HealthandSafetyPolicy Version 7 1 by 88Xh49

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									NON-CLINICAL NON-CLINICAL NON-CLINICAL NON-CLINICAL NON-CLINICAL NON-CLINICAL NON-CLINICAL NON-CLINICAL NON-CLINICAL




                                                                                                                                   HEALTH & SAFETY
                                                                                                                                       POLICY



                                                                                                                                 NON CLINICAL POLICY – NEE168




                                                                                                                       Version 7.1: July 2011

                                                                                                                       Policy Owner: Head of Risk Management

                                                                                                                       Date approved: February 2009

                                                                                                                       Approved by: NEE PCT Health & Safety Group Membership

                                                                                                                       Review date: December 2011

                                                                                                                       Target Audience: All PCT staff
                                                                                                                                          CLINICAL
                                                                                                                                          CLINICAL


                                                                                                                                                     -
                                      CONTENTS
                                                                  Page No

1      General Statement of Health and Safety Policy                  5

2.     Organisational Responsibilities

       2.1     Chief Executive                                        6

       2.2     Trust Board                                            6

       2.3     Executive Directors                                    7

       2.4     Heads of Service and Managers                          8

       2.5     Local Management                                       9

       2.6     Safety Representatives and Staff Representatives       10

       2.7     Head of Risk Management / Assistant Risk Manager       10

       2.8     All Staff                                              11

       2.9     Mobile Workers                                         12

       2.10    Occupational Health Service                            12

       2.11    Health & Safety Group                                  12


3.     Health and Safety Arrangements

       3.1     Accident/Incident Reporting                            14

       3.2     Buildings & Plant                                      14

       3.3     Clinical Practice                                      14

       3.4     Consultation                                           15

       3.5     Communication                                          15

       3.6     Contractors                                            15

       3.7     Driving Vehicles                                       16




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Version 7.1 July 2011
Policy Owner: Head of Risk Management
Approved by: First Approved by Health and Safety Group
Review date: December 2011
       3.8     Equipment testing & maintenance            16
                   Electrical
                   Mechanical
                   Mobile
                   Fire Fighting
                   Personal Protective Equipment

       3.9     Fire Safety                                17

       3.10    First Aid Arrangements                     18
                    First Aid
                    Training
                    First Aid Supplies and Facilities
                    Infection Control and Immunisation
                    Implementation and Monitoring

       3.11    Hazardous Substances                       20

       3.12    Health & Safety Group / Representatives    20

       3.13    Incident Reporting                         20

       3.14    Inspections                                21
                   Departmental
                   Annual
                   HSE

       3.15    Infection Control                          22

       3.16    Lift Emergencies                           22

       3.17    Manual Handling                            22

       3.18    Mobile Phones                              23
                  Health
                  Driving
                  Security of Mobile Phones

       3.19    Monitoring Health & Safety Performance     24

       3.20    Occupational Health                        24
                  Alcohol / Drugs
                  Display Screen Equipment
                  Hepatitis B
                  Needle stick Injuries
                  Work Related Stress
                  Smoking
                  Counselling
                  Work Time Regulations

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Version 7.1 July 2011
Policy Owner: Head of Risk Management
Approved by: First Approved by Health and Safety Group
Review date: December 2011
       3.22    Policy Review                             27

       3.23    Risk Assessment                           27

       3.24    Security                                  28
                   General
                   Violence & Aggression
                   Lone Working

       3.25    Training & Training Records               30

       3.26    Waste                                     30

4.     Key Performance Indicators                        31

5.     Equality Impact Assessment                        31



APPENDICES

Appendix A Lines of Responsibility/Accountability        32

Appendix B Principal Health and Safety Contacts          33

Appendix C Departmental Inspection Checklist             34




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Version 7 April 2011
Policy Owner: Head of Risk Management
Approved by: First Approved by Health and Safety Group
Review date: July 2011
SECTION 1

          GENERAL STATEMENT OF HEALTH and SAFETY POLICY

The Chief Executive and the Board of North East Essex Primary Care Trust
(The PCT) recognise the need for development of effective Health and Safety
management. The PCT’s policy is to comply with relevant legislation as a
minimum, and exceed this wherever possible to improve the health, safety and
wellbeing of any person (staff, patient, visitor, agency or contractor) who may be
affected by the PCT’s activities.

Systems will be put in place, which will allow the PCT to maintain, monitor and,
where necessary, improve its safety performance.

