Health and Safety Committee Six Monthly Report, 1 April to ...

Health and Safety Committee Six Monthly Report, 1 April to 30 September 2016 Trust Board 6 December 2016

Strategy and Transformation Directorate G:\BOARD SECRETARIAT\MEETINGS\Board\Meetings\2016-17\06.12.16\Annex 4.1 Board 06.12.16 - Health & Safety Six Monthly Report 01.04.16-30.09.16.docxMeetings/Board/Meetings/2016-17/06.12.16 Page 1 of 11

EXECUTIVE SUMMARY REPORT TO: Trust Board DATE: Tuesday 6 December 2016 AGENDA NO: 4.1 AGENDA ITEM: Health and Safety Six Monthly Report 1 April to 30 September 2016 SPONSOR: Andy Ibbs, Director of Strategy and Transformation PREPARED BY: Mike Cousins, Health and Safety Manager & Local Security Management

Specialist (LSMS) PRESENTED BY: Andy Ibbs, Director of Strategy and Transformation

Purpose

The purpose of this paper is to present the Health and Safety Committee Six Monthly report. The six monthly period covered is 1 April 2016 to 30 September 2016. Key issues comprise:

This report provides assurance that health and safety is being managed in accordance with requirements under the Health and Safety at Work etc. Act 1974 and supporting regulations.

The established Health and Safety Committee receives reports from specialist advisors and teams to ensure a Trust wide perspective.

Decision

Approval

Receive

Ratify

Key Issues

Key issues include:

Twenty seven incidents were reported to the Health and Safety Executive (HSE) under the Reporting of Injuries Diseases and Dangerous Occurrences Regulations (RIDDOR).

With the transfer of the Local Security Management Specialist (LSMS) to the Royal Devon and Exeter NHS Foundation Trust (RD&E) under Transforming Community Services (TCS) on 30 Sept 2016, LSMS responsibilities have been allocated to the Health and Safety Manager. The Health and Safety Manager has gained LSMS accreditation following completion of a four week Security Management course delivered by NHS Protect.

Following Transforming Community Services and the transfer of services and staff to RD&E, the Security Incident Review Group (SIRG) has been disbanded. On review of reporting functions, duplications were identified which has resulted in SIRG being merged with the Health and Safety Committee.

Under TCS due diligence, information regarding the management of health and safety has been shared with the Risk Manager and Health and Safety Advisor, RD&E. At least 131 documents were shared with RD&E.

Supporting Information

The Health and Safety Committee Six Monthly Report covering the period 1 April to 30 September 2016 is attached.

Controls and Assurance

The Health and Safety Committee members include union appointed safety representatives, management representatives, specialist advisors and a Non-Executive Director. As an assurance to the Board, the Non-Executive Director (Board Workforce Champion) acts as a

scrutineer, independently challenging decisions, actions taken and progress made on matters relating to the management of health and safety.

Quarterly Health and Safety Incident Reports are presented to the Health and Safety Committee. The Trust’s incident management arrangements have been developed to meet the requirements of national guidance e.g. National Reporting and Learning Service and Northern Devon Healthcare NHS Trust Clinical Risk Management Standards (formerly NHS Litigation Authority’s Risk Management Standards for Acute Trusts).

Impact Assessments Explanation

Quality The Trust ensures that patients, the public and staff are involved in the decision-making process when appropriate. Membership of the Health and Safety Committee includes clinical and management staff and safety representatives. Robust and effective risk and incident management systems ensure that the Trust’s services can be developed and delivered to meet the needs of staff and patients.

Equality and Diversity The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. No adverse or positive impacts have been identified from this report.

Regulatory & Legal Robust risk management processes and management of incidents enable the Trust to meet the legal requirements of the Health and Safety at Work etc Act (1974), the Management of Health and Safety at Work Regulations (1999) and other supporting regulations. In addition, the Trust has a duty to comply with the following:

The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, and the Care Quality Commission (Registration) Regulations 2009 – which set out the regulatory framework of health and adult social care providers under which the Care Quality Commission operates.

The Health Act 2009 – which sets out the measures to improve the quality of NHS care, the performance of NHS Services, and to improve public health

Finance Failure to comply with statutory requirements could result in prosecution in fine and / or the serving of improvement notices or prohibition notices by the HSE. Under Fee For Intervention (FFI), the HSE seek to recover costs where material breaches in health and safety law are identified (£124.00 per hour under FFI).

