Health and Safety Policy · Risk assessment - careful, systematic examination of the hazards, the...

Health and Safety Policy

Incorporating Incident Reporting

Originator: Barbara Gale

Chief Executive

___________________________________________________________________

Review Date: January 2015

Revision Date: January 2017

___________________________________________________________________

Approved by: Personnel Committee

Date of meeting: 17 April 2015

Name of Chair: Marion Miles

___________________________________________________________________

Approved by: Board of Trustees

Date of meeting: 24 September2015

Name of Chair: Adrian Williams

S:\Organisational\Policies - current\CURRENT Policies\ORGANISATIONAL\Health and Safety\Health & Safety.docx

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Contents

1. Policy Statement 4

2. Introduction 5

2.1 Definitions 5

3. Responsibilities and Accountability 6

3.1 Chief Executive Officer (CEO) 6 3.2 Directors 6 3.3 Managers 7 3.4 Employees 7 3.5 Representatives of the Staff Forum 8 3.6 Health and Safety Assistance 8 3.7 Occupational Health Team 8 3.8 Health Benefits 8

4. Procedures and Implementation 9

4.1 Managing areas of risk 9 4.1.1 Risk assessments 9 4.1.2 Working in areas of risk 9 4.1.2.1 Safe systems of work and permits to work 9 4.2 Areas of identified risks (alphabetical order) 10 4.2.1 Asbestos 10 4.2.2 Blood products 10 4.2.3 Chemicals and hazardous substances 10 4.2.4 Contractors 11 4.2.5 Dangerous substances 11 4.2.5.1 Medicines 11 4.2.6 Driving and transport 12 4.2.7 Electrical safety 12 4.2.8 Environmental procedure 12 4.2.9 Fire 13 4.2.10 Infection Prevention 14 4.2.11 Legionella 14 4.2.12 Lifting equipment 14 4.2.13 Lone working 15 4.2.14 Manual handling 15 4.2.15 Noise and vibration 16 4.2.16 Occupational Health 16 4.2.17 Personal protective equipment (PPE) 16 4.2.18 Pregnancy 16 4.2.19 Pressure systems 16 4.2.20 Slips, trips and falls 16 4.2.21 Smoking 17 4.2.22 Stress 17 4.2.23 Visual display units (VDUs) 17 4.2.24 Violence 17 4.2.25 Waste 18 4.2.26 Work at height 18 4.2.27 Work equipment 18 4.2.28 Workplace 18 4.2.29 Young persons 19


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4.3 Training and information 19 4.4 Incident management 19 4.4.1 Incident reporting (see Appendix 2) 19 4.4.2 Incident Investigations (see Appendix 3) 20 4.4.3 Learning from incidents 20

5. Related Policies / Guidelines 20

6. Monitoring and Review 20

7. Statutory Compliance and Evidence referenced 21

8. Appendices 21

Appendix 1 Health and Safety Organisation Chart Appendix 2 Risk Likelihood and Consequence Severity Scores Appendix 3 Likelihood and Consequence Matrix Appendix 4 Incident reporting procedure (for actual incidents or near misses) Appendix 5 Incident investigation procedures Appendix 6 Investigating a Serious Untoward Incident procedure Appendix 7 Reportable Injuries or Events to the HSE under RIDDOR Appendix 8 Reporting of Incidents to the Charity Commission (CC) Appendix 9 Compliance with the NHS East of England Serious Incidents Requiring Investigation


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1. Policy Statement

Health and safety is an essential and integral element to delivering the best palliative care to patients and their families in the West Suffolk area and providing a wide range of successful fundraising activities; it also helps to contribute to the success and longevity of St Nicholas Hospice Care.

St Nicholas Hospice Care is an independent charity delivering specialist palliative care to patients and their families within the communities of West Suffolk and Thetford. Care is delivered by a specially trained multidisciplinary team supported by a large team of volunteers to patients within our Sylvan Ward, Community Hospice Team, Orchard and Burton Centres. The organisation also includes an Education Department that delivers palliative care education to the local community, a Fundraising Department that manages a range of fundraising activities and a Retail Section with several shops in the local community staffed by paid staff and volunteers.

Clarity, communication and co-operation between all employees, volunteers, trustees, patients and families, contractors and consultants from other agencies who work closely with St Nicholas Hospice Care is vital to the success of this policy and ultimately the success of St Nicholas Hospice Care.

This Policy includes the requirements of mandatory reporting processes, with a commitment to reducing accidents, incidents, and near misses. A single reporting system is in use that incorporates the reporting of both clinical and non-clinical incidents.

All staff have responsibilities to ensure that our working environment continues to be a safe, secure, healthy and fulfilling place to work.