A robust health and safety culture and operational system will be maintained by
ensuring that, in so far as is reasonably practicable:
         Adequate resources (financial and physical) to maintain and improve
          health and safety, are provided
         Activities are risk assessed and those assessments reviewed as
          necessary
         All systems of work are safe and without unnecessary risks to health
          and safety
         Systems of work for the safe use, handling, storage and transportation
          of articles and substances are provided and maintained
         Suitable and sufficient information, instruction, training and supervision
          are provided for all staff, to ensure their competence
         A safe working environment is provided, along with adequate welfare
          arrangements and facilities
         Employees and Union Representatives are consulted on matters that
          affect their health, safety and welfare
         Contractors undertaking work on behalf of the PCT, are competent to
          do so
         Advice, support and guidance will be provided across the PCT

This policy will be brought to the attention of all employees, contractors and
made available to the general public and regulatory authorities.

This Policy will be reviewed annually and following any changes in legislation.




Sheila Bremner
Chief Executive

21st April 2011


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Version 7 April 2010
Policy Owner: Head of Risk Management
Approved by: First Approved by Health and Safety Group
Review date: July 2011
SECTION 2

                                   ORGANISATION

This section of the Policy sets out the duties and responsibilities of those
personnel and groups with key roles in the management of Health, Safety and
Welfare within the Primary Care Trust.

The lines of responsibility and accountability for health and safety are
summarised in Appendix A.

Contact details of the main groups and individuals involved in Health & Safety
Management are shown at Appendix B

The Terms of Reference of the Health & Safety Group (including aims,
objectives and membership) are available via the extranet or on request from
the Risk Management team.

2.1       Chief Executive (CEO)
The Chief Executive Officer has overall responsibility for ensuring that the Trust
complies with the Health and Safety at Work, etc Act 1974, the Management of
Health and Safety at Work Regulations 1999 and all other relevant legislation.

The CEO also has responsibility for:
         Ensuring that adequate resources are available to implement the Health
          and Safety Policy
         Ensuring that health and safety performance is regularly reviewed at
          Board level
         Monitoring the effectiveness of the Health and Safety Policy
         Ensuring that this policy is reviewed at least annually, and
         Ensuring that the Health and Safety Group is appropriately chaired and
          represented.

The Interim Director of Corporate Development and Governance is the
Executive Director with responsibility for Health & Safety and has been given
delegated authority to ensure the PCT fulfils its statutory and moral duties.

2.2        Trust Board
The Trust Board is responsible for considering any significant actions needed
for compliance with Health and Safety legislation. Board members will receive
reports on health and safety from the Integrated Governance Committee (IGC)
and via the Risk Register for significant health and safety risks.




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2.3      Directors
Within their respective Directorates, are responsible for:

Directors and Assistant Directors will support the Chief Executive and carry
direct responsibility for the implementation of Health & Safety related polices.
They will do all that is reasonably practicable to establish and maintain high
standards of health, safety and welfare in their areas of control.

Directors and Assistant Directors shall
      a) Monitor and evaluate the health & safety performance in areas under
         their control, paying particular attention to safety inspections, training,
         accident statistics and action plans developed in conjunction with the
         Risk Management Team.
      b) Promote and support PCT Health, Safety and Welfare polices and
         procedures, ensuring communication and implementation through line
         management.
      c) Provide adequate resources and training arrangements to enable staff to
         discharge their health and safety responsibilities and ensure that all
         policy objectives and legal requirements are met as so far as is
         reasonably practicable
      d) Ensure that facilities are provided for employees and they are aware of
         Health & Safety Polices, and other safety rules or procedures.
      e) Ensure regular health & safety inspections are conducted. Monitor the
         recommendations and prioritise any remedial actions. There is a clear
         obligation to communicate with relevant staff/teams about any actions
         necessary. Equally it is important that appropriate feedback and
         consultation is undertaken when specific actions are not going to be
         taken, along with a clear rationale for the decision.
      f) Ensure that all staff levels report safety related incidents and near
         misses.
      g) Bringing to the attention of the IGC and Board significant or uncontrolled
         Health and Safety issues.
      h) Notifying the Risk Management Team of areas of significant or
         uncontrolled health & safety issues.
      i) Providing representation at the Integrated Governance Committee and
         Health and Safety Group and ensuring Health and Safety issues are
         raised at these forums as appropriate.




