety within the context of NHS England s vision and values. To us that means: We create a positive and participative working environment and culture, providing the conditions for individuals and teams to thrive and achieve the highest standard of performance. Our leaders demonstrate their commitments to health, safety and welfare to generate a positive safety culture throughout the organisation. 1.6 This policy provides the overall direction, enabling NHS England to plan, set targets, monitor and implement its organisational health and safety arrangements. 2 Policy Statement 2.1 The Chief Executive is ultimately responsible for health and safety throughout NHS England. The staff, managers and leaders of NHS England will support the Chief Executive to discharge this responsibility through the arrangements set out in this policy. 2.2 NHS England acknowledges its legal responsibilities as an employer and will as far as reasonably practicable provide a safe and healthy environment for its employees and visitors to its premises with regards to areas under its control. 2.3 NHS England will work closely with partner organisations, such as NHS Property Services, to gain assurance that health and safety is being effectively managed where this impacts on NHS England staff or our visitors. These assurances will be monitored and reviewed. Status: Final Next Review Date: Apr 2014 Page 5 of 16

NHS England Health and Safety: Policy & Corporate Procedures 2.4 The standards set by the legal requirements are seen to be the absolute minimum by which NHS England will operate, and therefore, will strive to meet the highest standards of occupational health and safety as is reasonably practicable. 2.5 NHS England will take steps to ensure that our statutory duties are met at all times, including the provision of sufficient funds and facilities to meet the requirements of this policy. 2.6 Maintaining a healthy and safe environment in which to work is seen as a key objective which is not over-ridden by any other business requirements. 2.7 NHS England will provide every employee with all information, instruction and training as is necessary to enable them to safely carry out their role. 2.8 NHS England fully accepts responsibility for other people who may be affected by our activities and will seek to provide those others with appropriate information to ensure their safety. 2.9 NHS England will specifically: i. Provide staff with safe systems and processes; ii. Identify hazards, assess risks and implement preventative measures which support staff to safeguard their health and safety; iii. Provide adequate facilities and arrangements to enable employees and their representatives to raise issues of health and safety. 2.10 Fundamental to the success of this policy is the responsibility and co-operation of all our staff. We will expect each member of staff to take reasonable care of their own health and safety and for the safety of others who may be affected by their acts and omissions. 2.11 NHS England will employ a competent person(s) to advise and support the organisation to develop and implement effective health and safety arrangements. 2.12 NHS England will consult with its staff and their representatives to ensure that these arrangements are effective. 2.13 This policy will be regularly reviewed and where necessary updated to reflect organisational, operational and legislative changes and any lessons learnt from experience. A copy of this policy is available to all NHS England members of staff and consultants, contractors, other building users and their employees. Status: Final Next Review Date: Apr 2014 Page 6 of 16

NHS England Health and Safety: Policy & Corporate Procedures 3 Scope The scope, application and implementation of this policy will be overseen by an NHS England Health and Safety Committee. 3.1 This policy applies to: National Teams; Regional Teams; Area Teams All Clinical Senates; IQ; Sustainable Development Unit; Staff working on or on behalf of NHS England (this includes contractors, temporary staff, secondees and all permanent employees). 3.2 Training Plan A training needs analysis will be undertaken with all staff affected by this document. Based on the findings of that analysis appropriate training will be provided to staff as necessary. Guidance will be provided on the NHS England intranet. Status: Final Next Review Date: Apr 2014 Page 7 of 16

