Health & Safety Management Manual
Health & Safety Management Manual
Health & Safety Management Manual
SAFETY
MANAGEMENT
MANUAL
1.4.1 Health
1.4.2 Safety
1.4.3 Welfare
Good Health & Safety performance is not only a legal requirement; it is an essential
element in both the overall performance and accountability of the organisation and
also a contributory factor in our goal of being an exemplar employer.
Therefore, good health and safety performance also makes sound business sense.
In addition to protecting our employees and others from the suffering caused by
accidents and ill health, it also helps maintain our reputation, retain staff, improve
efficiency and avoid/reduce the costs of accidents and ill health.
This Health & Safety Manual is designed as a tool to assist managers in controlling
health & safety risks within their department/area of responsibility and is based on
the 5 key elements of managing health & safety as published in Health & Safety
Executive guidance. These key elements are;
The basis for health & safety law in Great Britain is the Health & Safety at Work etc
Act 1974 (HSWA) which sets out, amongst other provisions, general duties for both
employers and employees.
These are summarised below;
Employers must
Provide and maintain safe systems of work (e.g. procedures & equipment)
Ensure safe handling, storage, transport and use of substances
Provide information, instruction, training and supervision to ensure the health
and safety at work of all employees
Provide and maintain a safe working environment
Employees must
Take care of their own health and safety and the health and safety of others
who may be affected by their acts or omissions
Co-operate with their employer in health and safety matters
Not misuse or interfere with anything provided for health and safety purposes
These duties are qualified by the term ‘so far as is reasonably practicable’.
'Reasonably practicable' means the measures taken to avoid or control risks should
be in proportion to that risk i.e. balancing the cost of steps taken to reduce a risk
against the degree of risk presented.
Cost should include the time, trouble and effort required, not just the financial cost.
Since the introduction of HSWA, numerous sets of regulations have been introduced,
many aimed at hazards that can be encountered within the NHS, e.g. hazardous
substances, work equipment, manual handling, working with computers. Many of
these regulations outline absolute duties and do not allow for ‘reasonably
practicable’.
The term workplace applies to common areas of shared buildings and includes
private roads, paths and other outdoor areas under NHSGGC control.
What you are required to do with regards to the Workplace Regulations will be
explained further in Section 1.4 - Workplace.
The key elements of successful health and safety management are set out in this
summary. The five elements form the basis for this manual.
Policy
Effective health and safety policies set a clear direction for the organisation to follow.
They contribute to all aspects of health care as part of a commitment to continuous
improvement. They also recognise that there are cost effective approaches to
preserving and developing physical resources and staff, which reduce financial loss
and liabilities.
Organising
An effective management structure and arrangements are in place for the delivery of
the policy.
Managers must motivate staff to work safely and to protect their long-term health, not
just simply to avoid incidents. This will also include the safety of patients and others.
The manager should use this manual in partnership, working locally with staff, their
Representatives and specialist Advisors to improve Health and Safety within their
area of control.
A positive health & safety culture is fostered by the visible and active
leadership of managers at all levels within the organisation.
Planning
There is a planned and systematic approach to implementing policies through an
effective Health and Safety Management System aimed at minimising risks for all.
Managers should ensure that they, or a competent deputy, receive training in the
methodology of risk assessment. Risk assessments are used to decide on priorities
and set objectives for eliminating hazards and reducing risks (see Section 1.3.1). All
significant risks should be included in the local risk register (see Section 1.3.2).
Measuring performance
Performance is measured against agreed standards to establish when and where
improvement is needed.
Managers should actively monitor their own performance, which includes reviewing
documentation, carrying out workplace inspections, completion of workplace hazard
checklists, risk assessments and setting clear objectives based on their outcome.
The aim is to look at both hardware (premises, equipment and substances) and
software (people, procedures and systems) including individual behaviour and
performance.
The aim of the audit is to identify areas for improvement as well as where you are
compliant, it should not be viewed simply as a point scoring or tick box exercise.
You and your staff should regularly review what has happened based on the active
monitoring of the department/ward and any independent audit by others e.g. Health &
Safety Committees, specialist Advisors.
Both active and reactive monitoring should feed into management meetings and local
H&S committees.
Management Manual Audit Form has been designed as a tool that the Health &
Safety Department will use to audit the performance of departments/wards.
The Chief Executive has overall accountability for Health & Safety matters. Some of
these responsibilities have been delegated e.g. the Director of Human Resources is
responsible for ensuring that the H&S policy is implemented across the organisation.