To ensure the general safety and welfare of all employees, volunteers, contractors, placements, consultants, patients and visitors St Nicholas Hospice Care will:

Control the health and safety risks arising from business activities to prevent accidents, injuries and ill health

Appoint competent people and give them adequate training

Provide and maintain safe places of work and equipment

Ensure the safe handling, use, storage and transport of substances

Provide information, instruction and supervision as appropriate

Manage any incidents, taking action to prevent further incidents when possible.

Consult employees on matters affecting health and safety.

Employees of St Nicholas Hospice Care are required to co-operate with this policy to ensure not only their own health and safety, but that of others too.

Employees must remember to:

Use any equipment, substance and facilities provided in accordance with the information and training given – or seek out instruction as needed

Not misuse or interfere with anything provided to safeguard the health and safety of staff and patients


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Take care of themselves and others

Report incidents or near misses

Report any health and safety concerns to their manager.

2. Introduction

The policy outlines how health and safety is managed, organised and put into practice at SNHC. Whilst all have responsibilities for health and safety; some have more responsibility than others.

This section outlines everyone’s specific responsibilities which, when followed, will ensure the health, safety and wellbeing of all employees, volunteers, visitors and others who may be affected by SNHC activities.

This Policy was developed in consultation with a Health and Safety Consultant with the Directorate and Management Team and Staff Forum.

2.1 Definitions

Policy - A statement of intent, what the organisation intends to do. Managers and employees must follow/do what is in the policy.

Staff – this encompasses staff, volunteers, sessional workers and those on placement.

Incident – an incident is an unplanned event where there is loss of life, injury, loss or damage to persons or property, or public profile; it can also include any event that may give rise to physical, emotional or psychological harm

Serious incident (clinical / NHS) - An event that causes or has the potential to cause serious injury, mental trauma, unexpected death or where there could be police involvement, major litigation and/or media interest (see Appendix 9).

A serious incident - is defined by the Charity Commission as something that has resulted or could result in a significant loss of funds or a significant risk to a charity’s property, work, beneficiaries or reputation.

Accident – where physical or emotional harm was caused.

Near miss – A ‘near miss’ is an accident waiting to happen, circumstances where an incident could have occurred, but was avoided.

Safe system of work - A written set of instructions defining step by step how to do a job safely – sometimes they are called ‘procedures’ or ‘operating instructions’ which must be followed.

Practices - What SNHC actually does – usually built up over time.

Permit to work - a specialised type of safe system of work for ensuring that potentially dangerous work is done safely. It must be followed and each


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permit is only valid for one episode, where damage could arise to body or building.

Risk assessment - careful, systematic examination of the hazards, the existing control measures and deciding whether the residual risk is adequately controlled. It is a process and the end document.

Hazard - something with the potential to cause harm e.g. unguarded machinery, unsafe act, driving.

Risk -Risk is the likelihood that harm or damage may occur and the consequence/severity of the outcome.

Guidance - Useful background information to give context and understanding to an activity.

3. Responsibilities and Accountability

Anyone –directors, managers, employees, volunteers, trustees - who fails to comply with the requirements of this policy and/or endangers their own health and safety and/or that of other people, may be subject to disciplinary proceedings.

3.1 Chief Executive Officer (CEO)

The CEO has ultimate responsibility for the strategic direction and implementation of this policy to ensure that staff can work in an environment which does not damage their health or affect their safety and wellbeing. The CEO will ensure that this policy is approved by the Board of Trustees. The CEO will ensure that SNHC has adequate financial and organisational resources to put this policy into effect and that the management team have access to professional advice on health and safety matters.

The Directors and CEO will monitor SNHC’s performance on health and safety, initiating investigations or taking action as required with a view to preventing accidents, ill health and improving the health and safety provisions.

The CEO has specific responsibility to ensure that Trustees of the Charity and regulatory and commissioning bodies are kept informed of matters of Health and Safety (see Appendix 2).

3.2 Directors

Directors are responsible for the day to day implementation of this Policy and for ensuring that their managers and supervisors are adequately trained so that they understand their role and their legal responsibilities. Executive Directors will liaise with Health and Safety Executive Inspectors and other enforcing authorities as required.

Directors will ensure there is a robust system in place to record information related to risk and incidents.


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3.3 Managers

Managers are responsible for ensuring that employees and volunteers comply with the requirements of this policy. Managers are responsible for identifying the hazards in their work area – including chemicals, work activities or machinery - and for assessing the risks posed by those hazards.

Managers must ensure that staff are aware of any risks that have been identified in their area of work.