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2.4      Heads of Service and Managers
      Responsibility for Health, Safety and Welfare in their areas.
      a) Ensure that local health & safety polices, relevant risk assessments and
         procedures exist, are adequate for the working environments and
         regularly reviewed.
      b) Motivate staff by stimulating interest in health and safety matters,
         allocating specific time and proper importance to health & safety issues
         at departmental meetings.
      c) Implementing and monitor the compliance with this policy
      d) Ensure that any incident, accident, near-miss, dangerous occurrence,
         damage to property or other untoward occurrence is correctly reported
         and investigated in accordance with the PCT Incident Reporting and
         Management Policy and Serious Incident Requiring Investigation Policy
      e) Keep and maintain statutory records and other relevant legal documents.
      f) Ensure that arrangements exist so that equipment is adequate, fit for
         purpose and adequately maintained
      g) Authorise time off, with pay, for Safety Representatives in accordance
         with regulations.
      h) Ensure that ‘appointed’ Safety Representative(s) in their department are
         consulted on all matters pertaining to Health and Safety at work.
      i) Ensure that monthly Health and Safety inspections of the department
         take place and that any remedial action is taken.
      j) Contribute to the formulation of policy and procedures for health and
         safety, making recommendations for improvements or modifications.
      k) Ensure that adequate arrangements exist for the control of infection in
         their area.
      l) Ensure that all contractors engaged refer to Works’ Contractors Policy
         (NEE 174) and are aware of and comply with all relevant Trust
         procedures, including undertaking of appropriate risk assessments prior
         to commencement of any work.
      m) Provide adequate arrangements for monitoring contractors’ activities and
         standards whilst on site.
      n) Notifying Occupational Health of any staff requiring health surveillance
         and referring any employee where signs of health problems arise which
         may be considered to be a result of an occupational health and safety
         issue
      o) Ensuring there are instructions for all health and safety procedures used
         within the department or unit.
      p) Ensure departments send copies of all risk assessments, to the Risk
         Management Team if a significant risk is identified
      q) Carry out safety inspections at prescribed intervals and keep copies of
         those inspections.

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   2.5         Local Management (Those responsible for day to day operation)
   a) Ensure the satisfactory communication, implementation and monitoring
      of the relevant Trust and departmental health and safety policies
      including any relevant risk assessments (covering the full range of
      activities in which staff are involved). Be fully aware of their
      responsibilities and advise their manager of any concerns.
   b) Promote and support the Trust Health and Safety Policy, ensuring that
      employees under their control are aware of the Policy and carry out their
      work in a safe manner. Allocate time to Health and Safety issues
   c) Undertake and review Risk Assessments
   d) Ensure that new and transferred employees receive full local safety
      instruction. Identify any particular training needs of those under their
      supervision as part of their induction arrangements
   e) Investigate the circumstances of any incident, dangerous occurrence,
      damage to property or other untoward incident within the area of control.
   f) Ensure an incident form is completed and appropriate action is taken.
   g) Ensure that all potential hazards and relevant Trust rules and procedures
      pertaining to the areas under their control are brought to the attention of
      the relevant persons.
   h) Ensure that all persons including temporary staff and students in the area
      under their control are made aware of any hazardous work or activity,
      which is being, or is about to be, undertaken.
   i) Ensure that unsafe or defective plant or equipment is not used, taken out
      of service and reported, ensure that appropriate action is taken to
      prevent accidents.
   j) Ensure that plant and equipment is operated by trained and competent
      persons and where appropriate authorised/licensed persons. Ensure that
      equipment is in a safe and secure state when unattended.
   k) Ensure the preparation, implementation and compliance with safe
      systems of work
   l) Liaise with the appointed Safety Representative(s) in the department on
      all matters concerning safety, health and welfare at work.
   m) Ensure employees (and others) take proper precautions to minimise
      potential H&S risks.
   n) Ensure that where safety equipment and devices are used and that
      protective clothing and equipment is supplied and used where
      appropriate.
   o) Co-operate with and participate in health and safety inspections and
      ensure that local health and safety inspections are conducted and
      relevant actions taken. Clinical areas are every 2 months, non clinical
      every 3 months.
   p) Ensure that all employees for whom they are responsible are aware of
      first aid facilities, their precise location and the procedures to be adopted
      in the event of an emergency.
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      q) Restrict employees from engaging in horseplay or other activities, which
         may affect health and safety on site.
      r) Contribute to the formulation of policies and procedures for health and
         safety and where necessary make recommendations for improvements
         or modifications.