Directors of CH(C)P/Mental Health Partnerships and Chief Operating Officer in Acute
are responsible for ensuring that H&S policies and plans are implemented throughout
their areas.
These responsibilities continue through the line management structure i.e. managers
are responsible for ensuring that health & safety risk is managed within their area(s)
of responsibility.
Management Accountability
Chief Executive
A positive health and safety culture is fostered by the visible and active
leadership of managers.
As stated within 1.1 Legal Framework, the Management Regulations require co-
operation and co-ordination of health and safety arrangements between NHSGGC
and the contractors and other agencies that we work in partnership with e.g. Local
Authorities, Dentists & General Practitioners.
This does not remove the responsibility of a manager to manage health &
safety within their department.
Health & Safety Management Structure and Contacts Form should be completed
detailing the management structure and health & safety contacts for the
Directorate/Partnership that your Department sits within.
Corporate Accountability
NHSGGC Board
Governance and Strategy Responsibility
Chief Executive
Risk Committee
Staff
Governance Clinical
Non-Clinical Clinical Governance
Committee
Committee
Director of Medical
HR Director
Clinical Governance
Divisional Arrangements
Trade Union
Representatives
Key Result Areas
In many cases professional training and experience will indicate a level of competence
however individual capabilities of staff should also be taken into account when
communicating new procedures or health & safety instructions.
Health & Safety Training Needs Form should be used as a guide for training, both generic
and individual, that is required within your department. For example manual handling,
violence & aggression, fire or spill procedures training may be required for the vast majority
or all staff within a department whereas risk assessment, display screen equipment, first aid,
high voltage electrical work or lone working procedures may only be required by some staff.
If a record of training is already recorded elsewhere in your dept (individual training records),
this can be cross referenced on the form to save duplication.
NHSGGC promotes the reporting of incidents and near misses. This allows the
organisation to learn from previous incidents, prevent re-occurrence and improve
current systems.
Reporting an Incident
All incidents and near misses involving patients, staff, contractors or members of the
public should be reported and where necessary investigated. Once an incident or
near miss occurs it should be verbally reported to the appropriate line manager and
the incident form should be completed by the member of staff who is first to know
about the incident.
It is vital that near misses are reported so that preventative action can be taken
in order to prevent more significant incidents occurring.
Once an on-line incident form (DIF1) has been completed Managers can then log
onto DatixWeb and review and approve this incident. It is the managers
responsibility to review the information on the form and enter additional information
including the severity of the incident, whether the incident should be reported to
RIDDOR and what type of investigation, if any, is being carried out. Managers must
remember that they are still required to report any incidents marked as a RIDDOR to
their respective Health & Safety Practitioner. Incidents will go through a number of
stages within DatixWeb as detailed in the Incident Lifecycle.
Role responsible
New incident for action
awaiting input
to system
Reporter
Incident has
Final Approval
Status
(appears in
reports)
An injury which results in an employee being absent from work, or unable to do their
normal duties for more than 7 days. This includes rest days & other non-working
days.
Dangerous occurrences are specified events which may not result in a reportable
injury, but have the potential to do significant harm.
If you are unsure if an incident is RIDDOR reportable contact the Health &
Safety department for advice.
Health Surveillance
One of the most important features of good health and safety management is the additional
precautions taken for staff who are particularly at risk. This may be because they are
exposed to agents with particular hazardous properties (substances causing asthma, for
example) or it may be that the risk to certain individuals is heightened because of personal
factors such as inexperience or injury.
Several sets of regulations require a consideration of the need for health surveillance. For
example, the COSHH Regulations require regular health surveillance if exposures to a
hazardous substance create a reasonable likelihood of measurable health effects and the
surveillance results might be of value in protecting a person‘s health.
Formal health surveillance, such as the checks given to users of sensitising agents (which
may cause asthma or allergic dermatitis) or for staff regularly working within areas deemed
high risk for exposure to tuberculosis as an example are carried out by Occupational Health
A simpler but equally important form of health surveillance is the awareness that should be
encouraged in all staff of their own state of health. This form of health surveillance is most
effective against two of the most common causes of occupational ill-health: skin problems
and musculo-skeletal injury, where early action is important if serious problems and
prolonged sickness absence are to be avoided. In both cases, it is the individual who will first
be aware of the symptoms and seek help. Staff must be made aware, and reminded of this
vital ‘self-health surveillance.
