Around 1.1 million people in Great Britain suffered from MSDs caused or made worse by work, in 2001/02. An estimated 12.3 million working days were lost due to work related MSDs and on average each sufferer took 19.4 days off in 2001/02. These figures include upper limb disorders from which approximately 400,000 suffered, resulting in a loss of around four million working days in the same period. MSD web pages on the HSE site: .
The goals we had set out to achieve were:
- Minimal injuries associated with DSE
- Low absenteeism
- Prevention of litigation
- Maintain Trust Reputation
Glossary
A.S.T.R.E.A.M: Agreed, Specific, Time, Realistic and Relevant, Empower, Achievable and Measurable is an approach used to set goals and Objective within an organisation.
CHI: Commission for Health Improvement
Clinical Governance: is about the systems the organisation has for ensuring high quality care
DOH: Department of Health
DSE: Display Screen Equipment
HSE: Health and Safety Executive
L.O.O.P: Legal, Occupational, Organisational, and Personal
MHSW: Management of Health and Safety at Work Regulations
P.E.S.T.O: Political, Economical, Sociological, Technological, and other is a checklist for analysing the environment in which an organisation or its sub-unit operates.
Risk Assessment (RA): The collation of information from sources about risks and the monitoring of incidents and trends.
RSI: Repetitive Strain Injury
S.M.A.R.T: A smart approach to be Specific, Measurable, Achievable, Realistic and Relevant, Time bound.
S.W.O.T: Is an acronym used foe examining an organisation’s Strength, Weaknesses, Opportunities and Threats.
T.H.E.I.M.M: Time, Human, Equipment, Information, Money and Material is a process to evaluate continuous quality services: Musculoskeletal disorders such as backaches or Repetitive Strain Injury
Appendix 1
Stakeholders Matrix analysis, Powers of internal interests associated with effective Leadership/Management before and after my influences.
Table 1: Stake holder’s Power/Interest Matrix Before my influences
Table 2: Stakeholder’s Power/Interest Matrix after my Influence
Appendix 2
LOOP Factor:
Legislation Factors: include professional regulatory body such as the Nurse Midwifery council (NMC), Health and Safety at Work Act 1974 states that Employers have a duty of care to protect its employees from any risk within the workplace.
Organisational Factors: would include implicit commitments from senior management to support and embrace standards set by Clinical Governance with regards to risk management.
Occupational Factors: Include high workloads, lack of resources and interprofessional working together leading to stress, and staff being put at risk whilst working in a non-conducive environment.
Personal factors: include lack of experience, knowledge, ill health and lack of interest.
Appendix 3
Johnson’s (1988) Culture-web Approach
Rituals & Routines Stories & Myths
Symbols The Cultural Paradigm Power Structures
Control Systems Organisational Structures
Rituals and Routines: Staff who are resistant to change due to lack of knowledge, would continue to work in a way that may harm their health. Good ergonomic design of workplaces and behavioural practices can create a working environment, which will protect employees against many debilitating effects of computer related injury.
Organisational Structures: An annual risk assessment programme for all wards and departments would enable the Trust to be proactive in trying to identify and prevent potential incidents. A reporting system should be in place so that we can successfully react to things that occasionally go wrong and learn lessons from them, as staffs are aware of reporting protocols.
Organisational Culture: There needs to be an open culture where staffs feel confident in reporting incidents. This should be done on the basis that The Trust is eager to be informed about such incidents in order to deal and improve and not looking to apportion blame.
Appendix 4
The 7Es
Economic: The contribution that team working can make to the effective delivery of quality. Efficient use of resources and staff satisfaction and well-being can make a substantial contribution to improvements in quality of patient care. Additional resources such as time, money, experienced staff, training facilities, equipment can demonstrate the added value of result of financial support.
Efficiency: This will reflect in the changes taking place in the delivery of care as a result of change in working practices as a direct result of risk assessment and management. The quality of and benefits to stakeholders can be monitored in terms of their satisfaction with the service provided.
Empowerment: This will allow staff to become more informed regarding their working practices and aware of their health and safety.
Appendix 5
DISPLAY SCREEN EQUIPMENT POLICY
Version 1.0
Document control summary
1.0 POLICY STATEMENT
It is the policy of East London and the City Mental Health NHS Trust to comply with Health and Safety at Work Act 1974. The Trust will ensure so far as is reasonably practicable , the Health, Safety and Welfare at work of it’s employees and any others who maybe affected by its undertaking. Furthermore, The Trust will ensure compliance with the Display Screen Equipment Regulations 1992 by ensuring that all risks associated with Display Screen Equipment use are reduced to the minimum level possible. In addition to this The Trust will ensure that staff have access to eye care provision and any other equipment required to reduce the level of risk.
