Corporate Health and Safety Strategy

Corporate Health and Safety Strategy 2010-2013 Policy Author: Health and Safety Committee Policy Owner (for updates) Head of Estates and Facilities Engagement and Consultation Groups: Approval Record Date Health and Safety Committee Quality and Improvement 02/02/11 Committee Board 28/04/11 Equality and Diversity Rapid 31/01/11 Impact Assessment Version Control Version Number 1 Date of Original Document Last Change and Approval Date Last Review Date Next Formal Review Date Location and Access to Documents Location of master document Location of backup document Location of E&D assessment Access to document for staff Access to document for public attached Post holders names at last review Head of Estates and Facilities Malcolm Colquhoun

If you require this or any other NHS Orkney publication in an alternative format (large print or computer disk for example) or in another language, please contact the Clinical Safety & Quality Department. Tel: (01856)888204 or email alternativeformats@nhs.net 2

Contents 1. Executive Summary 2. NHS Orkney Setting the Scene 2.1 Current Situation 2.2 The Future 3. The Aim of this Corporate Health and Safety Strategy 4. Objectives 5. Objectives in Detail 6. Delivering the Objectives 7. Summary List of Appendices Appendix1 Diagram of key elements of successful health and safety management (HS(G)65) 3

1. Executive Summary The past decade has seen significant change to health and safety in the workplace as a result of the introduction of the Health and Safety at Work Act 1974. In particular, the changes that have occurred in the legal system regarding claims arising from injuries at work, and the attitude of public and staff in terms of blame, redress, and negligence, have contributed to the increasingly litigious society in which the NHS operates. One of the key challenges for this Corporate Health and Safety Strategy is to examine the most appropriate direction which should be taken by NHS Orkney (NHSO). NHSO must ensure that policies and procedures are in place to ensure health and safety legislation is followed and to protect the organisation, staff, patients and visitors. As an employer, NHSO must comply with our duty of care at all times. NHSO also needs to take into account the various contractors across all service departments in all buildings and in all properties. Sub-contractors employed by NHSO will be expected to ensure the safety of their staff, and that procedures and processes are in place to do this. NHSO Estates Department will be expected to ensure that all contractors are suitably supervised and comply with NHSO s processes and procedures that make up the Control of Contractors. NHSO needs clarity as to its priorities for effective H&S management, as well as an awareness of the benefits of implementing proactive measures to achieve this. Early involvement of the workforce and their representatives and successful communication of health and safety messages across the organisation is essential to ensuring the success of this strategy. NHSO must ensure that good quality and professional advice is available to all staff and managers, and that supervisors at all levels have a working knowledge of, and are competent in the administration of, Health and Safety. Managers/Supervisors must ensure that development plans are in place for their staff. This will be a significant challenge for NHSO over the next three years and must be a priority for the Learning & Development Department (L&D). Without suitable training, staff education cannot succeed and therefore working knowledge of health and safety will become limited and could lead to de-motivation. Through the implementation of the strategic aim and objectives contained within this document, as well as the adoption of the HS(G)65 H&S Management System, NHSO will be enabled and encouraged to develop a culture, whereby staff, patients and others are afforded optimum protection to their health, safety and wellbeing. 4

2. NHS Orkney - Setting the scene As an introduction to the Strategy, it is recognised that there is a level of importance associated with NHSO s origins, from both an organisational and health and safety (H&S) perspective. This, coupled with a brief synopsis of the current health and safety arrangements, is necessary to provide a reasonable status report of the current situation. In order to assist in predicting what may lie ahead a future outline is then indicated, with consideration given as to where the organisation intends to be in three years time; this will assist in providing direction to the Strategy. 2.1 Current Situation Senior Management within NHSO have already taken significant steps to improve Health and Safety involvement, training, and supervision. However the requirement for further development is significant and will require a greater investment of time and effort throughout the organisation. At present NHSO cannot claim to be compliant with all the Health and Safety requirements, duties and competencies. Although the improvements made to date have been positive, at the time of creation of this document a considerable amount of work is still outstanding. NHSO presently have a service level agreement (SLA) with Orkney Islands Council for the provision of Health and Safety advice and support. While it can be demonstrated that there is a competent person there are restrictions on the time and input NHSO can have from that person. This is not an ideal situation and while it enables NHSO to comply with its statutory obligations, it perhaps prevents significant developments and improvements from being achieved. This SLA is currently under review. The Health and Safety Committee consists of a number of supervisors, managers, front line staff and staff side representatives. It is viewed that this is not representative of the organisation and NHSO would benefit from a more robust and accountable group of people that can make significant decisions representative of their departments and the organisation. 2.2 The Future Some of the key drivers for change are: Resources are becoming ever more finite, driving the need to prioritise them more effectively to ensure their best practicable usage The perception that there is no clear, coherent direction to the overall health and safety management system across NHSO. There is a lack of a robust management process and an accountable committee that encourages good practice and clearly communicates Health and Safety legislation and any necessary systems. 5