If other aspects of the department’s activities suggest a possible need for health
surveillance, this should be discussed with the Occupational Health Service.
Staff undertaking ‘exposure prone procedures’. (These are procedures where is a risk that
injury to the worker may result in the exposure of the patient’s open tissues to the blood of
the worker. These include procedures where the worker’s gloved hands may be in contact
with sharp instruments, needle tips or sharp tissues (e.g. spicules of bone or teeth) inside a
patient’s open body cavity, wound or confined anatomical space where the hands or
fingertips may not be completely visible at all times).
For all such staff, it must be confirmed that they cannot be a source of Hepatitis B, Hepatitis
C and HIV infection to patients. Confirmation is obtained by blood tests. Other staff may be
at risk of infection themselves but not be in a position to infect patients.
Health Checks
Glove use and frequent hand washing, together with allergy to glove constituents
(e.g. latex), have the capacity to cause health problems, posing risk to the health of
patients and staff.
Staff experiencing persistent skin problems or symptoms they attribute to glove use
must report these to line management. Line management will refer such staff for
Occupational Health assessment.
Health & Safety Risk Management is the systematic identification, assessment and
reduction of risks to staff, patients and others who may be affected by our work
activities. It is important to recognise and understand that risk cannot always be
removed completely from the workplace.
This is especially prevalent within the health service where many activities involve a
degree of risk. However, these risks have to be managed and controlled.
Therefore good Health & Safety Risk Management should, wherever possible,
enable tasks to be undertaken safely, controlling risks within tolerable or acceptable
levels, rather than prohibiting activities.
There are also legal duties requiring NHSGGC to assess and manage the health &
safety risks arising from its activities. These risk assessments must be both suitable
and sufficient. The law does not expect NHSGGC to eliminate all risk, but we are
required to protect people as far as ‘reasonably practicable’.
What is Risk?
In a health & safety context Risk is the chance of a hazard causing harm, together
with an indication of how serious the harm could be.
NHSGGC uses a simple colour coded risk matrix to calculate the level of risk and to assist in
clarifying the need for remedial action and the urgency of such measures.
Risk Matrix
Likelihood Impact/Consequences
Summary of Hazards & Risks Form can be used initially as a checklist of hazards.
Once completed it becomes a working document for the Health & Safety risks within
a department.
Risk Assessment Form should be used for general risk assessments. Some risks are
best assessed using forms and guidance specific to the hazards that they present,
for example, hazardous substances, violence/aggression, manual handling or display
screen equipment.
Designated guidance and risk assessment forms for assessing these risks are
available within Section 3 - Supplementary Guidance.
Where similar tasks or activities are undertaken across a service, there is scope for
working with colleagues to produce generic risk assessments to share the burden
and avoid duplication of workload. However, these assessments must be reviewed
and adapted to take account of local circumstances e.g. environmental issues, layout
or design of workplace.
The level of detail recorded in the assessment should relate to the level of risk.
What is a Hazard?
A Hazard is simply anything with the potential to cause harm.
For example, hazards could be work materials, equipment, work methods or practices.
Although many hazards are self-evident to those involved in the work; others may only
become apparent through careful investigation.
Other factors (e.g. lone-working, pregnancy, lack of experience, existing injury) are not
hazards. They may, however, be important factors affecting the level of risk from particular
hazards (e.g. violence & aggression, falls from heights, or exposure to certain substances).
Wherever possible, give priority to those controls that best protect everyone exposed
to the risk.
New Precautions - If, after evaluating the risk, the current control measures are not
adequate then new precautions need to be considered. Use the ‘Action Plan’ part of the
assessment form to make sure you do all you can to get these actions implemented.
An action plan should be developed with estimated timescales set as to when any remedial
actions should be completed. The more serious issues should be given priority. As each
action is completed it should be dated and noted on the action plan.
A risk register is a simple and effective way of documenting and managing the risks
that require further action.
It is recognised that having assessed the risks within your department, not all of them
may currently have enough controls in place to keep the risk within acceptable levels.
Additionally, you may not have the access to the resources required to achieve this.
Therefore a risk register should be a proactive tool for managing health & safety risk
which will not only ensure that risks are visible and managed; it will also enable
resources to be prioritised both locally and within the wider management structure of
the organisation.
Your risk register should be completed and managed locally. Outstanding risks
should be taken to the next level of management for consideration and inclusion
within the relevant Service / Directorate / Partnership / Division Risk Register, in
accordance with NHSGGC Health & Safety and Risk Management policies.
