Health and safety policy

1 Introduction

The trust owes a duty of care to employees, patients and others who use its services. This policy provides details of the health and safety arrangements in place in the trust.

As part of the legal requirement the policy must contain the following:

a general statement of intent which summarises how the trust will manage health and safety (specifying objectives) (see section 1.1)
organisation of health and safety (people and their duties)
arrangements (systems and procedures). This part of the policy deals with how the policy will be implemented

Health and safety policy statement

It is the trust’s policy to ensure, as far as it is reasonably practicable, the health, safety and welfare of all employees whilst at work and to have due regard for the health and safety of patients, visitors and others.

Every employee has a statutory duty to take reasonable care of their own health and safety and that of others who may be affected by their acts or omissions at work and to co-operate with the trust to meet its duties. To enable these duties to be carried out it is the intent of the trust to ensure that responsibilities for health and safety are effectively assigned, accepted and managed at all levels within the organisational structure, consistent with good practice throughout the trust. The trust will, so far as it is reasonably practicable:

provide and maintain a safe and healthy work environment conditions, safe equipment and safe systems of work
provide and maintain a safe workplace with safe access and egress
ensure the storage, handling, usage and transport of articles and substances is safe and without risk to health
provide all employees with information, instruction, training and supervision as necessary to secure their safety and health at work
ensure risk assessments are carried out where necessary
ensure monitoring activities are undertaken to maintain safety standards

The health and safety lead is the competent person as required by the Management of Health and Safety at Work Regulations 1999 who will assist the trust in undertaking the measures needed to comply with relevant statutory provisions. The trust will provide the health and safety lead with sufficient authority and resources to implement the health and safety policy.

The health, safety and security forum will provide and maintain effective measures for consultation and communication between all levels of management and employees on any matter regarding the trust’s health and safety arrangements. The trust expects the full co-operation of all employees to ensure continuous improvement of standards in all aspects of health and safety.

Signed by
Toby Lewis, Chief Executive

2 Purpose

The purpose of this policy is to set out the trust’s provisions for the management of health and safety. This includes defining roles and responsibilities and identifying the arrangements that are in place to ensure that the trust meets it legal obligations with regard to the requirements of the Health and Safety at Work Act 1974 and associated regulations.

3 Scope

The policy applies to all trust employees, patients, visitors and others to whom the trust owes a duty of care. It specifically relates to non-clinical risks and whilst there is an overlap in many areas with clinical risks, these are supported by a suite of patient safety policies and procedures which are not within the scope of this policy.

4 Responsibilities, accountabilities and duties

4.1 Trust board of directors

The Trust board has ultimate responsibility and ‘ownership’ for the implementation of health and safety within the trust.

This is provided by:

demonstrating strong and active leadership from the top and ensuring there is visible, active commitment from the board
integrating effective health and safety management into business decisions
ensuring there are effective ‘downward’ and ‘upward’ communication channels embedded within management structures.
board members will take the lead in ensuring the communication of health and safety duties and benefits throughout the organisation
ensuring adequate resources are made available so that the requirements of this policy and good health and safety practice can be fulfilled

4.2 Chief executive

The chief executive has specific accountability to ensure that responsibilities for health and safety are effectively assigned, accepted and managed at all levels in the trust consistent with good practice. In practice the chief executive will discharge these responsibilities by delegation to executive directors and then through the line management structure.

The chief executive shall arrange for regular monitoring of the health and safety arrangements through the trust’s reporting structures.

4.3 Executive directors, care group directors and directors of corporate services

Executive directors, care group directors and directors of corporate services have delegated responsibility for the management of health and safety, providing leadership and integrating health and safety into day-to-day business activities. They will ensure that there are suitable and sufficient arrangements and resources to ensure this policy is implemented for areas under their control. This duty is further delegated to heads of services, other managers and supervisors

4.4 Executive director of nursing and allied health professionals

The executive director of nursing and allied health professionals has delegated responsibility for health and safety which includes ensuring that health and safety arrangements are in place, that serious issues are escalated and to provide assurance that the trust is compliant with its health and safety responsibilities.

4.5 Executive director of finance and performance

The director of finance is the current nominated security management director (SMD) and has responsibility for security management within the trust. This includes promoting and leading on security matters at board level to ensure legal compliance.

4.6 Care group or heads of department

Heads of department have delegated responsibility for the management of health and safety in areas under their control, including ensuring that there are suitable and sufficient arrangements to ensure this policy is implemented. This is further delegated to managers and supervisors.

4.7 Head of estates and facilities

The head of estates and facilities has a delegated responsibility for the safety of buildings and building services under the control of estates and facilities. This includes, but is not limited to: water safety, the management of asbestos, electrical safety, building safety and maintenance and the management of contractors.