Potential Risk to the Organisation

There is a risk if Health and Safety incidents are not reported, investigated, acted upon, and lessons learned are not implemented, then the Trust will be at risk of not complying with statutory requirements under health and safety law. The Trust will be at a high risk of not providing safe, high quality care to patients or a safe working environment for staff. The HSE have entered into an agreement with the Care Quality Commission (CQC). The Memorandum of Understanding, effective from 1 April 2015, allows sharing of information and notification to the CQC of information received by the HSE. Where it is considered appropriate, the CQC rather than the HSE may lead in any investigations or related actions that could subsequently be taken.

Board / Committee Prompts

Has the Board received sufficient information to be assured that the Trust’s arrangements for the

management of health and safety are sufficiently robust?

References

Strategic Objectives The Trust’s strategic objectives are reviewed by the Board on an annual basis. This paper supports the achievement of the following strategic objectives

We will deliver high quality care measured by effectiveness, safety and the person’s experience of care.

We will ensure access to a sustainable range of services that are delivered locally through partnerships and networks.

People will tell their story only once. We will deliver integrated health and social care, seamlessly to meet the needs of individuals.

We recruit and develop a flexible, fulfilled and multi-skilled workforce fully engaged in turning our vision into a reality.

We will efficiently and effectively run our services to benefit our local communities.

We will work in partnership with stakeholders to promote independence and well-being.

We will support individuals and communities to have more influence over how services are delivered and encourage others to do likewise.

Annual Corporate Objectives

This paper provides evidence to support the achievement of the following annual Corporate Objectives for 2016/17.

2: Compliance with CQC Fundamental Standards 8: Ensure safe transition of Eastern TCS Principal Risks

The Trust’s principal risks have been identified through the Trust’s risk management processes. They are updated as they are identified by the Risk Management Committee. This paper supports the mitigation of the following principal risks

Financial planning & management Clinical records management

Strategic & business planning Leadership & management

Workforce numbers Unsafe behaviour

Workforce skills External demands

Procedural management Partnership arrangements

Equipment & facilities arrangements Communication

Health and Safety Six Monthly Report

1 April to 30 September 2016

1. Overview

1.1. Purpose and key issues

The purpose of this paper is to present the Health & Safety Committee Six Monthly Report for the period, 1 April 2016 to 30 September 2016.

The Health & Safety Report is presented twice yearly to the Trust Board in order to highlight the key issues, decisions taken and risks discussed as part of the business of the Health and Safety Committee over the previous six months. The Report also provides additional assurance to Trust Board that health and safety matters are being appropriately identified and managed in accordance with Health & Safety Executive (HSE) legislation.

2. Significant Areas of Interest

During the period of 1 April 2016 to 30 September 2016, the health and safety areas of work included:

2.1. Incident Reporting

All health and safety related incidents were reviewed by the Health and Safety Manager and other specialists such as (but not limited to) the Back Care Advisor and Fire and Security Advisor to ensure managers have taken appropriate actions.

Incidents categorised under health and safety are reviewed by the Health and Safety Team to ensure any incidents are identified for the purposes of statutory external reporting e.g. RIDDOR. See table 1 for health and safety related incidents covering the period of 1 April to 30 September 2016.

Quarter 1, 2016-17 (1 April to 30 June 2016) a total of 3,289 incidents were reported, of which 626 were health and safety related and highlighted in table 1.

Quarter 2, 2016-17 (1 July to 30 Sept 2015) a total of 3,229 incidents were reported, of which 653 were health and safety related and highlighted in table 1. Table 1: Health and Safety Related Incidents

Incident category Q1, 2016-17 Q2, 2016-17

Patient Accidents (including Falls) 397 (63%) 419 (64%)

Staff Accidents 101 (16%) 95 (14%)

Violence and Aggression 86 (14%) 104 (16%)

Fire 35 (5%) 26 (4%)

Visitor / Contractor Accidents 7 9

It should be noted that patient accidents, including falls are reviewed by the Head of Physiotherapy and Occupational Therapy and are presented at the Patient Safety Operational Group to provide a Trust wide approach for the management of patient accidents. The quarterly incident reports are available electronically by clicking the following icons:

Annex 5.3 Incident Report Quarter 1 2016-17.docx

Annex 5.2 Health and Safety Incident Report Quarter 2 2016-2017.docx

2.2. RIDDOR Regulations

Under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR), certain categories of incident are reported externally to the Health and Safety Executive (HSE). Guidance relevant to the healthcare sector (Reporting of Injuries, Diseases and Dangerous Occurrences in Health and Social Care) is published on BOB.