2.0 ORGANISATIONAL RESPONSIBILITIES
Responsibilities for Health and Safety and the implementation of the Display Screen Equipment Policy will be in line with those responsibilities laid out in the Trust’s Risk Management Policy. Those Key personnel are:
- The Associate Director of Estates & Facilities
- Directors
- Department Managers
- The Risk Manager.
The Risk Manager will be directly responsible for the implementation of the Display Screen Equipment Policy and supporting procedures.
3.0 THE AIM OF THE POLICY
3.1 To identify all Display Screen Equipment users in line with Display Screen Equipment 1992 - See Appendix 1.
3.2 That risks associated with Display Screen Equipment use will be reduced to the lowest practicable level.
3.3 All defined “users” will all undergo a display screen equipment risk assessment.
3.4 The Trust will ensure all Display Screen Equipment users receive sufficient information, instruction and training relating to associated risks. Through this individuals can adapt their own work activity / environment, to reduce these hazards to the lowest practicable level on a day to day basis.
3.5 The Trust will provide Display Screen Equipment “users” with vision screening, eye tests and glasses dependant on individual need. This will be provided at a no cost to the “user”.
4.0 DEFINITIONS
4.1 “The Trust” means East London and The City Mental Health NHS Trust.
4.2 “Display Screen Equipment” means any alphanumeric or graphic display screen, regardless of the display process involved.
4.3 “User” means an employee who habitually uses display screen equipment as a significant part of his normal work.
4.4 “Workstation” means an assembly comprising -
4.4.1 display screen equipment (whether provided with software determining the interface between the equipment and its operator or user, a keyboard or any other input device),
4.4.2 any optional accessories to the display screen equipment,
4.4.3 any disk drive, telephone, modem, printer, document holder, work chair, work desk, work surface or other item peripheral to the display screen equipment, and
4.4.4 the immediate work environment around the display screen equipment.
5.0 RISK ASSESSMENT
The Trust will ensure that a suitable and sufficient analysis of a “users” workstation is carried out.
5.1 Format of The Assessment
The risk assessment will identify any hazards associated with the workstation and the associated risks of them.
5.2 In ensuring this assessment is suitable and sufficient it will be:
5.2.1 Systematic - include investigation of non - obvious causes of problems such as, poor posture being response to screen reflections or glare not necessarily poor furniture.
5.2.2 Appropriate to the likely level of risk depending on duration, intensity or difficulty of work undertaken.
5.2.3 Comprehensive covering organisational, job, workplace and individual factors
5.2.4 Carried out with the involvement of both worker and employer.
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East London and the City Mental Health NHS Trust will use a standard checklist (appendix 2) to carry out assessments.
- The risk assessment will be carried out by a “competent person/s” who has received the necessary training and has sufficient skills and resources to carry out the assessment to a high standard.
5.3 Shared Workstations
Persons who share a workstation with one or more people should each receive their own individual assessment.
5.4 Review of Risk Assessment
Assessments will be reviewed on a yearly basis to ensure it remains valid. If , in that period, changes to the workstations, environment, task or individual occurs, a new assessment will be carried out to identify any new hazards which may arise. The assessment can also be reviewed if the “user” has individual cause for concern, for example physical symptoms of musculoskeletal ill health problems.
6.0 DAILY WORK ROUTINE OF USERS
6.1 The Trust will ensure, so far as it is reasonably practicable, that the work routine of “users” will be arranged, to allow for periodic breaks or changes in activity in order to reduce their workload at the Display Screen Equipment.
6.2 It is not appropriate to lay down precise criteria on the timing and duration of breaks, but general guidance will be included in Display Screen Equipment training (see Training Section 10.0..) Generally speaking it is best to allow “users” the discretion over when to take breaks and the following guidance should be followed.
6.2.1 breaks should be taken before the onset of fatigue, not in order to recuperate and when performance is at a maximum, before productivity reduces. The timing of the break is more important than its length;
6.2.2 breaks or changes of activity should be included in working time. They should reduce the workload at the screen, i.e. should not result in a higher pace or intensity of work on account of their introduction;
- short, frequent breaks are more satisfactory than occasional, longer breaks: e.g. a 5-10 minute break after 50-60 minutes continuous screen and/or keyboard work is likely to be better than a 15 minute break every 2 hours;
6.2.4 if possible, breaks should be taken away from the screen;
- Informal breaks, that is time spent not viewing the screen (e.g. on other tasks), appear from study evidence to be more effective in relieving visual fatigue than formal rest breaks;
6.2.6 wherever practicable, “users” should be allowed some discretion as to how they carry out tasks; individual control over the nature and place of work allows optimal distribution of effort over the working day.