They are also responsible for developing and maintaining safe systems of work (procedures) in their area, ensuring that all the arrangements as detailed in this policy are complied with at all times and that employees and volunteers wear any personal protective equipment.

Managers will also ensure that equipment is in good working order and that all checks, repairs, servicing and statutory inspections are carried out promptly using approved contractors.

Managers will identify safety training needs and facilitate the development of their employees and volunteers through training or the provision of information.

Managers will ensure that:

Health and Safety and Incident Folders will be kept in their department.

Every department will display posters giving instructions about incident and near miss reporting.

An annual review of their workplace is carried about by a competent person.

3.4 Employees

Employees and volunteers must ensure that they are aware of the requirements in this policy.

Employees or volunteers need to take reasonable care of themselves and others who may be affected by acts or omissions.

Staff must ensure that they are fit for work. The use of alcohol prior to work or during work hours is strictly forbidden and would result in disciplinary action. Staff should also not use drugs that may affect their ability to perform their duties.

Staff must:

Work safely.

Do not misuse or interfere with anything provided to safeguard health and safety.

Use equipment, facilities and machinery in a safe manner and in accordance with training and instructions given.

Co-operate with the management team, follow emergency procedures and participate in fire evacuation drills.


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Report hazards, accidents, incidents or work-related diseases to their manager – as well as any concerns about personal health, safety or wellbeing.

Consultation with employees

SNHC will consult with staff on issues that could substantially affect their health and safety such as the introduction of new technology, safety training or the provision of competent advice. Consultation will either take place with staff directly or through elected representatives at the Staff Forum meetings. Records will be kept of these meetings and posted in on the saved in public folders on the s:drive, information about them will be posted using the internal newsletter. Consultation and Information will also be disseminated via volunteer meetings.

3.5 Representatives of the Staff Forum

The Forum meets quarterly to facilitate consultation on issues that affect the health and safety of employees, a consultative committee meets three times a year.

The Representatives of Staff Forum are responsible for representing the opinions of employees with regard to health and safety matters. These opinions are brought to the attention of the Management Team and taken into account before any changes are made that materially affect employee health and safety.

Occasionally, consultation may take place directly with the employees concerned.

3.6 Health and Safety Assistance

A Health and Safety Consultant – with the relevant qualifications, training and experience - is appointed to assist with the technical health and safety aspects of running and maintaining SNHC.

The Consultant is responsible for advising and helping the Management Team to implement the health and safety policy and for helping SNHC to meet its statutory obligations in respect of all relevant health and safety legislation and Approved Codes of Practice.

The Consultant will also carry out periodic workplace inspections as necessary to help maintain standards within SNHC.

3.7 Occupational Health Team

SNHC employs the services of a local occupational health team. Occupational health is a specialist branch of healthcare which is concerned with the prevention, identification and management of work-related health issues. Occupational practitioners are healthcare professionals who have received additional training to understand the complex relationship between work and the impact it may have on the health of the individual.

3.8 Health Benefits

As part of the benefits available to staff, staff can join a healthcare benefit scheme provided by Westfield Health giving them access to a variety of health benefits.


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4. Procedures and Implementation

4.1 Managing areas of risk

4.1.1 Risk assessments

Task based risk assessments will be carried out by Managers. A risk assessment identifies hazardous work activities with the objective of reducing the risk of injury or illness in the workplace to a minimum. Only significant hazards are recorded. If a risk assessment indicates that a risk is moderate or high, action will be taken to reduce the risk to an acceptable level. The Health and Safety Consultant carries out specialist risk assessments where required e.g. for dangerous substances, noise, work at height.

Risk assessments are recorded in writing; staff should read and understand the risks associated with their duties. Staff must comply with the precautions and control measures, which are in place to keep staff safe and healthy; failure to do so could result in disciplinary proceedings.

Risk assessments must be reviewed annually or when any change in the workplace or the activity occurs.

Specific risk assessments must be undertaken for the following activities:

COSHH assessments (Control of Substances Hazardous to Health)

Dangerous substances

Manual Handling assessments – lifting, moving and pushing/pulling.

Noise and vibration assessments.

Pregnancy risk assessments – carried out as required.

Visual Display Unit (VDU) assessments.

Working at height assessment.

Young person risk assessments – carried out as required at start of employment.

A central list of risk assessments is kept by the PA in the Chief Executive’s department and on the in the public folders on the s:drive.

4.1.2 Working in areas of risk

4.1.2.1 Safe systems of work and permits to work

A safe system of work is a written set of instructions defining how to do a job safely – sometimes they are called ‘procedures’, ‘guidelines’ or ‘operating instructions’. Staff must follow the relevant procedure or safe system of work if there is one for their job or part of their job.