During the period of 1 April to 30 September 2016, 27 RIDDOR reports were submitted to the Health and Safety Executive.

• Quarter 1, 2015-16, 13 incidents were reported under RIDDOR • Quarter 2, 2015-16, 14 incidents were reported under RIDDOR

The incidents reported to the HSE fell under the following RIDDOR categories:

• Specified Injuries (Bone Fracture) – 3 • Specified Injuries (Loss of consciousness) – 1 • Patient Accident (Specified injury) – 7 • More than 7 days absence from Work – 14 • Dangerous Occurrence – 1 • Visitor (requiring treatment) – 1 In comparison, 17 RIDDOR reports were submitted for the previous six month period (Quarter 3 and Quarter 4, 2015-16). Seven patient accidents occurred during this period that met RIDDOR reporting criteria. Guidance regarding RIDDOR reportable patient incidents has been published to support the Trusts Investigations, Analysis and Improvement Policy and will be issued to investigation leads to support identification of patient incidents that meet RIDDOR reporting criteria.

2.3. Transforming Community Services Under Transforming Community Services (TCS) and the transfer of certain services and staff

to RD&E, in accordance with due diligence requirements, information concerning the management of health and safety shared with RD&E included:

• Quarterly Incident Reports. • Health and Safety Committee minutes.

• Six Monthly Health and Safety Report to Trust Board. • Audit Inspection Reports (Community Hospitals, Mid and East Devon). • Contact and correspondence with the HSE (affecting those services and staff transferred

under TCS). • Full details of RIDDOR reports submitted to the Health and Safety Executive over a 12

month period (affecting those services and staff transferred under TCS). • Arrangements concerning the management of lone working. • Health and Safety related policies, procedures, guidelines and a number of risk

assessments. • PowerPoint Presentations for training programmes and supporting notes (Induction,

Refresher, Risk, COSHH).

At least 131 separate documents have been provided by the Health and Safety Manager under due diligence and shared with RD&E.

2.3. Lone Working Following a local tendering process managed by the Procurement Department, a contract

has been awarded to Skyguard for the supply of 250 MySOS Personal Safety devices over a three year period. The personal safety devices will be issued to community staff who meet the definition of a lone worker in accordance with the Trust’s Lone Working Policy and are intended for staff who regularly visit patients unaccompanied in community settings such as the patients home. Information regarding MySOS personal safety devices has been published on the Trust intranet site (BOB). A representative from Skyguard will attend NDDH on 01 December 2016 to commence training and roll out of safety devices.

2.4. Smoking and E-Cigarettes (Vaping)

Public Health England and Smoking Cessation Services have published a number of guidance documents during 2016 concerning the use of e-cigarettes and vaping. NHS Trusts are now required to implement clear policies concerning vaping on their sites.

This requirement prompted the Health and Safety Manager to write and present a report on smoking and vaping at the 23 September Health and Safety Committee meeting. Subsequently a supplementary Smoking and Vaping Report benchmarking how other Trusts manage smoking and vaping was presented at the 22 November meeting.

With the Trust current policy concerning Smoking due for review an opportunity was taken to present information in a balanced and factual way to reflect realities concerning smoking outside of building entrances.

Recommendations have been made by the Health and Safety Manager after consultation with the Health and Safety Committee members to pragmatically manage smoking and vaping outside. It is acknowledged that recommendations will require further discussion and a decision as to what is possible at Executive level.

The Smoking and Vaping reports in full can be accessed electronically via the following icons:

Annex 5.1 Vaping and Smoking.docx

Annex 5.1 Vaping and Smoking Supplementary Report Nov 2016.docx

3.0. Specialist Advisors Reports

The Health and Safety Committee is a forum for other specialist advisors e.g. Back Care and Fire and Security Advisors to identify good practice and highlight risks to the organisation.

The Health and Safety Committee receives regular reports from a number of specialist advisors, and the following key issues were noted:

3.1. Health & Safety

3.1.1 Care Quality Commission Enquiry

An enquiry was received from the Care Quality Commission 07 June 2016 following a patient accident that met HSE reporting criteria under the RIDDOR Regulations. RIDDOR report EFF805A14A submitted to the HSE, 03 June 2016 (Patient accident IR29774, 08 November 2015) was shared with the CQC under a Memorandum of Understanding that exists between the two organisations. The sharing of information resulted in the CQC contacting the Trust. The enquiry included a concern regarding the timescales between the patient accident and the date of completion of the RIDDOR report.