4 Roles and Responsibilities 4.1 The Chief Executive The Chief Executive has overall responsibility for all matters relating to health and safety, security and fire safety and is the designated Responsible Person with regards to fire safety management within NHS England. The Chief Executive has overall responsibility for ensuring that NHS England complies with legislation concerning fire, health, safety and welfare. Implementation is delegated to the National Director of Policy who will be held accountable at each annual review. 4.2 National Director: Policy The Director of Policy has responsibility for establishing and maintaining effective health and safety policies, procedures and systems to ensure that health and safety is accepted as an integral part of NHS England s culture. To do this the National Director: Policy will ensure that: the Board is regularly appraised of health and safety matters at each meeting and will provide updated information on the action that has been taken to deal with the H&S items identified at previous meetings; sufficient resources are available to provide health and safety equipment, training, instruction and supervision for all employees; health and safety is considered within the planning and life cycle of new projects; this will be undertaken by ensuring the Health and Safety Manager is informed of all new projects; responsibilities have been allocated for health and safety to specific staff and that they are competent to undertake those duties and are measured in its implementation at each annual review; health and safety performance is monitored by line managers as advised by the Health and Safety Manager; any information from that monitoring is used to identify situations that create risks and take the necessary preventative action; arranging appropriate health and safety assistance; these arrangements are actively monitored by the Health and Safety Manager who will provide an annual report to the board; establish and chair the Health and Safety Committee. 4.3 National Director: HR The National Director: HR is responsible for: Staff welfare through the provision of appropriate systems, policies and arrangements; The provision of health and safety training; Status: Final Next Review Date: Apr 2014 Page 8 of 16

4.4 Directors Ensure new staff receive appropriate health and safety induction; HR policies and procedures are consistent with health and safety requirements; HR supports the successful achievement of NHS England s health and safety obligations. The term Directors refers to all Directors within the National Support Centre, Regional or Area Teams. Each Director has delegated responsibility for health and safety within their area of responsibility and should provide leadership, ensure compliance and promote responsible attitudes towards health and safety by: Ensuring that line managers are accountable for health and safety in areas of their control Compliance to be reviewed at annual appraisal; Ensuring that staff are aware of and understand NHS England s Health and Safety Policy; Ensuring adequate health and safety arrangements are in place; Ensuring that risk assessments are undertaken annually and risks properly managed; Ensuring effective training is provided regularly as agreed with the Health and Safety Manager along with information and supervision to enable employees to carry out their work safely; Ensuring health and safety is always considered at the planning stage for all new services, buildings, conversions/change of use of buildings and reviewed by the Health and Safety Manager; Ensuring the reporting and investigation of all accident/incidents to identify learning or improvements needed to these arrangements; Monitoring the effectiveness of the Health and Safety Policy and arrangements in their area of responsibility by arranging for an annual health and safety audit/review by the Health and Safety Manager. 4.5 Senior Managers/Line Managers Managers have delegated responsibility for ensuring that the Health and Safety Policy is understood and acted on within their area of responsibility. In order to achieve this they are required to: Develop and maintain local rules and arrangements for health and safety specific for their areas of responsibility; Ensure that risk assessments are undertaken and risks are properly managed; Ensure that employees, contractors and visitors know, understand and apply safety procedures; Establish that all equipment used is suitable for the task and is kept in good working condition including the regular maintenance and servicing of equipment; Ensuring staff have had appropriate training; Status: Final Next Review Date: Apr 2014 Page 9 of 16

4.6 Employees Ensure that all accidents, incidents and near misses are properly recorded and reported; Ensure that an investigation is carried out to establish the cause of all accidents, incidents and near misses and to prevent a recurrence, where possible and in line with the reporting procedure; Ensure that lessons learnt from accidents/incidents and near misses are reported back to staff; Consult with NHS England s Health and Safety Manager regarding health and safety issues and, where necessary, promptly inform Senior Management of any issue that requires their attention. Ensuring this policy is effective needs the co-operation and involvement of every NHS England employee. NHS England expects every member of staff to take reasonable care for their health and safety and others who may be affected by their acts and omissions, and specifically expects staff to: Take time to understand and follow the health and safety policies and procedures; Complete mandatory health and safety training; Follow the training and procedures provided; Only to undertake activities which they are trained and competent for; Reporting any hazard or defect; Report all accidents/incidents or near misses without delay using the relevant procedure; Operating in a way that supports an effective health and safety culture. 4.7 Occupational Health Service Occupational Health Services will: Advise managers and employees on sickness related absence and measures; Provide advice on health matters to staff; Provide advice to ensure staff are fit for the role they are undertaking; Undertake health surveillance as necessary; Provide reports to NHS England to enable it to review its arrangements for health, safety and welfare. 4.8 Health and Safety Manager The Health and Safety Manager will assist and support NHS England with: The overall health and safety strategy; Developing a health and safety culture; Status: Final Next Review Date: Apr 2014 Page 10 of 16