4.8 Health and safety lead

The health and safety lead is the trust’s ‘competent person’ for health and safety as required under the management of Health and Safety at Work Regulations 1999.

The health and safety lead will provide information, guidance and training to enable the trust to comply with relevant statutory provisions as required by the Health and Safety at Work Act, the Management of Health and Safety at Work Regulations and other relevant health and safety legislation.

4.9 Other specialist advisors

The trust has a number of other employees and external providers who are able to provide a source of competent advice within their particular specialism and experience. These include:

fire safety advisor, the role includes, but is not limited to; providing advice and assistance to trust staff on all fire related matters, carrying out fire risk assessments and ensuring that there is suitable fire equipment and means of escape in place
local security management specialist (security advisor), duties include, but are not limited to; carrying out security inspections, providing security and personal safety advice, carrying out incident investigations and liaising with the police
health, safety and security officer, duties include; but are not limited to providing advice and assistance on health and safety, fire and security matters
Manual Handling team, duties include, but are not limited to; providing training and advice relating to the manual handling of objects and patients and the use of display screen equipment (DSE), assisting managers with manual handling and DSE assessments
occupational health, the trust has appointed an external company to provide occupational health information and services to support employee wellbeing

4.10 Managers

Managers have delegated responsibility for implementing the policy within areas under their control. This includes, but is not limited to the following within their areas of responsibility:

bringing health and safety matters to the attention of employees
ensuring that there are adequate arrangements in place for the management of health and safety, including emergency arrangements
encouraging employees to report all incidents and near misses using the trust’s incident reporting system
ensuring that risk assessments are carried out, regularly reviewed and updated if the work pattern and workplace environmental hazards alter
communicating significant findings from assessments to employees
providing necessary information, instruction, training and supervision to enable staff to undertake their tasks without risk to themselves or others
investigating and addressing any health and safety issues raised by employees. Where they do not have the authority to deal with such matters they should be brought to the attention of more senior management
investigating incidents and implementing any actions to prevent reoccurrence

4.11 All employees

All employees have a delegated responsibility, which includes, but is not limited to:

taking reasonable care for the health and safety of themselves and any other persons who may be affected by their acts or omissions at work. This duty not only relates to avoiding obvious reckless behaviour, but also includes taking positive steps to understand the hazards in the workplace, to comply with safety rules and procedures and to ensure that nothing they do or fail to do places others at risk
co-operating with the trust and its managers, to ensure that all relevant statutory regulations, policies, codes of practice and departmental procedures are adhered to
using any machinery, equipment, dangerous substance, transport, equipment, means of production or safety device provided by the trust in accordance with any guidance, information, instruction and training which is provided
reporting all accidents or near misses that occur via the trust’s incident reporting system
informing their line manager of any circumstances that may affect their ability to work safely. For example, becoming pregnant or suffering from an injury or illness
ensuring that they attend relevant health and safety training and refresher training
being aware of local safety arrangements such as what action to take in the event of a fire and actions set out in emergency plans

4.12 Contractors

The trust requires all contractors that it employs to:

comply with the trust’s health and safety policies and procedures by working safely and not exposing persons in and around their work area to risk
ensure that their employees or sub-contractors meet their statutory responsibilities and adhere to the health and safety induction information they have received from the trust. More comprehensive details of the requirements are given in the trust’s management and control of contractors policy

5 Arrangements for health and safety

The requirements of this policy will be met by:

the development of other subject-specific policies, procedures and guidance that meet the requirements of applicable health and safety law. Refer to section 9
ensuring that suitable and sufficient risk assessments are carried out by managers and controls are put into place to reduce the level of risk in their areas of responsibility
the provision of appropriate health and safety training
carrying out effective consultation with recognised trade unions, employees and employees safety representatives

5.1 Risk assessments

It is a legal requirement under the Management of Health and Safety at Work Regulations 1999 to carry out risk assessments and to establish controls to reduce the level of risk identified. Risk assessments should be carried out before work is undertaken that gives rise to the risk, when tasks or processes change, if new technology is introduced or if there is a change in legislation. Assessments should be reviewed on an annual basis or if there is an incident that indicates that existing controls are inadequate. Guidance on carrying out risk assessments and templates is available to employees on the trust’s intranet site and within subject-specific health and safety policies.