7.0 EYES & EYESIGHT
7.1 Vision Screening
All Display Screen Equipment “users” will be offered a vision screening test. This test will, in the first instance identify individuals with defective vision who will need a full eye test. This test will be obtained through the appropriate locality Occupational health Department within which the member of staff falls. Where test results indicate that vision is defective at relevant distances the “user” should be informed, a written report completed and the “user” is entitled to a full sight test.
7.2 The vision screening test only tests vision at the distances appropriate to the user’s display screen work, including the intermediate distance at which screens are viewed ( normally 50 - 60 cm). A full eye test will test eyes at all ranges of vision as well as testing for eye defects, such as injury or disease, that may not at first affect vision.
8.0 REGULARITY OF EYE & EYESIGHT TESTS
The process of sight testing should be initiated:
8.1 as soon as practicable after DSE users request it.
8.2 for those who know they will become users, the test should ideally be carried out prior to becoming a user.
8.3 for established users, eye tests are available on a yearly basis, however any serious concerns within that period should be put forward to Occupational Health and/or Risk Management for individuals assessment.
- Exclusion of Liability
The Trust is not responsible for any corrections for vision defects or examinations for eye complaints which are not related to display screen work. These are the responsibility of the individual concerned.
9.0 PROVISION OF CORRECTIVE APPLIANCES
9.1 “Special” corrective appliances (normally spectacles) will be provided to correct vision defects at the viewing distance or distances used specifically for the display screen work concerned.
“Normal” corrective appliances are spectacles prescribed for any other purpose.
9.2 Liability of Cost
The provision of vision screening, eye and eye sight tests and special corrective appliances is at the cost of the Trust. However “users” are obliged to follow the Trust’s “Procedure for “The Provision of Eye Testing and Glasses For Display Screen Equipment Users.”
9.3 Any employee not following this procedure will not have the costs covered.
9.4 Costs covered are those for:
- a full sight test as defined in the Optician’s Act Legislation.
- the cost of a “basic” appliance.
9.5 If the “user” chooses to opt for a more costly appliance, the value of the “basic” appliance can be contributed to the total cost. The user must then make up the remaining cost.
10.0 PROVISION OF TRAINING
10.1 All identified “users” will receive appropriate Health and Safety training in addition to the training received in order to do the work itself. The purpose of this training is to increase the “users” competence to use workstation equipment safely and reduce the risk to their own or anyone else’s health.
10.2 Training will be adapted to the requirements of the particular Display Screen Equipment tasks, to users’ skills and capabilities and be refreshed or updated as the hardware, software, workstation, environment or job are modified.
Special training can be arranged for those absent for long periods, particularly if ill health problems are related to the visual, musculokeletal or stress related risks.
- The content of training should be aimed out at reducing or minimising the risks associated with
- Physical (musculoskeletal) problems.
- Visual fatigue
- Mental stress
10.4 Staff should attend Display Screen Equipment training on a yearly basis. Appendix 3 outlines the main inter related aspects of training that should be covered.
11.0 REVIEW
11.1 This policy will be reviewed annually, initiated by Risk Management. Changes will be consulted to all staff and the reviewed document presented to the Chief Executive for Board acceptance.
DSE “Users” can be classified using the following criteria:
A person can be classified as a DSE ‘user’ if most or all of the following criteria apply:
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The individual depends on the use of display screen equipment to do their job, an alternative means is not readily available for achieving the same results.
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the individual has no discretion as to use or not use the display screen equipment
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the individual needs significant training &/or particular skills in the use of DSE to do the job
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the individual normally uses DSE for continuous spells of an hour or more at a time
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the individual uses DSE in this way more or less daily
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fast transfer of information between user and screen is an important requirement of the job
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the performance requirements of the system demand high levels of attention and concentration by the user, for example, where the consequences of error may be critical.
Display Screen Equipment (DSE) Assessment
NB. “User” means an employee who habitually uses Display Screen Equipment as a significant part of their normal work. “operator” refers to a self-employed person. It is recognised that the use of the term “users” in the following text could be replaced by the word “operator”.
Equipment
Environment
Interface between Computer & User
Other Considerations
Summary of Action Required:
To have a risk officer to assess the workstations and the office as 15/12/03
Soon as possible to have a good ergonomic workplace design.