The management team will consider and approve any updates to procedures or safe systems of work which may be prompted by new legislation, revised working practices, guidelines or new equipment.

A Permit to Work is a specialised type of safe system of work for ensuring that potentially dangerous work is done safely. They are used where the potential risks


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are high and the careful co-ordination of activities and precautions is essential to a successful and safe operation.

Permit to Work will be issued by the Facilities manager but authorised by the CEO for any work on live electrics, maintenance work requiring the fire alarm to be disabled, hot works, work in confined spaces or maintenance work in the In-Patient Unit. Staff will receive training if affected by a Permit to Work.

4.2 Areas of identified risks (alphabetical order)

4.2.1 Asbestos

Asbestos surveys will be carried out on the buildings owned or leased by SNHC. Asbestos Management Surveys will be carried out for normal occupancy; a Refurbishment & Demolition Asbestos Survey will be carried out if any intrusive maintenance or refurbishment or building works are going to be taking place. Where asbestos containing materials are identified, SNHC will manage the asbestos by producing an Asbestos Register and an Asbestos Management Plan. Relevant staff will be provided with a copy of the Asbestos Register and the Asbestos Management Plan and provided with information on the hazards and the simple precautions to take when working in the vicinity of asbestos.

External contractors working on our buildings will also be notified of the presence of asbestos and given a copy of the Asbestos Register so that they can take it into account and take appropriate precautions when maintenance work is carried out.

4.2.2 Blood products

Transfusion of blood and blood products is potentially hazardous as well as

beneficial, so should be undertaken when the perceived clinical benefits to the

patient outweigh the likely risks. Stringent procedures must be followed to ensure

that the correct blood is given to the correct patient and that any adverse reactions

are dealt with promptly and effectively. It is a legal requirement that all blood must be

fully traceable and records documenting this are kept for 30 years. Full information

can be found in the Blood Products Policy.

4.2.3 Chemicals and hazardous substances

SNHC uses a variety of medicines and products, which, if handled or administered incorrectly, can have potentially fatal or severe effects. Patients receiving our care may also be suffering from or carrying diseases such as MRSA, Clostridium Difficile, Hepatitis, HIV/AIDs. Under the Control of Substances Hazardous to Health (COSHH) Regulations, COSHH assessments are required for any hazardous substances – chemical or biological. The clinical managers are responsible for carrying out the COSHH assessments relating to drugs/medication and biological hazards.

Hazardous chemicals and substances are also used at SNHC for cleaning, maintenance activities, pest and weed control. Where it is necessary to use hazardous substances (i.e. substances that are very toxic, toxic, irritant, harmful or corrosive), a COSHH assessment will be carried out by the Facilities Manager and reviewed annually. The Facilities Manager will investigate and where appropriate


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trial any new products; suitable products will be approved by the Directorate before they are introduced.

Staff are responsible for the safe use, handling, storage and transport of hazardous substances; and must comply with the requirements of the COSHH assessment to ensure that their own health or safety is not compromised.

4.2.4 Contractors

SNHC uses reputable, well established, local contractors. The Facilities Manager issues works instructions and is responsible for ensuring that only contractors who have supplied a copy of their safety policy, public liability, employer’s liability or professional indemnity insurance and risk assessments are allowed to carry out maintenance work on the offices, buildings, shops, grounds or equipment.

With the exception of low risk work, all contractors must provide a risk assessment and a safe system of work for the work being undertaken which should:

Describe the task(s) to be carried out

Identify the physical hazards and any chemicals or hazardous substances involved

Specify any precautions to be taken

Specify emergency procedures

List the equipment required

Contractors will be accompanied to the work area and informed about any hazards in that area by the relevant Manager of the area where the work is taking place. A copy of the Asbestos Register and the Asbestos Management Plan will also be given to contractors.

Permits to Work will be issued by the Facilities Manager for any work on live electrics, maintenance work requiring the fire alarm to be disabled, hot works or work in Sylvan Ward. (For more information please refer to the section on Safe Systems of Work).

4.2.5 Dangerous substances

Substances which are explosive, oxidising, flammable or consist of dust/air mixtures are classified as dangerous substances. SNHC uses medical gases cylinders, oxygen concentrators for clinical care and Liquefied Petroleum Gas (LPG) or natural gas to cook with. The Health and Safety Consultant will carry out a risk assessment on the use, handling and storage of these substances; which will be reviewed annually. Nursing and facilities staff will attend mandatory training in the handling of medical gases.

4.2.5.1 Medicines

The Hospice will ensure that all medicines are stored and handled safely and effectively, that all relevant staff are suitably trained in their use, storage and disposal, and that all staff and volunteers involved in the clinical area understand the extent and limits of the permissions and practices involved in their role. Full details found in the Medicines Management Policy. Any incidents involving medicines must follow the procedures for reporting in the Medicines Management Policy.