2.6       Safety Representatives and Staff Representatives
Safety Representatives are PCT employees who are designated and
appointed by a Trade Union in accordance with their respective membership
regulations and the Safety Representatives and Safety Committees Regulations
(SRSCR) 1977.

Staff Representatives are PCT employees who are not Union appointed but
are designated to represent staff regarding Health & Safety issues in
accordance with the Health & Safety (Consultation with Employees)
Regulations (HSCER) 1996.

Any PCT employee, including those who are not members of a union, may
consult Safety Representatives and/or Staff Representatives in respect of
Health & Safety at work.

The function of a Representative is to:
         Investigate potential hazards, dangerous occurrences and accidents
          (Safety Representatives only)
         Investigate employees’ complaints
         Make representations to the employer on Health and Safety matters.
         Carry out workplace inspections (Safety Representatives only)
         Receive information from inspectors and represent employees in
          consultations at the workplace with inspectors
      Attend meetings of safety groups, including specifically the PCT’s Health
       and Safety Group
NB: Safety reps are entitled to time off with pay for performing the above
functions, or undergoing relevant/reasonable training in connection with them.

2.7       Head of Risk Management / Assistant Risk Manager
The Head of Risk Management and Assistant Risk Manager have been
appointed the competent persons in relation to Health and Safety and will
provide professional advice to Directors, Assistant Directors, Managers and
staff.

The Head of Risk Management is responsible for:
      a) Ensuring the effective implementation and monitoring of the Health and
         Safety Policy, and all other directly associated policies
      b) Ensuring so far as is reasonable practicable that the PCT complies with
         Health and Safety legislation

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      c) Liaising with Human Resources and the Training, Education and
         Development Team in ensuring training is organised for implementation
         of this policy. This can be devolved to individual Directorate Managers
         where appropriate
      d) Ensuring the provision of advice and guidance to PCT staff on health and
         safety matters.
      e) Manage the Trust Incident Reporting System (Datix)
      f) Provision of Health and Safety reports to the Integrated Governance
         Committee and Health and Safety Group on Health and Safety
         performance.
      g) Use sound judgement to liaise with the Healthcare Quality Team on
         significant health and safety issues relating to patient safety.
      h) Providing expert advice and information on Health and Safety issues
      i) Co-ordinating the PCT’s risk management and risk assessment
         processes
      j) Developing, implementing and reviewing the PCT’s health and safety
         inspection programme
      k) identifying Health and Safety training issues
      l) Providing Health and Safety training for new staff as agreed with the
         Training, Education and Development Department
      m) To act as the responsible person under RIDDOR legislation for
         reportable accidents.
      n) Escalate uncontrolled or significant health and safety issues

2.8       All Staff
All of the Trust’s employees have duties and responsibilities under the Health
and Safety at Work etc. Act 1974. These duties and responsibilities are to:

         Take responsibility for their own health and safety and for that of others
          who may be affected by their acts or omissions
         Co-operate with their employers to enable them to fulfil their statutory
          duties under the Health and Safety at Work etc. Act 1974 and any
          subservient legislation
         Not knowingly interfere with or misuse any article provided in the
          interests of health, safety or welfare
         Comply with the PCT’s procedures and health and safety rules
         Identify and report defects and other health and safety concerns to either
          their line manager or the Risk Management Team
         To attend Occupational Health for health surveillance as requested
         To report all accidents, incidents or near misses promptly to their
          manager, using a PCT Incident Report Form


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Review date: July 2011
         To ensure all vaccinations and other job related health precaution
          measures are up to date (where applicable).
         Book and attend any relevant training courses, in conjunction with their
          line managers.

2.9       Mobile Workers

      a) Staff whose work takes them into several departments and clients homes
         may be exposed to greater risks with regards to their health & safety.
         The managers of both the department responsible for these staff and the
         departments in which they work should liaise to produce departmental
         safety statements covering such potential hazards.
      b) The department/ service manager of peripatetic workers should ensure
         that staff have a copy of the Health and Safety departmental/ Service
         policy covering the area in which they are working. If assistance is
         required in facilitating this, the department / service manager should
         contact the Risk Management Team
      c) Staff have a duty to report any hazards to their manager, who must raise
         them with the manager of the premises. If no action is taken regarding
         the hazard the Risk Management Team must be informed

2.10      Occupational Health Service
The Service is responsible for the following:
         Undertaking where appropriate health surveillance of employees,
          required by health and safety legislation and risk assessment findings.
         Provide specialist OH advice and support to Managers and staff.
         Informing Department and Service Areas where health and safety
          procedures may not be adequate following a reported health problem,
          identified by Management
         Ensuring that all employees in clinical areas are up to date with relevant
          immunisation
         Working with managers in the investigation of adverse outcomes (i.e.
          long term sickness) related to health and safety incidents
         Providing appropriate information, advice and training.