Following review of procedures and implementation of a new process (prior to the CQC enquiry), it is anticipated that the number of patient accidents reported under RIDDOR will increase. Any potential trends will be monitored. All RIDDOR reports are presented to the Health and Safety Committee for Information and assurance of appropriate actions taken. The CQC were satisfied with the Trust report submitted in response to their enquiry.

Full details of the report can be accessed electronically via the following icon:

Annex 5.1 Patient Incidents reported under RIDDOR.docx

3.1.2 Successful Repudiation of a Personal Injury Claim Findings and recommendations from Health & Safety and Legal Claims investigations

resulted in the successful repudiation of a personal injury claim made by a member of staff. The claim related to an incident whereby the claimant collided into a lamppost in a Trust car park on 09.01.14 which also resulted in internal and external civil and criminal investigations.

Resolution of the matter has resulted in saving the Trust a total of £6,113.70 by successfully

defending the claim against the Trust for £3,363.70 and recovering the costs spent replacing the lamppost at £2,750.00.

Following conclusion of the investigation, a referral was made to the NHS Local Counter Fraud Specialist for suspected dishonesty and falsifying statements for pure financial gain. The full report can be accessed electronically by clicking the following icon:

Annex 5.2 Successful Repudiation of a Civil Claim Against the Trust.docx

3.1.3 Working Arrangements Honiton Hospital

Union appointed safety representatives raised a number of concerns on behalf of their members regarding working arrangements and associated travel arrangements for staff under a temporary relocation from Exmouth to cover shifts at the Honiton Hospital Minor Injuries Unit (MIU).

A two page open letter raising 12 separate concerns and queries was presented at the Health and Safety Committee meeting held 17 May 2016. The letter raised concerns about “working conditions at Honiton MIU as listed”, which “until these concerns and issues have been addressed” they will be “working under protest”. Each concern was investigated and responded to within the report which addressed issues, provided assurances, demonstrating where applicable that suitable and sufficient controls were in place to manage (not eliminate) risks at an acceptable level so far as is reasonably practicable. Of the concerns raised that were a matter of health and safety, the Union representatives were satisfied and assured that suitable and sufficient control measures were in place. The full report can be accessed electronically by clicking the following icon:

Annex 3.1 Working Arrangements Honiton Hospital Minor Injuries Unit.docx

3.1.4 Successful Defence of a Pre Trial Personal Injury Claim The learning, findings and conclusions of a Health & Safety and Legal Claims investigation

were presented at the 27 September Health and Safety Committee meeting. The report outlined actions taken leading up to the Trial window regarding a member of the public who alleged she sustained injury following a trip into an Audiology Booth whilst attending an appointment on 26.01.2015. Following the investigation of the Incident and Personal Injury Claim, a robust case for defence and denial was presented to the NHS Litigation Authority. The claimant served Notice of Discontinuance with the Courts 3 weeks prior to Trial, which resulted in and estimated total financial cost saving to the Trust and NHS Litigation Authority in the region of £559,770 representing Insured, Un-insured and Intangible/Hidden Costs savings.

The full report can be accessed electronically by clicking the following icon:

Annex 5.3 Successful Defence of a Pre-Trial Non-Clinical Claim Against the Trust.docx

3.1.5 Internal Safety Alerts Three internal safety alerts were issued (or amended and re-issued) during the six month

period 1 April 2016 to 30 September 2016:

Alert 8 Office Chairs on Castor Wheels (revised and updated 15.07.16)

Alert 9 Unsuitable Footwear (25.07.16)

Alert 10 Disposable Wipes Blocking Drains (12.08.16)

3.1.6 Benchmarking A benchmarking exercise has been completed and presented in a report. Benchmarking was

undertaken comparing accident rates within the Trust over the past three financial years and also in comparison to certain accident rates with another Trust in the South West.

When comparing accident rates with another Trust, it is possible there has been

underreporting of certain categories of incident for example Patient accidents that meet RIDDOR reporting criteria. Work has been undertaken to address this issue including the revision and incorporation of additional examples of patient accident that meet reporting criteria under RIDDOR within a guideline now published on BOB. The guideline is issued to all investigation leads tasked with co-ordination of 72 hour or Significant Event Audits.