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4.2.6 Driving and transport

Only drivers with the appropriate training, experience and licences are permitted to drive on hospice business. Staff will be required to submit copies of their driving licence, insurance and where appropriate MOT certificate on an annual basis.

Staff must drive safely and responsibly, ensuring their vehicle is fit for purpose – they are responsible for their own safety and that of others who may be affected by their actions such as other road users and pedestrians. It is strictly forbidden for employees to drive a vehicle under the influence of alcohol, illegal drugs or any other substance that impairs judgement such as certain prescribed medication or glue. If staff are taking medicines or prescribed drugs that may affect their ability to drive they must inform their manager.

It is a criminal offence to use a mobile phone whilst driving. Given the nature of SNHC work and the extremely sensitive nature of the phone calls that our employees receive, SNHC has decided to take a more rigorous position than the law. Any phone calls whilst driving – even using hands free – are banned. Staff must not be distracted whilst driving; likewise patients and health professionals staff require undivided attention.

Responsibility for the maintenance of the fleet lies centrally with the Facilities Department.

4.2.7 Electrical safety

A competent trained person will test portable electrical equipment annually and carry out any necessary electrical repairs on equipment more than one year old. Equipment will be labelled as having been tested and records will be kept. Failed equipment will not be used; it will either be repaired or confiscated.

The permanent electrical installations will be inspected and tested every year. Access to switchboards, fuse boards and isolator switches must be kept clear at all times.

Equipment brought into the organisation must first be PAT Tested before use.

Staff should ensure that electrical equipment is used safely, not overloaded and switched off when not in use. Residual Circuit Devices (RCDs) should be used when required.

Faulty equipment should be turned off, unplugged, labelled as faulty and reported immediately to the Facilities Manager. Do not use it until it has been repaired.

4.2.8 Environmental procedure

The key points of SNHC’s stance towards minimizing its impact on the environment are to:

Minimise waste by evaluating operations and ensuring they are as efficient as possible.

Minimise toxic emissions through the selection and use of its fleet and the source of its power requirement.


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Actively promote recycling both internally and amongst its customers and suppliers.

Source and promote a product range to minimise the environmental impact of both production and distribution.

Meet or exceed all the environmental legislation that relates to the Hospice.

Use an accredited program to offset the greenhouse gas emissions generated by our activities.

4.2.9 Fire

Details about how the Hospice manages the fire are detailed in the Fire Policy. The general action to be taken in relation to fire is shown below – (ward nurses and nurses attending day therapy are excluded from this general instruction):

On discovering a fire:

Sound the alarm either by shouting ‘FIRE’ or using nearest ‘break glass’ point if there is one.

Leave the building by the nearest fire exit.

Report to the fire assembly point.

On hearing the fire alarm:

Leave the building by the nearest fire exit.

Do not stop to collect belongings.

Report to the fire assembly point.

Only re-enter the building when told it is safe to do so by the Fire Officer.

Staff should be familiar with the local arrangements because SNHC has a specific fire strategy covering the different areas of SNHC’s operations.

Fire risk assessments are carried out by a competent person and reviewed annually to ensure that the fire prevention and fire protection measures remain effective. A separate fire log book contains details of who carries out the statutory inspections of the fire detection, alarm system and fire extinguishers and who carries out the weekly fire alarm tests etc.

Fire exits, stairways and landings must be kept clear of obstructions at all times.

All staff and contracted staff are required to attend fire awareness training appropriate to their needs and responsibilities within a twelve month period. For new staff this should take place as soon as possible

Any new members of staff are to receive a local induction in the fire procedures and fire instructions relevant to his/her department within the first day of employment. This is to include:

The actions in the event of fire

A walk over all escape routes

The location of the fire alarm call points and position of the automatic fire detectors


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The location, type and use of fire fighting equipment.

4.2.10 Infection Prevention

The Chief Executive Officer is responsible for the implementation of Infection Prevention best practice across the whole organisation in line with national legislation and responsible for the contingency plans being up-to-date in case infectious epidemics that occur e.g. winter flu, swine flu.

The Clinical Services Director is accountable for exemplary practice in all clinical departments and teams and for updating guidelines to demonstrate compliance with legislation.

The Consultant in Palliative Medicine is responsible for exemplary anti-bacterial/anti-viral prescribing in line with best practice.

The Infection Prevention Link Nurse is responsible for providing guidance and information on a day to day basis on infection prevention issues

The Director of Personnel is responsible for the database regarding staff inoculations in association with the Occupational Health provider and for ensuring managers encourage staff and volunteers to be inoculated.