Training for users are using VDUS as no training given. 05/01/04
Work place exercise to be advised 15/12/02
Regular Breaks to be taken away from the Computer. Immediate effect
Good posture to be encouraged Immediate effect
Date for Reassessment: … 01/03/04
BASIC COMPONENTS THAT SHOULD BE COVERED IN TRAINING
- the desirability of comfortable posture and the importance of postural change;
- the use of adjustment mechanism on equipment, particularly furniture, so that stress and fatigue can be minimised;
- the use and arrangement of workstation component to facilitate good posture, prevent over-reaching and avoid glare and reflections on the screen;
- the need for regular cleaning (or inspection) of screens and other equipment for maintenance;
- the need to take advantage of breaks and changes of activity.
Appendix 6
East London and The City
Mental Health NHS Trust
RISK MANAGEMENT POLICY
Version 1.0
Important: a Clinical Risk Section is to be added to this document at a later date
RISK MANAGEMENT POLICY
Version 1.0
Document control summary
INDEX
1.0 BACKGROUND
- This statement is issued in accordance with the requirements of the Health & Safety At Work Act 1974, Management of Health & Safety at Work Regulations (1992) and the N.H.S. Controls Assurance Standards (1999) and describes how the East London and The City Mental Health N.H.S Trust discharges its duties under the Act. The Trust Board will monitor the effectiveness of this policy at regular intervals and will revise and amend it whenever appropriate.
- The Act places a duty on every employer to promote health, safety and supervision of staff. It also places a duty on every employee to take reasonable care of the health and safety of themselves and other persons who may be affected by their actions.
- The Trust Board has a duty to ensure that all persons using its premises are protected from all foreseeable hazards/risks in so far as they may be affected by the activities of the East London and The City Mental Health N.H.S. Trust.
- The Trust Board is committed to meeting the nineteen key controls Assurance Standards relating to risk management and organisational control. (See section 13) These standards reflect potential areas of risk and are based on existing statutory, mandatory and best or good practice requirements. The Trust takes a holistic approach to risk management incorporating both clinical and non-clinical risk.
- DISTRIBUTION OF POLICY
- The Risk Management Policy and strategy is available to all staff and to the public.
Staff have access to the policy through the following means;
- Each new staff member receives a copy of the policy when they sign on with payroll
- Each ward/department will have their own copy of the policy as part of the local Risk Management Handbook.
- Additional copies are available from the Risk Management Department.
- Electronic copies will be available on the ‘P’ section of the Trust’s network drive.
- Members of the public have access to the Risk Management Policy through;
- The Community Health Council/or equivalent regulatory body
- Reference is made to the policy within the Trust’s Annual Report.
- Requests to the Trust’s Consumer Relations Manager.
- POLICY STATEMENT
-
The Trust Board accepts its responsibilities imposed under the Act and the standards set by Controls Assurance. The Trust will ensure, so far as is reasonably practicable, the health, safety and welfare at work of its employees, and the health and safety of other persons using the health services premises within East London and The City Mental Health N.H.S. Trust.
- The Trust Board believes their obligations under the Act include the following;
- Ensuring the management at all levels fulfils its obligation for health and safety in the areas under their control.
- Providing Managers with support and resources where practicable to fulfil their respective duties.
- Establishing a safe and healthy workplace in accordance with relevant legislation, codes of practice, manufacturers’ instructions or any other approved standards or knowledge.
- Providing and maintaining safe plant and equipment for use at work.
- Establishing and maintaining procedures for safe systems of work and making available all necessary safety devices, including adequate and suitable protective clothing.
- Making arrangements to monitor the health of its employees through appropriate referral to occupational health.
- Providing suitable information and training to persons at all levels in the organisation, including youth training scheme trainees, and staff from agencies, contractors and other organisations.
- Providing for safe use, handling, storage and transport of equipment, substances and persons.
- Ensuring safe access to and egress from the workplace and formulating effective procedures and plans for the evacuating of building in the event of emergencies.
- ACCEPTABLE RISK
- The Trust is committed to reducing all risks, both clinical and non-clinical, but what is acceptable risk? The Health and Safety Executive (1988) has suggested the following definitions;
Acceptable Risk - “the risk although present, is generally regarded by those who are exposed to it as not worth worrying about.”
Tolerable risk - “a risk that society is prepared to live with in order to have certain benefits and in the confidence that risk is being properly controlled.”
Risk must be controlled. Managing risk can be seen as a logical progression through the following stages;
LOSS CONTROL → LOSS PREVENTION → SAFETY
There are three stages in the risk management process:
- Stage One - Risk Identification
This is achieved by undertaking a number of techniques:-
Hazard Spotting - A scheduled examination of the work area to ensure that acceptable health and safety standards are been maintained. A general “look round” with no fixed “check list.”