The term ‘workplace’ applies to any part of non domestic premises that are made
available as a place of work. This includes corridors, stairways, roads and common
areas of shared premises.
Quarterly Workplace Inspection Checklist has been developed to assist with the
programme of inspection. Any issues should be recorded together with action taken
or required.
Temperature
A reasonable working temperature requires to be maintained. The minimum
acceptable temperature is 16°C (13°C where work involves severe physical effort).
There is no stated maximum temperature, however suitable steps should be taken to
remove or reduce exposure to environments which are excessively hot. The normal
comfort range for sedentary work e.g. office work is 19°C – 22°C.
Consideration should also be given to other factors e.g. humidity, ventilation, work
involving hot or cold processes, clothing, physical demands.
NHSGGC Temperature Guidelines provide further information on managing
workplace temperature.
Lighting
Should be suitable and sufficient to enable people to work, use facilities and move
around safely. Lighting and light fittings should not create additional hazards.
Technical guidance is available for specific areas of hospitals and workplaces. If you
have concerns regarding lighting levels guidance should be sought from Estates or
Health & Safety departments.
Suitable cleaning arrangements are required to be made for the workplace, including
provision for spillages and soiling. These arrangements should be specified in a
Service Level Agreement that does not create additional risks and is appropriate to
the activities each workplace.
This room dimension calculation does not apply to rooms used for lectures, meetings
and similar purposes.
The workstation including seating should be suitable for any special needs of the
individual worker, including workers with disabilities.
Seating should be suitable for its purpose and where appropriate a footrest should be
provided for anyone who cannot comfortably place their feet flat on the floor.
Maintenance
Maintenance of workplace, equipment, devices and systems
Should be free of any holes, uneven or slippery surfaces which could cause a
person to slip, trip or fall or cause instability/loss of control to any vehicle or its
load.
Immediate arrangements should be made for the repair of holes and other
hazards. Such temporary measures as are necessary require to be taken until
suitable repairs have been effected e.g. barriers, conspicuous marking etc.
Where floors are likely to become wet or subject to spillages then suitable slip
resistant flooring should be provided.
“Traffic route” refers to routes used by pedestrians and/or vehicles and includes
stairs, fixed ladders, doorways, loading bays and ramps.
Additional guidance will be issued to Facilities & Estates with regards to the hospital
grounds and other communal areas.
Access to roofs, attics, ceiling voids or ducts should be secured and restricted to
authorised personnel only.
1.4.3 Welfare
Washing facilities must have hot and cold running water, soap and clean towels or
other means of cleaning and drying. Where work processes require them, showers
should also be provided.
The following tables show the minimum number of toilets and wash stations that
should be provided.
Mixed use
Male only
(or female only)
No. of No. of
No. of No. of No. of No. of
people people
toilets washbasins toilets urinals
at work at work
1-5 1 1 1 - 15 1 1
6 - 25 2 2 16 - 30 2 1
26 - 50 3 3 31 - 45 2 2
51 - 75 4 4 46 - 60 3 2
76 - 100 5 5 61 - 75 3 3
76 - 90 4 3
91 - 100 4 4
Where facilities provided for workers are also used by members of the public then the
number of sanitary conveniences and wash stations should be increased as
necessary to ensure that workers can use the facilities without undue delay.
Facilities provided for the public will require to be inspected on a regular basis each
day to ensure that they are in reasonable condition and fit for use. Prompt action will
be required for inadequate supplies, spills, flooding, faulty lighting or ventilation,
vandalism or any foreign objects, i.e. needles/ syringes.
Drinking water
An adequate, easily accessible supply of drinking water is required in all premises.
Water should normally be supplied by tap from the mains supply. Bottled water or
water dispensers may be provided as a secondary source. Supplies need to be
clearly marked only if there is a significant risk of people drinking non–drinking water.
Rest areas should be provided with in offices and other reasonably clean workplaces,
work seats or other seats in the work area will be sufficient, provided workers are not
subject to excessive disturbance during breaks. Work areas can be counted as rest
and eating facilities provided they;
Have suitable seats for the number of workers likely to use them at any one
time.
Are in a sufficiently clean place and there is a suitable surface on which to
place food.
Eating facilities should include a facility for preparing or obtaining a hot drink.
Where hot food cannot be obtained in or reasonably near the workplace, workers
should be provided with the means for heating their own food.