Managers and clinical professional leads are responsible for the implementation of agreed infection prevention practices within their areas thereby ensuring the whole organisation is protected.

All staff and volunteers are responsible for upholding the highest standards within their own practice and for reporting concerns.

This work is achieved through formal links with West Suffolk Hospital (WSH) Infection Prevention Team.

Staff working in the community and within other care organisations such as care homes will uphold best practice principles but take note of local arrangements too.

4.2.11 Legionella

There is a large and complex water system at SNHC. It is recognised that there are the potential conditions for the existence and multiplication of legionella bacteria. A legionella risk assessment and a site survey have been carried out by a competent person. The Facilities Manager will be the designated ‘responsible person’ (as required in the Legionnaires’ Disease: The control of legionella bacteria in water systems Approved Code of Practice.) The Facilities Manager will be responsible for ensuring that any recommendations, inspections and testing are carried out in accordance with the written scheme.

4.2.12 Lifting equipment

There is a passenger lift in SNHC building and other lifting equipment is used in the clinical area, shops and warehouse and in the Burton Centre. All lifting equipment that lifts people must have a Thorough Examination every 6-months.


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The Facilities Manager is responsible for ensuring:.

That a register of all lifting equipment be maintained for the organisation as a whole (including Clinical & Retail Settings)

That 6 monthly and Annual inspections and tests be conducted ensuring that current and valid certification is held for all lifting equipment in use across the organisation as a whole (including Clinical & Retail Settings)

That in addition to the statutory examinations the passenger lift installed at SNHC Hardwick Lane and at SNHC Retail Premises Barton Road be subject to planned maintenance: records of servicing and remedial works will be maintained in the facilities Office.

That in addition to the statutory examinations the passenger stairlift platform installed at SNHC The Burton Centre, Haverhill and at SNHC Retail Premises St John Street Bury St Edmunds be subject to planned maintenance; records of servicing and remedial works will be maintained in the facilities Office.

4.2.13 Lone working

Many staff will work alone or work in remote areas of SNHC and the local environment without direct supervision as part of their job.

A corporate lone working risk assessment has been carried out; it lists the variety of precautions already in place which we use to control the risk from working alone. Staff must keep their manager informed of their whereabouts and let them know about any threatening behaviour or actual physical violence.

Safe systems of work for lone working guidance are available in relevant departments.

4.2.14 Manual handling

There may be a requirement to lift, move, assist a variety of loads e.g. laundry bags, boxes of fruit, patients and furniture. Manual handling assessments will be carried out annually on all manual handling tasks. Staff must comply with the control measures specified.

Health and Safety Executive (HSE) guidelines indicate the maximum weight lifting and lowering a load close to the body between knuckle and elbow height is 16Kg for a woman and 25Kg for a man. SNHC policy is to endeavour that the maximum weight that a woman has to carry regularly does not exceed 16Kg and 25Kg for a man.

When dealing with items heavier than this. Staff should

Ensure they have training in lifting techniques

Decant the contents in manageable portions

Use team lifts or mechanical aids


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Staff must not

Attempt to lift or push ‘heavy’ objects alone

Lift a heavy or awkward object

All persons involved with manual handling on a regular basis will be given suitable training and information. Training needs should be identified by the line manager; with suitable training courses arranged by the Training Officer.

4.2.15 Noise and vibration

If staff work in the Facilities Department, they may be exposed to noise and vibration from the power tools, woodworking machinery and mowers. The risk of work-related hearing damage from noise and Hand-Arm Vibration syndrome (HAVs) will be assessed by a competent person and appropriate controls implemented.

4.2.16 Occupational Health

The Personnel Department monitors sickness absence and may ask a member of staff to see an occupational health doctor or nurse either because of length of sickness period or type of sickness or before returning to work. Occupational health practitioners specifically look at how work affects health. (See 3.7)

4.2.17 Personal protective equipment (PPE)

Staff will be provided with the relevant Personal Protective Equipment (PPE) such as gloves, aprons, boots and goggles. If staff need PPE, it will be provided free of charge. If PPE is lost, damaged or wears out, it will be replaced.

Staff must wear or use any PPE given to them; staff must keep it clean and in good condition. Managers must ensure that their employees wear their PPE.

4.2.18 Pregnancy

Staff must inform their Manager or the Personnel Department as soon as they know that they are pregnant so that a pregnancy risk assessment can be carried out.

4.2.19 Pressure systems

The pressure systems and pressure vessels in all hospice buildings will be inspected and maintained by a competent person as per a Written Scheme of Examination. The Facilities Manager will ensure that these statutory inspections are carried out. Records will be kept in the Facilities office of the inspections and any maintenance work carried out.