A “suitable and sufficient” assessment is one that:

correctly identifies all reasonably foreseeable significant hazards and risk
identifies all of the existing control measures and from this evaluates the level of risk
enables the assessor to decide what action needs to be taken, and what the priorities should be
is appropriate for the type of activity
will remain valid for a reasonable time
reflects what employers may reasonably practicably be expected to know about the risks associated with their undertaking

Managers are responsible for ensuring that all significant risks within areas of their control are identified and recorded on a relevant trust risk assessment form. Advice on the completion of these forms may be obtained from the Health and Safety team, intranet fire and safety (staff access only) (opens in new window).

5.2 Information, instruction and training

The trust will ensure that all employees are provided with the information, instruction, training and supervision necessary to ensure, so far as it is reasonably practicable, their health and safety at work. This includes:

local and corporate inductions, job specific and refresher training. Information provided to employees as part of the training will include: Health and safety responsibilities, how to report an accident and the trust’s arrangements for managing health and safety risks
copies of the poster ‘health and safety law: what you need to know’ are displayed in employee areas around the trust
appropriate safety signs are displayed in premises to warn of specific hazards

5.3 Consultation with employees

The trust recognises that an effective safety culture requires a partnership between management and employees, working together to identify risks and to improve safety standards and working practices.

In accordance with the Safety Representatives and Safety Committees Regulations 1977, trade unions may appoint Safety Representatives from amongst employees of the trust, who are members of a recognised Trade Union. Where employees are not members of one of these trade unions the trust must consult employees directly or via nominated employee representatives in accordance with the Health and Safety (Consultation with employees) Regulations 1996.

Employees are formally consulted about health and safety at the trust’s health, safety and security forum that meets every 2 months. The group includes trade union and employee representatives from across the trust. Information from the group is disseminated to care groups for discussion at quality and Safety meetings. This includes requesting feedback about health and safety policies and addressing any trust-wide or local issues raised by Forum members on behalf of the employees they represent.

5.4 Accident and incident reporting

All employees are encouraged to report accidents or near misses as these can be indicative of inadequately controlled risks. All incidents must be reported as per the trust’s incident reporting policy using the Safeguard electronic incident reporting system available via the intranet site.

The trust is required to report certain serious events to the health and safety executive (HSE) under the reporting of injuries, diseases and dangerous occurrences regulations 2013 (RIDDOR). Reports are either made by the manager in the area where the injury occurs or by the health and safety lead and recorded on the trust’s incident reporting system.

6 Training implications

6.1 New trust staff

How often should this be undertaken: Once.
Length of training: 30 minutes.
Delivery method: Face to face.
Training delivered by whom: Safety team.
Where are the records of attendance held: ESR.

6.2 Current trust staff

How often should this be undertaken: Every 3 years.
Length of training: 45 minutes.
Delivery method: Face to face.
Training delivered by whom: Safety team.
Where are the records of attendance held: ESR.

7 Monitoring arrangements

7.1 Health and safety compliance

How: Workplace or premises inspections.
Who: Safety team, building and service manager.
Reported to: Manager and director responsible for the building and service. Health and safety forum.
Frequency: Annually Every 2 months.

7.2 Health and safety performance

How: Annual health and safety report.
Who: Health and safety lead or Safety team.
Reported to: Trust board of directors.
Frequency: Annually.

7.3 Regular review of risk assessments

How: Premises inspection or incident reports.
Who: Designated managers or their deputies.
Reported to: Health, safety and security forum.
Frequency: Every 2 months.

7.4 Ongoing health and safety issues

How: Minutes of the health, safety and security forum.
Who: Head of estates and facilities.
Reported to: Executive Management team (interim arrangement).
Frequency: Every 2 months.

7.5 Management arrangements for health and safety

How: Internal audit investigation or external accreditation.
Who: Internal audit or contractors health and safety accreditation scheme (CHAS).
Reported to: Director of nursing and allied health professionals. Quality committee.
Frequency: As requested by the Executive team.

8 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

8.1 Privacy, dignity and respect

The NHS constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

8.1.1 How this will be met

No issues have been identified in relation to this policy.

8.2 Mental Capacity Act 2005

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

8.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the principles of the Mental Capacity Act (2005).

9 Links to any associated documents

The trust has numerous other policies which support the health and safety of staff, patients, visitors and others to whom owes a duty of care. These are available on the trust public website.

10 References

Document control

Version: 2.1.
Unique reference number: 501.
Approved by: Corporate policies approval group.
Date approved: 11 January 2024.
Name of originator or author: Health and safety lead.
Name of responsible individual: Health, safety and security forum or executive director of nursing and allied health professions
Date issued: 12 January 2024.
Review date: September 2025.
Target audience: All trust staff, volunteers, agency and bank employees.

Page last reviewed: September 13, 2024
Next review due: September 13, 2025

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