2.11      Health and Safety Group
The Trust has established a Health & Safety Group in accordance with the
Health and Safety at Work etc Act 1974; the Management of Health and Safety
at Work Regulations 1999; the Health and Safety (Consultation with
Employees) Regulations 1996 and the Safety Representatives and Safety
Committee Regulations 1977.

The Group will consider major changes to the Health & Safety Policy, before
submission to the Integrated Governance Committee for final approval. The
Group is also responsible for ensuring significant Health and Safety issues are

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progressed. The Group can also supply expertise to contribute towards
investigations and the furtherance of Health and Safety issues.

The Trust further recognises that its safety aims and objectives can best be
achieved through consultation with Staff Representatives, Trust Managers and
Board representation, through the Integrated Governance Committee within the
remit of a Health and Safety Group.

The Terms of Reference, Membership and meeting details of the Health &
Safety Group are detailed in Appendix D.




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Version 7 April 2011
Policy Owner: Head of Risk Management
Approved by: First Approved by Health and Safety Group
Review date: July 2011
SECTION 3

                HEALTH and SAFETY ARRANGEMENTS
This part of the document outlines how the Trust, as an employer, will fulfil its
statutory duties as set out in the General Statement of Health and Safety Policy.

The guidelines set out below are typically general in nature. Where more
specific guidance in the form of a Policy or Procedure document is already in
circulation then reference will be made to that document.

All Trust policies and procedures relating to workplace Health, Safety and
Welfare will be consulted upon through the Health and Safety Group, before
being endorsed by the Integrated Governance Committee and, where
necessary, the Trust Board.

3.1    Accident/Incident Reporting
All accidents, incidents and near misses (clinical and non-clinical) must be
reported, as per the guidelines set out in the Trust’s Incident Reporting and
Management Policy and using the Trust’s Incident Reporting Form. Copies
of the Policy and forms can be found in Departments or Service Areas from the
Extranet or by request from the Risk Management Team.

Any accident that resulted or had the potential to result in death or major injury,
the Serious Incident Requiring Investigation Policy must be followed

The Department or Service Area Manager should initially investigate all
accidents/incidents, take action to prevent a recurrence and note the
findings/recommendations on the Incident Report Form. All forms should then
be forwarded to the Risk Management Team (RMT) for entry on to the Incident
Reporting System within the timescales indicated on the form. The RMT will
determine whether incidents require onward reporting to the Health and Safety
Executive, under the Reporting of Incidents, Diseases and Dangerous
Occurrences Regulations 1995 (RIDDOR).

Incidents caused which are related to medical devices, must be immediately
and clearly reported to the Risk Management Team for onward reporting to the
Medicines and Healthcare Products Regulatory Agency (MHRA). – see Medical
Devices Policy

3.2    Buildings & Plant
The Head of Community Hospitals, PCT Practice Managers, Assistant Director
of Estates and Facilities Management and Heads of Service are responsible for
ensuring the upkeep of buildings and plant in their own respective areas.

3.3    Clinical Practice
All policies and procedures referring to Clinical or Medical practice must be
complied with by all relevant staff.

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Staff requiring professional registration and their Line Managers are responsible
for ensuring that registrations are valid at the start of employment and are
renewed at the required intervals. See Process for Checking Maintaining
Professional Registrations Policy – Nursing & Therapeutic Staff and the
Process for Maintenance of Professional knowledge and Competence
Policy

3.4       Consultation
Employees will be consulted on matters relating to health and safety through
the forum of the Health and Safety Group. Membership of the Health and
Safety Group includes Trade Union appointed Safety Representatives (in
compliance with the Safety Committee and Safety Representatives Regulations
1977) and Staff Representatives (in compliance with the Health & Safety
(Consultation with Employees) Regulations 1996.

Any member of staff may make representation to Safety Representatives or
Staff Representatives on any matter relating to their Health, Safety or Welfare.