Building awareness of legal obligations; Management of risk; Management of contractors and projects; Accident investigation; Training programmes; Advising on compliance with relevant fire safety legislation; Developing and delivering effective fire safety training programmes; Ensuring fire incidents are reported and recorded in accordance with current policies, and advising on appropriate mitigating action; Ensuring robust fire safety management systems throughout NHS England; Ensuring any risks to the provision of fire safety advice and training are recorded; Advising on fire safety requirements for disabled staff; Liaison with enforcing authorities; Producing the Annual Report on Fire Safety; Producing the Annual Statement of Fire Safety; Producing reports on fire, health and safety issues for appropriate committees and the Board; Liaise with external organisations, regarding NHS England Health & Safety matters; Undertaking or arranging an annual health and safety audit of all sites by a competent person 4.9 Fire Wardens Fire Wardens are identified and trained and will support the Health and Safety Manager on a day to day basis. The main duties of the Fire Warden are to: 4.10 First Aiders Act as a focal point on fire safety issues for their local area of the building. Organise and assist in the implementation of fire safety procedures within local areas. Raise issues regarding fire safety with the Health and Safety Manager. Assist with coordination of the response to an incident within the immediate vicinity. Be responsible, within an allocated area, for ensuring evacuation of personnel during an incident or fire drill. Be trained to tackle a fire with fire-fighting apparatus where appropriate. All Fire Wardens must be identified by location, name, and hours worked and a list compiled that must be displayed in the appropriate place(s). First Aiders must only provide first aid within the limits of their training (First aiders will be required to gain a First Aid certification after attending a 3 day training course). Their key responsibilities are: Status: Final Next Review Date: Apr 2014 Page 11 of 16

Provide first aid in cases where a person will need assistance from a doctor or nurse; treatment for the preserving of life and minimising the consequences of injuries and ill health until such help is required. Treatment of minor injuries which would otherwise receive no treatment, or which do not need treatment from a doctor or nurse. Ensure adequate first aid facilities are provided and maintained. Take charge of instances where first aid is required. Provide casualties with early and effective help. Arrange for casualties to be taken to hospital where required. Remain with casualty until help arrives. Ensure that casualties personal belongings are safe and secure. 4.11 Appointed Persons (First Aid) Appointed persons will only provide first aid within the limits of their training (Appointed persons will attend a 1 day basic training course). Their key roles are: To take charge of a situation where first aid is required. Call an ambulance if there is a serious illness or injury Arrange for casualties to be taken to hospital where required. Remain with casualty until help arrives. Ensure that casualties personal belongings are safe and secure. 4.12 Visitors to NHS England Offices: Hosts should ensure that where possible visitors only visit NHS England premises by prior appointment. Hosts should ensure that visitors are accompanied at all times while they are on the premises unless they are regular visitors, or restricted to a specific area of the building. Hosts should ensure that visitors are informed of any particular local hazards and risks, emergency procedures and first aid arrangements. Hosts should ensure that visitors are required to sign the visitors book at reception and carry suitable identification at all times. NHS England staff will visit other NHS England sites as part of our agile working plans, often without first needing to make an appointment. This policy will be supported by guidance on ensuring the safety of agile workers. 4.13 Trainees and New Starters HR and Line Management should ensure that: Trainees and new starters will typically attend a formal company induction some weeks after beginning working within NHS England and as soon as possible. Status: Final Next Review Date: Apr 2014 Page 12 of 16