The key message for the future has to be simplicity and policy should be the drive for health and safety. Historically NHSO has been poor at upkeep of policies and in some cases the implementation has not been as it should be. The management of policies needs to be more robust and accountable to audit. Training and development will help to improve NHSO s implementation of health and safety practices and procedures. The creation of a committee for Health and Safety that is truly representative of the organisation and has the authority to make decisions is an essential requirement. The Committee should be the starting point for effective Health and Safety policy making and implementation of changes and improvements for all employees, patients, visitors and others. NHSO Managers/Supervisors must ensure that all staff are aware of their individual responsibilities and obligations under Health and Safety law. Appropriate training and instruction is essential in ensuring that staff are competent to undertake their duties safely. It is essential that whatever measures are planned and/or implemented to improve Health and Safety standards are communicated effectively to all Staff. Addressing these points in a co-ordinated manner is of utmost importance to NHSO, especially in the climate of financial challenges within which the Board is operating. This is compounded by the societal changes that have occurred, in relation to health and safety, over the past decade: public attitudes have changed in terms of blame, redress, and compensation. Thus, the organisation must embrace strong, systematic direction to the management of health and safety. Some of the key links for the future of such a co-ordinated approach to NHSO s Health and Safety support services are: Staff and Management The Partnership Link Health and Safety Management/Supervisors The Corporate Health and Safety Strategy - the directional link The NHSO Occupational Health and Safety Committee (previously known as Operational Health and Safety Committee). The newly formed Occupational Health and Safety Committee will have more robust Occupational Health input. (It should be noted that Occupational Health as well as Health and Safety are enforced by the Health and Safety Executive (HSE)) The implementation of this Strategy initiative should be via the newly formed Occupational Health and Safety Committee which will report to Quality Improvement Committee (QIC) in terms of governance monitoring. It is intended that with the implementation of the co-ordinated approach detailed within this strategy document, by 2013 NHSO will be in a position where: 6

All levels of staff are regularly updated as to the progress and implementation of Health and Safety information and systems, and are aware of their obligations. The creation of an information centre on the BLOG so that all Health and Safety policies, documentation, risk assessment information, etc is stored in one place and can be viewed by all staff that have access to a PC. The importance of Health and Safety is clearly understood within NHSO. Healthcare environment and safety audits have become the principal tool by which local H&S performance is monitored; and for identifying both positives and deficiencies, to ensure the safety of staff, patients and others within the organisation. Regular Health and Safety inspections are conducted at local level, with nonconformities being dealt with by managers wherever reasonably practicable. The level of competency of NHSO s staff and management is raised to a level where Health and Safety is integrated as an operational norm, and the Organisation is moving towards a truly positive Health and Safety culture. NHSO will continue to improve, and develop new systems to support key H&S topics, such as: moving & handling, fire, infection control, violence and aggression, radiation etc. It is expected that an Occupational Health Strategy should be created and where relevant should support and feed into the H&S strategy. 7

3. The Aim of this Corporate Health and Safety Strategy The overall aim of NHSO's Corporate Health and Safety Strategy is to ensure the development and sustainability of high quality Health and Safety support services and systems. This should be delivered in a timely, efficient, effective and affordable manner to ensure the organisation meets its legislative obligation to safeguard the health, safety and welfare of people/property. This will enable the Board to meet, and exceed, the Statutory obligations placed upon the Organisation to safeguard the health, safety and welfare of staff, patients and others who might otherwise be affected by the actions and/or omissions of NHSO. 8

4. Objectives The principal Health and Safety objectives for NHSO over the next 3 years, are as follows: 1. Continue to review and improve the organisation s Health and Safety management structures and arrangements, with an emphasis on monitoring the implementation of policies, processes and associated outcomes. 2. To support managers and staff in achieving suitable levels of competency and Health and Safety knowledge. 3. To maximise the communication and consultation arrangements currently in place. 4. To ensure that staff understand the need to comply with Health and Safety standards. 5. To increase staff involvement in Health and Safety performance through line management, with a view to increased emphasis on partnership working. 6. To ensure that there is an identifiable top-down commitment to Health and Safety, in order to progress the acceptance of effective Health and Safety working arrangements as the daily operational norm. 7. To assess workplace risks and introduce safe systems of work 9