3.5       Communications
Health and Safety information will be communicated to employees and
managers in a variety of ways, including:
         Local and Corporate induction
         Via Health & Safety Representatives
         Formal training
         Staff meetings and forums
         Reports and action plans from Health and Safety related assessments
         Minutes of Health and Safety Group meetings
         Outcomes of investigations into Incident Reports, Serious Incidents and
          Near Misses.
         Risk Management and departmental training.
         Ad hoc circulars and publications
         Central Alert System (CAS)
         Extranet Risk Management Web page

3.6       Contractors Health and Safety Assessments
Long-term contractors (e.g. Facilities Management) must supply the relevant
site/service area managers and the Risk Management Team with a copy of their
H&S Policy, copies of their generic risk assessments and method statements
relating to all activities that may impact on the Trust’s staff, patients, visitors or
other contractors. See also the Trust’s Works’ Contractor Policy (NEE 174)



3.7       Driving Vehicles
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All employees who drive vehicles as part of their duties are expected to be in
possession of a full, valid and current driving licence for the category of vehicle
they are driving.

The Trust expects drivers to observe the Highway Code and all road traffic
laws, and to drive with due consideration and courtesy to other drivers at all
times.

All drivers should be adequately fit and healthy, and should bring to the Trust’s
attention any reason why they may not be fit to drive.

Drivers must not be under the influence of drugs or alcohol when driving.

All vehicles, including employees own vehicles, should be kept in a roadworthy
condition at all times and have a current, valid MOT Certificate. All drivers
should be adequately insured to take account of their business usage.

See also the Trust’s Driving Policy (under development)

3.8    Equipment - Maintenance & Testing
Electrical Equipment
New portable electrical appliances should be tested by a competent person
prior to use, wherever possible, or as soon as is reasonably practicable
thereafter.

All portable electrical appliances should be maintained and tested by a
competent person on a regular basis.

All portable electrical appliances should also be visually checked by each user
prior to use, any defects will require equipment to be taken out of service and a
Trust Incident Report Form completed.

Mechanical Equipment
All new mechanical and electro-mechanical equipment should be tested by a
competent person prior to use, wherever possible, or as soon as is reasonably
practicable thereafter.

All mechanical and electro-mechanical equipment should be maintained as per
manufacturing instructions or best practice and by a competent person.

All mechanical and electro-mechanical equipment should also be visually
checked by each user prior to use, any defects reported immediately, and a
trust Incident Report form completed.

Equipment used for lifting persons must be tested by a competent person every
six months. The equipment should not be used unless there is an in date
sticker on the equipment.



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Mobile Equipment
All mobile equipment (e.g. beds, wheelchairs, trolleys) should be visually
checked by staff as part of the Departmental Inspection, and appropriate action
taken. All faults must be reported immediately.

Fire Fighting Equipment
Extinguishers, hoses and blankets should be tested annually by a competent
person, and the date of testing displayed in a prominent position.

Extinguisher discharges, hose discharges or blanket use (whether accidental or
not) must be reported immediately to a manager for appropriate action and a
Trust Incident Report Form completed. See PCT Fire Policy (NEE.145).

Personal Protective Equipment (see also Hazardous Substances)
Where identified through risk assessment, Personal Protective Equipment
(PPE) will be provided, free of charge, by the Trust.

Employees will be expected to use/wear the identified PPE in accordance with
the manufacturers’ instructions and local procedures.

Any missing PPE, or PPE with defects, should be reported immediately and an
Incident Report Form completed.

3.9      Fire Safety
Managers must ensure that a current fire risk assessment is in place and all
staff are aware of and comply with, local fire procedures, including:
      a) The means of fire detection in their area of work
      b) The method(s) of raising the alarm
      c) The arrangements for evacuation (including patient evacuation if
         relevant)
      d) The location of the assembly point
      e) The location and use of extinguishers, hoses and/or fire blankets
      f) The Fire Marshall/s for their area

Further guidance and advice may be found in the Trust’s Fire Policy.




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3.10   First Aid Arrangements
First Aid
The Health and Safety (First-Aid) Regulations 1981 (as amended) require
employers to provide adequate and appropriate equipment, facilities and
personnel to enable first aid to be given to employees if they are injured or
become ill at work.

Managers are responsible for ensuring that there are adequate first aid
arrangements in place during the hours of occupation. This will include
ensuring adequate provisions of first aid boxes, Appointed Persons & trained
First Aiders and the location of the approved signage.

Training
The "Emergency First Aider" one day course will be considered an acceptable
minimum level of required training and will need to be refreshed every year.