Trainees and new starters will be given a local health and safety induction by the individual who will be supervising their work. Health and safety training should take place within the first month of work with NHS England and should include introduction to first aiders and fire wardens. Trainees and new starters, and in certain cases visitors, should be included in health and safety training programmes as soon as possible where this is appropriate. Special consideration should be given to those who are young, inexperienced or felt to be particularly at risk. 5 Monitoring and auditing NHS England will implement the following arrangements for monitoring health, safety and fire safety performance, to identify compliance with both the health and safety policies in place and legal requirements. Two basic types of monitoring will be implemented: 5.1 Active monitoring NHS England will work with Trades Unions representatives and staff representatives to establish a formal health and safety committee for the purpose of consulting on health and safety arrangements and ensuring a strategic overview of health and safety management effectiveness is maintained; NHS England will undertake routine inspections and checks to make sure that standards and policies are being implemented and that controls are working. Active monitoring will be provided by: A workplace fire safety inspection carried out by a fire warden on a monthly basis, using a pre-designed checklist. A workplace safety inspection carried out by a line manager across the whole office on a 6 monthly basis using a pre-designed checklist. The Health and Safety manager will support these inspections if required. Safety management audits will be carried out or arranged annually by the Health and Safety Manager and will be used to assess the adequacy of the whole organisation s health and safety management. 5.2 Reactive monitoring Measuring failures in risk control to provide opportunities to check performance, learn from failures and improve the health and safety management system. Reactive monitoring will be provided by implementing suitable systems to identify and report: Injuries and work related ill health. Other losses such as damage to property. Incidents including those with the potential to cause injury, ill health or loss Hazards and faults. Status: Final Next Review Date: Apr 2014 Page 13 of 16

Weaknesses or omissions in performance standards and systems including complaints from employees and enforcement action by the authorities. Figures identified from reporting procedures will be analysed and policies reviewed against the findings by the Health and Safety Manager. 5.3 Reporting concerns Any employee who has concerns about any aspect of health and safety management in NHS England should raise the issue, firstly, with their line manager or failing that with the NHS England Health and Safety Manager. 6 Equality impact assessment Equality and diversity are at the heart of the NHS strategy. Due regard to eliminate discrimination, harassment and victimisation, to advance equality of opportunity, and to foster good relations between people who share a relevant protected characteristic (as cited in under the Equality Act 2010) and those who do not share it, has been given throughout the development of the policies and processes cited in this document. 7 Associated documents This policy will be supported by a set of health and safety procedures. These will be reviewed, developed and added to as the need arises but at least on an annual basis. The procedures describe the practical arrangements NHS England has established to discharge the duties in this policy. Status: Final Next Review Date: Apr 2014 Page 14 of 16

Ref No Supporting Guidance - Title Version H&S001 Fire safety guidance H&S002 Accident and incident reporting (RIDDOR) H&S003 Safe use of workstations (DSE) H&S004 Control of substances hazardous to health H&S005 Ensuring the safety of those with disabilities H&S006 Safe use of electrical equipment H&S007 Protecting staff from violence H&S008 First aid H&S009 Stress at work H&S010 Guidelines for annual inspection H&S011 Managing contractors H&S012 Moving and handling H&S013 Noise at work H&S014 Office safety H&S015 Lone working H&S016 Working at height H&S017 Confined spaces H&S018 Driving at work H&S019 Infection control H&S020 Provision and use of work equipment H&S021 Building safety (including arrangements for lifting equipment, gas safety, legionella and asbestos) H&S022 Environmental management H&S023 Safety of agile workers H&S024 Medical devices Status: Final Next Review Date: Apr 2014 Page 15 of 16

NHS England 2013 First published November 2013 Published in electronic format only Status: Final Next Review Date: Apr 2014 Page 16 of 16