5. Objectives in Detail 5.1 To continue to review and improve the Organisation s Health and Safety management structures and arrangements, with an emphasis on monitoring the implementation of policies, processes and associated outcomes. The starting point for NHSO is to establish a foundation from which to work while identifying the correct people who will be expected to lead on H&S. Those people should be competent, and active in the pursuit of Health and Safety best practice and competencies, and brought together by the creation of an Occupational Health and Safety Committee with clear targets and goals. It is essential that realistic timeframes are agreed and this strategy should be implemented and embedded over the next three years. The creation and implementation of an audit tool that staff can use regularly to record health and safety checks, non-conformances and good practice is required. At this time NHSO has an effective incident reporting tool (Datix), however investigation and learning should be reviewed and streamlined to assist Health and Safety management. Outcomes: The foundation required and listed above must be implemented by December 2011 Implementation of an audit tool is a priority. 5.2 To support Managers and Staff in achieving suitable levels of competency and Health and Safety knowledge. The effective implementation and management of Health and Safety is best achieved by involving staff utilising their knowledge and skills to create a healthy and safe working environment. To achieve this in an effective and meaningful way, staff need to be educated on what Health and Safety is and why they must participate. It is therefore vital that line management have the necessary knowledge, skills and competencies, and that Line Managers are held accountable for disseminating the knowledge to their staff. Managers must utilise the NHS Scotland Knowledge and Skills Framework (KSF/e- KSF), involving the Learning and Development Department as necessary. Managers who fail to do this will be held accountable through robust performance management. Outcomes: NHSO continues to develop Managers' competency training in Health and Safety and hold them accountable for ensuring that e-ksf, Personal Development 10

Plans (PDPs) and basic Health and Safety training is undertaken by their direct reports. This should be an ongoing continuous improvement initiative. With regard to Health and Safety training for Managers, the standard course for all NHSO managers to attend will be the IOSH (Institution of Occupational Safety and Health) accredited Managing Safely Course. The intended outcome is for all NHSOs managers to be trained by December 2013. 5.3 To build upon, and maximise, the communication and consultation arrangements currently in place. NHSO intends to continue building upon the existing arrangements for communication and consultation with staff, and to enhance these by taking a more focused approach through: a comprehensive Health and Safety committee structure; continuous development of line management responsibilities and holding them accountable for staff briefings and for training and development; utilising and maximising existing resources; using new skills (IOSH training) to communicate and embed best practice and new safer ways of working to direct reports/staff. In essence, this will be a central NHSO Occupational Health and Safety Committee; with input from various sector / departmental committees. This structure will be further supported by communication links with a number of specialist committees and groups, in some cases still to be set up, (i.e. Safety Representative Group, Fire Committee, etc). In addition to the Committee structure, NHSO will endeavour to take a more proactive stance in the engagement of staff, when addressing areas / items for improvements in Health and Safety. Work will be undertaken in conjunction with the Orkney Area Partnership Forum (OAPF). It is intended that this work will involve exploring more innovative methods of communicating the message to many of our remote, lone worker, or hard to reach sites and staff. Outcomes: Implement best practice to carry out ongoing workplace assessments and audits, recording the findings and highlighting/reporting non-conformance or system failure to the appropriate people. Assessments/audits should be carried out by representatives from individual wards/areas/departments. The Occupational Health and Safety Committee will be represented more accurately on the various other partnership committees. 11

A representative from the NHSO OH&S Committee will be required to be coopted onto the OAPF, with the key remit of promoting improved health and safety communication across the Board. (August 2010) 5.4 To ensure that staff understand the need to be involved in achieving compliance with Health and Safety standards. Staff have a mandatory requirement to complete all statutory training. In doing so they should understand their commitments and the expectations of them, as well as the requirement of the organisation to protect staff. The Health and Safety at Work Act 1974 states that all have a duty to take reasonable care and behave in a responsible and safe manner while in the work place. Outcomes: All Staff will be educated and understand that they are accountable for the health and safety of themselves and people around them, and that their actions have both positive and negative consequences. 5.5 To increase Staff involvement in Health and Safety performance through line management with an increased emphasis on partnership working. As well as a new Committee structure, closer partnership working will be essential to deliver the measures identified in this Strategy. Due to the finite resources available for Health and Safety related roles within NHSO further involvement of trained Health and Safety representatives will increase the potential number of active stakeholders in the promotion of Health and Safety. It is intended that wherever practicable, staff and partnership representatives will be consulted and actively involved in any new, or altered working practice proposals that affect the health, safety and/or welfare of staff. Outcomes: The creation of a group of Health and Safety representatives which shall be chaired by a member of the Occupational Health and Safety Committee. The purpose of the group will be that suitably trained and competent Health and Safety representatives, including staff side representation, shall be active within NHSO. The chair will produce a short annual report to the OH&S Committee, which will be presented at the first meeting of the Committee in each new financial year. This will detail points from the previous financial year, for example, changes in the number of safety representatives, key H&S issues from staff side, and how the partnership arrangements have worked in terms of addressing these issues etc. 12