4.2.20 Slips, trips and falls

The most common cause of injuries at work is a slip, trip or fall. Regular inspections of the wards, hallways and grounds are carried out by the Facilities Manager. Staff need to wear suitable footwear at work and look out for obstructions, litter, trailing cables, rucked rugs and any other trip hazards on paths, floors, stairways and corridors. If staff come across slippery floors, poorly lit stairwells or spillages in any areas within SNHC, make the area safe and inform the manager of the area.


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4.2.21 Smoking

Smoking in enclosed spaces is illegal. It is illegal to smoke in the warehouse, the shops, the vehicles or temporary buildings such as the marquee. There are designated smoking areas within the Hospice grounds for patients and families only. See Smoke Free Environment Policy

4.2.22 Stress

The Health and Safety Executive define work-related stress as the adverse reaction people have to excessive pressure or other types of demand placed on them. Working in an environment which provides care for seriously ill people – often nearing the end of their lives can, at times, be very demanding and stressful. If staff feel that the demands of their job are becoming excessive they should inform their manager or the HR Department . Support is available via their line manager or the personnel department by using staff support vouchers, Westfield Health or Occupational Health.

4.2.23 Visual display units (VDUs)

If staff routinely use a display screen for more than one hour per day they are deemed to be a ‘VDU user’.

VDU users are entitled to a desk that is suitable for the task(s) to be carried out. Generally there is a requirement for a VDU assessment to be carried out annually (this may be sooner if staff move desks or new equipment is provided). The Department Manager should ensure that a VDU assessment is carried out.

There are certain health issues associated with VDU work; VDU users will receive the information leaflet ‘Posture and VDUs’ and training in the best way to organise their desks and equipment to prevent work related upper limb disorders. Any health problems should be reported to a Manager immediately. Staff may be advised to see the occupational health team or their doctor.

VDU users are entitled to a free eyesight test every two years to determine whether spectacles are required for VDU use. Staff can contact the Personnel Department for further details. A contribution will only be made by SNHC if prescription lenses are needed solely for VDU use.

4.2.24 Violence

We accept that SNHC is responsible for preventing violence to employees and volunteers so far as reasonably practicable. Verbal abuse, threatening behaviour and physical contact are often fuelled by anxiety and feelings of frustration or helplessness and staff will receive training on dealing with such feelings. Staff must be responsible for identifying any unacceptable behaviours and informing management when such situations arise.

The Line Manager is responsible for assuring intervention to prevention of indentified, foreseeable violence. In order to help management prevent violent incidents, the Hospice relies on staff providing information. Staff must report any incidents of threats or physical violence, intimidation or undue pressure from patients, their visitors, consultants or other employees to their Manager.


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4.2.25 Waste

Bodily waste from the clinical areas is classified as hazardous waste; it is placed in yellow bags/bins and kept separately from the general waste. Waste is removed by registered waste carriers with the appropriate Waste Carriers Licence. Waste transfer notes (for non-hazardous waste) and Consignment Notes (for hazardous waste) are kept for 2 and 3 years respectively in the facilities department. Procedures for managing soiled linen and spillages of waste are available within the Infection Prevention Guidelines

The Chief Executive and the Facilities Manager are responsible for ensuring that the Waste Management Duty of Care Code of Practice is followed and that contractors are checked periodically.

The Hospice’s Accountable Officer is responsible for Controlled Drug destruction.

4.2.26 Work at height

Work at height has a broad definition and ‘at height’ includes any distance where staff can fall and incur an injury. Staff will have a variety of work equipment available including hop-ups, stepladders, ladders and work platforms. Staff will receive training to ensure that they select most suitable type of equipment for the activity. Stepladders/ladders should only be used for short duration, low risk tasks. Stepladders and ladders will be Class 1 or EN131 and visually checked before use; the Facilities Manager will formally inspect them every 6 months.

4.2.27 Work equipment

Suitable work equipment will be provided for staff to work safely. Work equipment covers any equipment used at work to do a job e.g. trolleys, medical equipment, hoists, food mixer, ladders, photocopiers, vacuum cleaners. Managers will ensure that all new equipment meets the minimum health and safety standards and bears a CE mark.

Equipment will be maintained and regularly inspected as required by a competent person; records will be kept in the Facilities office of the inspections and maintenance. Prior to use staff must visually check the equipment for any obvious faults or defects. Staff must report any faults to their Manager immediately; never use faulty equipment and never carry out repairs - unless they have been specifically trained to do so.

Staff should only use equipment that they have been trained how to use and for the purposes for which it was designed.