Local Inspections of the Workplace - an examination of each ward/department should be carried out by the nominated Risk Officer/s to ensure that general safety standards are observed and obvious hazards are removed; This should be carried out at least quarterly.
The use of a “check list” ensures coverage of the following components:-
- Maintenance standards.
- Working practices.
- Housekeeping standards.
- Employee involvement.
- Safe systems of work are undertaken.
Audits - This is a systematic and critical examination of the Trust. The audit process submits each ward/department to this critical examination, on a rolling programme covering approximately 20 wards/departments each year. The overall objective is to minimise injuries and losses. All components of the risk management system are examined to:-
- Minimise potential hazards and level of risk.
- To detect falling standards.
- To ensure all tasks are performed in a safe manner.
Components of the audit include those covered in a local workplace inspection, but also include a detailed look into policy, training, process operations, emergency procedure and records kept in relation to these topics.
- Stage Two - Risk Evaluation
The evaluation of risk is undertaken on economic, social or legal grounds and incorporates some form of assessment to quantify the level of risk the Trust, it’s staff and services users, are subjected to, in the performance of it’s role as a healthcare provider.
- Stage Three - Risk Control
Risk Control involves considering one or more of the following;
Risk avoidance - a conscious decision is made to discontinue a particular task or hazardous operation.
Risk retention with knowledge - involves a conscious decision being made to retain a certain level of risk. The residual risk being accepted following a detailed assessment of the prevailing circumstances and not by default or lack of consideration of the process.
Risk retention without knowledge - involves self assumption of risk via errors of commission or omission. Where no formal assessment is made.
Risk transfer - the risk (or the resultant; loss or potential loss) is transferred to the conventional use of insurance companies or in the Trust setting, the N.H.S. risk pooling scheme for Trusts.
Risk reduction - tactics by which the Trust can reduce risks. The introduction of control measures to reduce and ultimately minimise risk.
- The Trust accepts that in an ideal situation any level of risk is unacceptable. However, in a real healthcare work setting, this is not realistic.
It is necessary therefore, to set standards to establish level of tolerable risk by using the East London and The City Mental health NHS Trust Risk Assessment Tool. This enables the Trust to evaluate residual risk levels, which can then be prioritised and properly controlled.
This is achieved by using the Trust’s Hazard Rating Number (HRN) system following a general risk assessment using the Trusts pro-forma contained in Appendix1.
In addition to this general risk assessment there are more detailed risk assessment procedures to be undertaken for use of display screen equipment, manual handling tasks and use of hazardous substances (C.O.S.H.H.)
- RISK MANAGEMENT PLAN
5.1 The risk management plan details the work programme for the Trust in relation to the management of risk. The plan is based upon the risk register and action plans generated from the initial self assessment undertaken in compliance with NHS Controls Assurance standards, in conjunction with the risk assessment process using the standardised Trust general and task specific risk assessment forms.
- The risk management plan is formally approved by the board and reviewed on an annual basis.
- The board approved risk management plan will clearly demonstrate how resources for risk management are identified and then prioritised.
- The plan will be prioritised by the use of a documented and approved method using the Controls Assurance guidelines on severity of consequences, likelihood of outcome and level of importance allocated to any particular standard or sub-standard thereof.
- Where the plan is prioritised by Board level debate, the reasons supporting such priorities will be fully documented.
- LOCAL RISK MANAGEMENT PLANS
- Each directorate/department will devise their own local risk management plan(s), which reflect the improvements that need to be made locally to treat and control risk.
- These improvements will be highlighted through the hazard identification process (inspections, audits, hazard spotting and risk assessment.)
- Local risk management plans may be developed in conjunction with one or a number of local risk management groups as well as the Trusts Risk Management Committee.
- Risk Management plans will be communicated to the Risk Management Committee and the local Controls Assurance Steering Groups.
- These groups will closely work together and take responsibility for prioritising the entire risk profile across the Trust and for ensuring that resources are made available to directorates/departments who are unable to meet priority risk treatment within their available resources.
- MANAGEMENT RESPONSIBILITIES
7.1 The Chief Executive is responsible for implementing this policy and to monitor it’s effectiveness. In practical terms, this means that the Chief Executive will;
- Ensure that management fulfils its responsibilities for health & safety.
- Ensure compliance and implement the Controls Assurance Standards laid out in Health Service Circular 1999/123.
- Consider the reports and recommendations submitted to him/her and act appropriately.
- Refer intractable health and safety problems to the Board for resolution.
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The Chief Executive has overall responsibility for risk management and to ensure that the Trust complies with all Controls Assurance standards.