An annual report from the Chair of the NHSO Occupational Health and Safety Committee will be presented to the Corporate Management Team (CMT) and to the Staff Governance Committee (SGC) and to QIC each meeting. This will detail, amongst other Health and Safety performance items, an overview of the effectiveness of Health and Safety partnership arrangements.. 5.6 To ensure that there is identifiable top-down commitment to Health and Safety, in order to drive forward the acceptance of effective Health and Safety working arrangements as the daily operational norm. As mentioned under section 2.1 above, Senior Management within NHSO has already taken a number of steps to enable Health and Safety to be improved throughout the organisation. Although this has been viewed as a positive measure, their continued support to drive Health and Safety forward, to build a positive and informed culture, is essential. It is recognised that achieving Health and Safety cultural change is not a quick-fix solution. NHSO must take account of the fact that the existing culture has evolved over a long period of time, and attempts to improve it too quickly may result in resistance or lack of engagement. Accordingly, this may well prove to be the most difficult element of the Strategy to achieve. However, we must recognise that a lot of good practice does exist and the positive cultural elements that are already in place in NHSO this should be used as exemplars. Outcomes: Health and Safety Management audits will be implemented in order to gain an overall picture of the level of understanding that NHSO s Senior Managers have of Health and Safety obligations. Where elements of good practice are found, these will be shared. In areas where improvements are required, support will be provided. The introduction of formal Health and Safety Department/Ward/Area inspections will be used as a means of measuring compliance with statutory obligations at operational level within NHSO. The results of these inspections will be reported to the NHSO OH&S Committee. Progress will be monitored via QIC in order to ensure effective governance processes. 5.7 To assess workplace risks and introduce safe systems of work NHSO have created a risk assessment tool that is accessible to all staff and is relatively easy to complete. Risks should be assessed and recorded to ensure that measures are taken to reduce the harm to people and property. Generic risk assessments for repetitive tasks can be created to aid in the establishment of safe systems of work for 13

certain tasks. Risk Assessment is the responsibility of all staff and is not just a management process. Outcomes: All staff have the ability to assess risk, record it on the correct paperwork, and implement or contribute to the implementation of safe systems that take into account possible harm to people or property and appropriately mitigate against this. 14

6. Delivering the Objectives In order to achieve the points identified in the objectives, it is necessary to consider how the Strategy will be delivered over the next three years. The present financial challenges faced by NHS Orkney restrict the options but do not remove the Health and Safety obligations. It is therefore part of the strategy to remove the service level agreement presently in place with Orkney Islands Council for Health and Safety advice and support, and to replace this with a Head of Occupational Health and Safety, supported by the necessary resources. It is recognised that a practical system is required that will allow the Strategy to be implemented within the operational constraints of the organisation, thus it is recommended that NHSO adopt the Health and Safety Executive s HS(G)65 Successful Health and Safety Management system. This was selected for a number of reasons: it is a no-cost option to acquire; it is the system that the HSE (the principal H&S regulators) use when NHSO is inspected; it does not require costly third party accreditation in order to demonstrate compliance; and it is a relatively easy-tounderstand system with which to work. Appendix 1 shows an illustration of the overview of the HS(G)65. 15

7. Summary The implementation of Health and Safety is a legal requirement consisting of many pieces of legislation intended to protect people and property. For several years NHS Orkney has operated without a Health and Safety Manager and systems and processes that were once in place and effective, are no longer so. Change is required and this includes communication and interaction with staff, the implementation of safety processes and procedures in their departments by Managers, and the governance and audit of these processes. In the last 12 months much work has been undertaken to address a number of nonconformances and failures with the Health and Safety requirements at NHSO. This strategy is intended to build on that good work, and provide leadership at all levels and direction to future work to ensure full compliance with the Health and Safety requirements. 16

Appendix 1 HS(G)65 Successful Health and Safety Management, HSE POLICY Policy Development ORGANISING Organisational Development AUDIT PLANNING AND IMPLEMENTATION MEASURING PERFORMANCE Developing techniques of planning measuring and reviewing REVIEWING PERFORMANCE 17