4.2.28 Workplace

SNHC will provide adequate ventilation, heating, lighting, toilet, washing and cloakroom facilities to ensure that buildings are comfortable and safe. Several areas have been designated ‘restricted access areas’ due to the nature of the hazards in those areas: the warehouse, maintenance workshop, kitchens, medications cupboard. Staff should not enter these areas without the permission of the relevant manager.


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Regular inspections will be carried out by the Facilities Manager to ensure that the buildings, offices, grounds and car parks are kept in good condition and free from risks to health and safety. The Retail Manager will inspect the shops and warehouse. Where repairs are needed, the Facilities Manager or the Retail Manager will issue works instructions to approved contractors.

4.2.29 Young persons

Any worker under the age of 18 will have a young person risk assessment. The line manager (prompted and assisted by the Personnel Department) will conduct the risk assessment and send a copy of the assessment to the parent or guardian of the young person.

4.3 Training and information

All new employees and volunteers will be given an induction to the operating procedures at SNHC by the Personnel Department. The Induction Checklist specifies the essential information to be given to all new employees on the first day of their employment.

Over the first month, the relevant manager and/or the Personnel Department will give the rest of the induction information which includes fire and first aid arrangements, manual handling, risk assessments, accident and fault reporting, lone working arrangements, security arrangements, chemical/COSHH assessments, asbestos register, violence, use of work equipment etc.

Managers, supervisors and staff with health and safety responsibilities will be given additional health and safety training on their specific responsibilities to enable them to implement the health and safety policy.

Refresher training will be given at appropriate intervals or when the job, work equipment or the law changes. Training is organised by the Head of Education and Personnel Department. Records of staff training will be kept in a staff member’s personnel file.

The Health and Safety Law Poster is displayed on staff notice boards in each place of work. It provides a summary of the key health and safety legal requirements. Further advice and information can be obtained from a manager, the Personnel Director, Facilities Manager or the Health and Safety Consultant.

4.4 Incident management

4.4.1 Incident reporting (see Appendix 2)

Employees and volunteers

All accidents at work must be escalated to a manager and recorded on an Incident Form as soon as possible after the event. The Incident Forms are held in a Red Folder in every department.

Some incidents may need to be reported to external bodies (see Appendix 2).


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First Aid

First aid boxes are kept throughout the organisation in all sites. The First Aiders are responsible for ensuring that there are adequate supplies in the first aid boxes within the Hospice and are checked twice a year. First Aiders are appointed by department managers

Patients, their visitors, consultants or contractors

Any accidents involving patients, visitors, the public, consultants or contractors must be escalated to a manager and recorded on an Incident Form. The Chief Executive needs to be informed immediately about serious accidents involving patients, visitors, the public, consultants or contractors.

4.4.2 Incident Investigations (see Appendix 3)

All reported incidents will be investigated to establish whether any action could be taken to prevent a recurrence.

4.4.3 Learning from incidents

All incidents and associated actions will be reviewed within departments and directorates (see section 6.)

5. Related Policies / Guidelines

Risk Management Policy Blood Products Policy Fire Policy Medicines Management Policy Smoke Free Environment Policy Complaints Policy Disciplinary Policy

6. Monitoring and Review

The Directors and CEO will use a variety of measures and indicators to monitor the effectiveness of this policy. These include:

All incidents and near misses will be signed as seen by the CEO or their deputy.

All incidents / near misses and their actions will be reviewed at monthly departmental management meetings

Department Directors will hold quarterly incident review meetings to ensure all actions required are taken and monitor the reviewing of risk assessment.

Trends from these meetings will be reported to quarterly management meetings and quarterly Staff Forum meetings

Review of all incident trends, actions and risks will be monitored quarterly by the Directorate

Numbers of incidents and trends will be reported to relevant Trustee Committee meetings and included in the quarterly report to the Board of Trustees

This policy will be reviewed annually and amended as necessary to ensure that it still reflects our activities, current legislation and healthcare best practice.


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7. Statutory Compliance and Evidence referenced

Health and Safety at Work Act Corporate Manslaughter and Corporate Homicide Act The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 2013.

8. Appendices

Appendix 1 Health and Safety Organisation Chart Appendix 2 Risk Likelihood and Consequence Severity Scores Appendix 3 Likelihood and Consequence Matrix Appendix 4 Incident reporting procedure (for actual incidents or near misses) Appendix 5 Incident investigation procedures Appendix 6 Investigating a Serious Untoward Incident procedure Appendix 7 Reportable Injuries or Events to the HSE under RIDDOR Appendix 8 Reporting of Incidents to the Charity Commission (CC) Appendix 9 Compliance with the NHS East of England Serious Incidents Requiring Investigation Policy

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