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The Chief Executive is accountable to the Board for the implementation of the Risk Management Policy and he/she will make the necessary arrangements to carry out the recommendations that are endorsed by the East London and the City Mental Health N.H.S. Trust Board.
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On behalf of the Chief Executive, the Director of Finance monitors and co-ordinates the implementation of the Health and Safety at Work Act 1974 and other related legal requirements and advises on action required.
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The Director of Finance is responsible for the following areas of activity on behalf of the Chief Executive:
- Provide guidance in relation to the implementation of the safety policy, procedures and legislation.
- Propose plans for adequate staffing, finances and other resources to ensure the safety of employees and others who may be involved.
- Co-ordinating and monitoring the arrangements for managing risk throughout the East London and The City Mental Health NHS Trust.
- Developing, publishing and updating as necessary Trust policies on all risk-related matters.
- Ensuring that the responsibilities for provision of adequate arrangements for risk related matters are assigned, accepted and implemented at all staffing levels.
- Acting as the day-to-day link between Directors/General Managers and the Chief Executive.
- Developing risk-related improvements programmes.
- Ensuring that adequate arrangements for staff training needs are identified and that appropriate risk-related training is given all levels.
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Directors are responsible for organising and arranging health and safety matters within their General Management Units. Intractable problems are referred to the Chief Executive. Directors are responsible for ensuring the following activities are carried out;
- That their units are represented at the Trust and Local Risk Management Committees and ensuring that decisions arising from such meetings which affect their unit are fully implemented.
- The conducting of regular risk audits for those areas under their control.
- Ensuring that Ward/Departmental Managers carry out departmental risk assessments/inspections at approximately 3-6 months intervals; that reports and recommendations are made and reviewed on a regular basis.
- Requiring line management to fulfil its responsibilities for health and safety, fire and C.O.S.H.H in particular, auditing, provision and revision of policies and procedures and completion of comprehensive risk assessments.
- Responding to requests from line managers to take appropriate remedial action to minimise risk following inspections/audits or assessments.
- Developing short, medium and long term strategies for minimising risk based on the findings of the above, and on advice from the Risk Management Department and other specialist advisors.
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Ensuring ALL members of their staff attend at least one training session per year on all risk-related matters, as provided by the Risk Management Department and other specialist advisors.
- Compliance with the Trust’s Incident Reporting procedure and evaluation of information provided by the Risk Management Department and other specialist advisors.
- Bring to the attention of other Managers within the Trust any problems that may affect the safe operation of their Department.
- Preparation and revision of any supplementary details relating to Hospital/Department etc. in conjunction with appropriate Advisors.
- Dissemination of Hazard Notices and Safety Action Bulletins to appropriate Ward/Departmental Managers for action and monitoring response.
- The appointment of a Risk Facilitator within their directorate together with sufficient number of Risk Officers at Ward/Departmental level to enable the Trust’s Risk Management Strategy to be properly implemented.
- ROLE OF RISK FACILITATOR
- to co-ordinate on behalf of the Chief Executive/Executive Director the activities of the Risk Officer at Ward/Departmental level.
- to act as their representative for all matters relating to managing risk encompassing environmental, fire health and safety and security issues.
- to act as Chairperson of the local risk management groups made up of Risk Officers from Wards/Departments, within the Directorate.
- to facilitate the supply of information from senior management to Ward/Departmental level (e.g. dissemination and co-ordination of Hazard Notices and Safety Action Bulletins.)
- to prepare and supply information from junior staff to Senior Managers as appropriate (e.g. defects/incident reports, referral of formal assessments etc.)
- to ensure that Risk Officers have adequate support, resources, information, knowledge, skills, training and supervision for them to fulfil their role as the “COMPETENT PERSON” for the Ward/Department they represent.
- ROLE OF RISK OFFICER
- to ensure the link person at Ward/Departmental level for all matters relating to risk management issues, i.e. environmental, fire, health and safety and security matters.
- to undertake the duties of:-
- Line Manager - Fire
- Ward/Departmental Safety Officer
- Security Co-ordinator on behalf of the ward/Departmental Manager.
- to undertake awareness training of staff within the Ward/Department for all new employees upon induction, on risk related issues.
NOTE - This can only be undertaken in conjunction with and following training from the appropriate fire/health and safety/security specialist employed by the Trust.
- to act upon all risk related information/directives received within their Ward/Department via the Risk Facilitator.
- to confirm action taken in accordance with previous item and reporting of all defects in equipment via the Trusts incident procedure to ensure that all appropriate personnel are kept informed of potential hazards.
- to ensure that the Trust’s incident reporting procedure is properly implemented throughout the Ward/Department at all times.