Alternatively the manager may assess that they require full "First Aid at Work"
persons to be present who will need to attend an initial three day HSE approved
First Aid at Work training course.

All First Aiders must then attend the PCT Emergency First Aider course
annually, in between attending the HSE requalification Emergency First Aid
course which is every 3 years.

The PCT “Emergency First Aid" course is designed to develop knowledge and
practical skills of Basic First Aid and Basic Life Support (BLS) Techniques.

Doctors or Nurses are not to be named as or expected to be Emergency First
Aiders unless they choose to be and will need to attend an Emergency First
Aider or a First Aid Course.

It is acknowledged by the HSE that Doctors or Nurses who may not have
attended a first aid course, if present at an incident at work can act in an
Emergency First Aider capacity if they feel competent to do so.

For more information on available courses contact the Training, Education and
Development Department.

Some buildings might have extra First Aid equipment, such as portable oxygen
and defibrillators. Local arrangements should be made to train first aiders in the
use of this equipment.

First Aid Supplies and Facilities
All PCT buildings should have First Aid boxes and, where there are substantial
numbers of staff, preferably also have access to a first aid room. The latter,
should as a minimum, consist of rest and hand washing facilities and a
reasonable stock of first aid supplies, plus Incident Reporting Forms (acts as
the First Aid Book)


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Volunteers, from the pool of Emergency First Aiders should be sought to accept
responsibility for the upkeep of the First Aid Boxes and the First Aid Room.
These tasks can be undertaken in conjunction with onsite administration or
Corporate Services Staff if possible. However it is the responsibility of all
individuals accessing the first aid box to highlight any low supplies.

Infection Control and Immunisation
All First Aid at Work Persons and Emergency First Aiders working within
NEEPCT must follow Trust Infection Control Guidelines whilst practicing First
Aid. All Clinical staff must at all times be in date with their IC training.

Immunisation against Hepatitis B is recommended for all First Aid at Work
Persons and Emergency First Aiders working within NEEPCT and is available
through the Occupational Health Department.

Implementation and monitoring
Local Managers are responsible for ensuring that all these arrangements are in
place within their areas and should be covered in routine Managers Health and
Safety Inspections.

http://nww.eastern.nhs.uk/Essex/NEEssexPCTHomePage/Education&Training/Mandat
oryTrainingDirectory2007/CourseDatesandDetails/FirstAidInformation.pdf




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3.11   Hazardous Substances
Hazardous substances are identified as substances that may be harmful to
health, for example - liquids (e.g. chemicals which may be toxic, harmful,
corrosive or irritant), dusts, fumes, gases and biological agents (bacteria and
micro-organisms).

Managers will ensure that appropriate assessments are undertaken of all
substances that employees maybe likely to come into contact with, and provide
and maintain safe systems of work, including health surveillance where
necessary.

Where identified Managers are to arrange Personal Protective Equipment
(PPE) be provided, free of charge to the employees. Employees are expected
to wear/use the identified PPE and report any faults with such equipment.

See the Control of Substances Hazardous to Health (COSHH) Policy and
Procedures for further details.

3.12   Health & Safety Group and Staff/Safety Representatives
Managers of all departments and service areas should strive to have in place a
reasonable number of Health and Safety Representatives. Whether or not
Health & Safety Representatives are Union members, full co-operation should
be given to training requirements and the time needed to perform assessments
and related duties.

The duties of Health and Safety Representatives are, to a degree, job and work
area specific with a common theme of ensuring the environment is as safe as is
reasonably possible and protecting their colleagues from harm.

The H&S Group are responsible for reviewing and approval of relevant polices,
such as the H&S Policy.

3.13   Incident Reporting
It is the responsibility of all employees to report all accidents, incidents and near
misses in the following categories:

      Health & Safety (e.g. falls, sharps)
      Fire (e.g. flames, smoke, burning smells)
      Security (e.g. thefts, )
      Violence & Aggression (e.g. non-physical abuse or physical assault)
      Clinical Incidents (e.g. drug errors, staff shortages)
      Occupational Health (e.g. needlesticks, manual handling)
      Environmental Restraint (e.g. locked doors)

Please refer to the Trust’s Incident Reporting and Management Policy for
further details and guidance on how to complete Incident Reporting Forms
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Managers have a responsibility to investigate all incidents, accidents and near
misses and forward the Incident Report Form to the Risk Management Team for
entry onto the Incident database and, if necessary, the Trust Risk Register.