The full report can be accessed electronically by clicking the following icon:

Annex 5.4 Benchmarking Accident Statistics.docx

3.2. Local Security Management Specialist 3.2.1 Security Incident Review Group Disbanded

Following Transforming Community Services (TCS) and the transfer of services and staff to RD&E, the Security Incident Review Group (SIRG) has been disbanded. On review of reporting functions, duplications were identified which has resulted in SiRG being merged with the Health and Safety Committee.

3.2.2 Role of LSMS With the transfer of the Local Security Management Specialist (LSMS) to the RD&E under TCS on 30 Sept 2016, LSMS responsibilities are allocated to the Health and Safety Manager. The Health and Safety Manager has gained LSMS accreditation following completion of a four week Security Management course delivered by NHS Protect.

3.3. Fire and Security 3.3.1 Training for Site Management Team The Fire and Security Advisor has arranged for Incident Management Training to be rolled

out for the Site Management Team.

3.4. Manual Handling

3.4.1 Documentation and Risk Assessments

The NDHT Moving and Handling Standard Operating Procedures and Risk Assessments written by the Back Care Team (already shared and used by various healthcare associated organisations across the South West) have now also been adopted by Plymouth Community staff and Devon Partnership Trust, and more recently Virgin Care are currently considering purchase of the rights to use NDHT Standard Operating Procedures and Risk Assessments.

3.5. Infection Control

3.5.1 Prevention of Inoculation Injuries The Infection Prevention and Control team confirmed that a Trust wide audit of the

management of sharps had been undertaken by NHS auditors. The report concerning sharps has been received and a number of actions have been identified. The audit was requested to assess how successfully the Trust had embedded the use of safer sharps following the implementation of the Health and Safety (Sharps Instruments in Healthcare) Regulations 2013.

3.6. Occupational Health

3.6.1 Stress Management

To support the work and services Occupational Health provide staff concerning the management of stress, a Critical Incident Stress Management (CISM) debriefing service is now available to all staff on the Occupational Health website (BOB) to prevent post-traumatic stress disorder.

4.0. Specialist Advisory Groups 4.1. Medical Gas Committee The Pharmacy Department working in conjunction with the British Oxygen Company (BOC)

have agreed under contract that the supply of gas cylinders to the NDDH will switch to the new lightweight cylinder technology. A plan is being implemented to ensure a smooth transition from the current old technology cylinders to new lightweight cylinders with integral regulators. The work is being co-ordinated by the Pharmacy Department.

4.2. Security Incident Review Group

NHS Protect are currently reviewing the level of operational support they are able to provide to organisations. It is anticipated that the current amount of support and resources available to Local Security Management Specialists will be significantly reduced. Announcements from NHS Protect are expected April 2017. A new Physical intervention training programme has been published on STAR and is available to staff (from July 2016).

4.3. Control of Substances Hazardous to Health (COSHH) Working Group Assurances are provided to the Health and Safety Committee by the COSHH Working Group

minutes of meetings in respect of routine and ad hoc monitoring of substances that may cause harm.

Hotel Services have changed supplier from Ecolab to Diversey for cleaning products, this is in line with a national contract held by Sodexo. As part of the changeover of supplier and review of COSHH risk assessments and manufacturer safety data sheets, a dishwasher concentrate classified with a carcinogenic risk phrases (under new packaging and labelling regulations) was substituted for an alternative “safer” product that does not carry the same risk phrase.

4.4. Acute Fire and Emergency Response Team (AFERT) Routine reports were presented at AFERT associated with fire alarms, unwanted alarm

activations and the causes of such activations.

At one community site a problem regarding an earth fault on the fire cable was discussed. It was agreed further investigation was required to rectify the issue which may be due to a software problem.

4.5. Central Alerts System (CAS)

A high increase in the number of Estates and Facilities Alerts issued by the Department of Health was noted. Not all alerts issued are applicable to NDHT, however each alert has to be actioned to provide assurance that the issue is either not applicable or actions are being undertaken to manage an identified risk.

5.0. Key Decision Taken The following policies, procedures and guidelines were approved by the Health and Safety

Committee:

Control of Substances Hazardous to Health Policy First Aid Policy Gritting at NDDH Standard Operating Procedure Guideline for RIDDOR Reportable Patient Accidents (amended and updated)

Health and Safety Policy Health and Safety Statement (signed by Chief Executive)

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