- to initiate and carry out (with others), local inspections of the workplace and provide written reports/recommendations to manage/risk facilitators.
- to complete initial and more detailed risk assessments, (in accordance with Trust policy), as appropriate for all task carried out within their Ward/Department.
- WARD/DEPARTMENTAL MANAGERS
- Are responsible for the health and safety of the staff they supervise and the workplaces they control. Ward/Departmental Managers maintain close liaison with their staff in all risk-related matters, and are responsible in particular for the following.
- Preparing departmental safety policies and procedures (Local Rules) in accordance with relevant legislation, Codes of Practice, manufacturers’ instructions or any other approved standard or knowledge.
- Identifying potential hazards in their own area and ensuring they are remedied. Intractable problems will be drawn to the attention of their Manager.
- Receiving representations from staff on local health and safety matters.
- Maintaining liaison with specialist staff work relates to health and safety.
- Organising and carrying out departmental risk/safety inspections on a regular basis. (approximately 3-6 months interval.)
- Advising their Manager on matters arising from incident reports, hazard notifications, first aid and changes in departmental policies and procedures.
- Ensuring all staff under their control receive appropriate risk -related training.
- THE RISK MANAGEMENT DEPARTMENT
- Headed by the Risk Manager, (and in close liaison with Occupational Health Department) provides advice on technical and professional matters concerned with the Health and Safety legislation as well as co-ordinating activities covering environmental health, fire, health and safety and security. The team is accountable to the Director of Finance and is available to all levels of management and to staff.
- The Risk Management team provides advice, information and guidance to both management and employees on all matters relating to the above subjects.
- A brief summary of these functions is as follows:
- To provide a comprehensive training programme for all grades of staff from Induction Training through to special courses for staff at senior management level;
- To serve on all appropriate Trust and Local Committees and to participate in and prepare detailed audits of all aspects of Risk Management throughout all Departments in the Trust through a continuous programme of inspection;
- Other day to day matters including the notification and follow up of unusual occurrences, to recommend preventive action and to provide recommendations as a result of surveys of particular problems arising and liaising with members of the Clinical Governance Support Team in improving safety standards and systems of work.
- To assist in the supervision and carrying out of special projects, e.g. asbestos removal work, security surveillance, provision of security at special meetings.
- The Risk Management team has specific responsibility for notifying accidents and dangerous occurrences to the Health and Safety Executive under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1985.
- CLINICAL RISK MANAGEMENT AND CONSUMER CARE
The Clinical Governance Manager and Consumer relations and Legal Affairs Manager will work closely with the Risk Management department to provide a comprehensive integrated service, ensuring that all matters relating to both clinical and general risk are efficiently and effectively monitored and implemented.
- CONTROLS ASSURANCE
- BACKGROUND
Controls Assurance is defined by the N.H.S. Executive as:
“ .......a process designed to provide evidence that the N.H.S. bodies are doing their reasonable best to manage themselves so as to meet their objectives and protect patients, staff, the public and other stakeholders against risk of all kinds.”
- 19 key Control Assurance standards relating to risk management and organisational control have been developed. These are:
- Risk Management systems.
- Building, land, plant and non medical equipment.
- Catering and food hygiene.
- Contracts and contractor control.
- Emergency management.
- Fire Safety
- Health and Safety Management
- Human Resources
- Infection Control.
- Information management and technology.
- Medical devices management
- Medicines management
- Professional and product liability.
- Records management.
- Security.
- Transport.
- Waste Management.
- Decontamination.
The standards reflect potential areas of risk and are based on existing statutory, mandatory and best or good practice requirements.
- RISK MANAGEMENT COMMITTEE
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The Risk Management Committee evaluates and reports on all aspects of clinical and non-clinical (including business and financial ) risk on behalf of the Trust’s Main Board.
14.2 Membership of the Risk Management Committee
Director of Finance (CHAIR)
Director of Service – Newham
Director of Service – City and Hackney
Director of Service– Tower Hamlets
Medical Director
Director of Nursing
Director of Human Resources and Corporate Development
Director of Information
Risk Manager
Associate Director of Estates and Facilities
Clinical Governance Manager
Consumer Care and Legal Affairs manager
14.3 Terms of reference of the Risk Management Committee
- To ensure Trust compliance with and implementation of Controls Assurance Standards as laid out in Health Service Circular 1999/123.
- Define a process, timetable and responsibilities for completing baseline self-assessments of compliance with Controls Assurance Standards through the monitoring of the Controls Assurance sub groups.
- Ensure that relevant and prioritised action plans are in place to address any risks and weaknesses identified in the baseline self-assessment.
- Consolidate the work of the Controls Assurance sub groups by monitoring progress of action plans and report on achievement in meeting objectives.
- Advise the Trust Board on future changes in national requirements such as the issuing of further standards and the amendment of existing standards.
- To implement the requirements of The Risk Management System (Core Standard) by ensuring that an adequate risk management system operates within the Trust and conforms with the generic principles contained in AS/NZS 4360:1999
- To ensure that appropriate policies and procedures are in place to effectively manage risks and address risk issues. To act as the co-ordinating body for consultation on risk related policies.
- To receive information on incidents and their analysis on a Trust wide basis and assess trends and developments and make recommendations on appropriate improvements.
- Provide quarterly reports to the board on progress made with the risk management plan and on incident occurrence.
- To meet at least quarterly
- To review membership of the group as required
- REPORTING ARRANGEMENTS
15.1 The Steering Group will report progress to main Trust Board at least twice a year and shall receive reports from relevant directors or sub-committee chairs as required by the agreed work programme.
- The attached management structure sets out reporting arrangements in more details and assigns the topics to be covered by the new Controls Assurance Standards to relevant Directors.
- It will be the responsibility of these directors to:-
- Undertake the baseline assessments.
- Devise and implement appropriate action plans.
- Report progress to the Steering Group.
- THE HEALTH AND SAFETY COMMITTEE
16.1 The Trust Board wishes to achieve by joint consultation, the effective co-operation and involvement of all employees in health and safety matters. A Risk Management Committee has been established by the Trust.
16.2 This will operate in accordance with Safety representatives and Safety Committee Regulations 1978.
- This Committee is concerned with the promotion of co-operation between management and staff in instigating, developing and carrying out measures to ensure the health and safety at work of the staff, and act as a focus for staff participation in the prevention of accidents and avoidance of industrial disease.
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This Committee provides a wide perspective on risk and health and safety matters, and advises the Chief Executive on priorities for planning, training and management intervention. The Committee will also provide quarterly reports to the Chief Executive.
17.0 EMPLOYEE INVOLVEMENT IN HEALTH AND SAFETY
17.1 Every employee has a legal duty to take reasonable care of the health and safety of themselves and other persons who may be affected by their actions.
- East London and The City Mental Health N.H.S. Trust intends that all employees should understand their duty of care for health and safety, and provides this statement as information on which that understanding be based. Special training in safety matters is made available for employees whose work requires more detailed knowledge of health and safety.
- Any trade union recognised by the Trust for the purpose of collective bargaining had the right under the Act to appoint Safety Representatives from amongst its members. Employees appointed as Safety Representatives should preferably have been employed for a least two years, or have had two years experience in similar employment. Safety Representatives are involved in the following activities:
- representing staff in consultation with Management under Section 2(6) of the Act;
- representing their members of any general or specific matter affecting their health and safety;
- representing those people employed at their place of work on general matters affecting their health and safety;
- carrying out safety inspections;
- receiving information from Health and Safety Inspectors (Section 28(8) of the Act);
- attending meetings of Safety Committee as appropriate.
NOTE: Shop Stewards and Safety Representative can sometimes fill a dual role with responsibilities for general Union activity in addition to Health and Safety;
- These functions do not impose a duty on Safety Representative but indicate the range of activities concerned. The Trust recognises that Safety Representatives require to have time off from their normal employment to carry out safety duties and will reach agreement with trade unions on this allowance through joint consultation. The Trust also recognises that Safety Representatives require training to make their contribution effective.
18.0 RESOURCES FOR HEALTH AND SAFETY
Not all-working environments with the premises managed by the East London and the City Mental Health NHS Trust are ideal. The Trust is faced with substantial demands on its capital and maintenance programmes to effect improvement to meet current legal requirements. Progress will therefore be slow but the Trust Board anticipates that where additional monies cannot be found for capital replacement or maintenance works, a safe system of work will be developed by management with staff involvement, which minimises risks to those concerned.
The East London and The City Mental Health NHS Trust remains committed to improving the conditions within its premises in accordance with advice from the Health and Safety Executive. The Trust has, therefore, given priority to programmes of work necessary to effect improvements in health and safety and to minimise risk. Prioritisation is aided by the risk assessment process and initiatives undertaken a part of Controls Assurance.
- REVIEW
This policy will be subject to reviewed on an annual basis and any changes consulted on through the agreed route of policy ratification.
Appendix
East London and The City Mental Health Trust
“Basic” Risk Assessment Tool
This is not a comprehensive severity list but an indicator of the types and scale of harm that may result from hazards facing the Trust.
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