3.14   Inspections
Departmental
Departmental inspections are to be conducted periodically using the
Departmental Inspection Report Appendix C.

The inspection should be undertaken by staff on a rotational basis to give as
many people as possible the opportunity to be involved in the health & safety of
their working area. Completed reports are to be forwarded to Line Managers to
action any issues arising.

Inspection reports, along with details of any action taken, should be retained in
the local Health & Safety Manual for inspection purposes, either by the Risk
Management Team or external bodies such as the Health & Safety Executive
(HSE).

Annual
A routine inspection of all areas takes place on an annual basis, co-ordinated by
the Risk Management Team. Staff Representatives are welcome to, and are
encouraged to attend.

Following the inspection, a report is issued to the appropriate person who can
action the points raised. Confirmation that action has been taken is to be
returned to the Risk Management Team within one month of the report being
issued.

Health & Safety Executive
The Health & Safety Executive (HSE) are the enforcing authority for Health and
Safety within a range of sectors including Healthcare. Their mission is to
protect people’s health and safety by ensuring risk in the changing workplace is
properly controlled. In the main this is done by guidance and support, however
they have the power to bring prosecutions for failings where deemed
appropriate.

The HSE can make unannounced visits to any work premises. HSE Inspectors
have the right to carry out investigations, order that areas be left undisturbed,
take samples, take statements, photocopy any relevant documentation and use
any personnel and working space he/she deems necessary.

The Inspector will, however, usually make his/her presence known to the senior
person on site at the time and will expect full co-operation.

It is also usual for an Inspector to consult with an appropriate Trade Union
Safety Representative during an inspection or investigation.


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3.15   Infection Control
The Health and Social Care Act 2008 places responsibility on every individual in
the healthcare setting to ensure infection prevention and control is embedded
into everyday practice and applied consistently by everyone.
Please refer to the NEEPCT Community Infection Prevention and Control
Guidelines NEE153.

3.16   Lift Emergencies
Estates and Facilities and the Corporate Services Departments have full
procedures in place to be followed in the event of a lift breakdown.

If you are in a lift which breaks down, raise the alarm by using the internal
telephone, or if unavailable, by calling to someone outside.

If you have someone in the lift who needs to be released as a matter of urgency
(e.g. for medical reasons or suffering from claustrophobia), make this very clear
to whoever you speak to so that the Fire Brigade can be summoned to effect a
quicker rescue should Facilities experience a delay.

3.17   Manual Handling
Manual Handling is “the transporting or supporting of a load, including lifting,
putting down, pushing, pulling, carrying or moving a load by hand or by bodily
force” Manual handling operations includes the movement of patients.

All managers have the responsibility for ensuring that arrangements made
under the policy are implemented properly and ensure that they -

      Be aware of manual handling situations including patient handling, within
       their area of responsibility.
      Make an assessment of any hazardous manual handling operations that
       cannot be avoided in order to reduce the risk of injury. This may need to
       be done in conjunction with a specialist Moving and Handling Advisor
      Ensure that suitable and sufficient mechanical aids are provided and that
       these are easily accessible for staff use.
      Ensure that all moving and handling equipment and accessories are
       thoroughly examined, serviced and maintained in accordance with “The
       Lifting Operations and Lifting Equipment Regulations 1998” (LOLER) and
       “The Provision and Use of Work Equipment Regulations 1998”
       (PUWER). (See section on manual handling equipment)

Detailed Responsibilities and Guidance on manual handling of both patients
and static loads may be found in the Trust’s Manual Handling Policy.




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3.18   Mobile Phones
Health
Mobile phones are low power devices which emit and receive radio waves.
Radio waves have been used for communication purposes for over 100 years
now, but the rapid rise in numbers and usage has led to concerns about
possible impact on health.

Current research evidence suggests that exposure to radio waves below levels
set out in International Guidelines, does not cause health problems to the
general population. All mobile phones sold in the UK meet the International
Guidelines.

There is, however, some evidence to show that changes in brain activity can
occur below these guidelines, but it is not clear why. A precautionary approach
is, therefore, recommended.

Department of Health guidelines suggest that in relation to health, to minimise
your exposure to radio waves, you should:-
      Consider the SAR (Specific Absorption Rate) of your phone
      Keep your calls as short as possible
      Use a hands free kit, and/or
    Purchase a phone with a built in shield
Further information can be found at www.doh.gov.uk/mobile.htm

Driving
Staff will not use mobile phones whilst driving. Legal advice is that if a driver is
using a mobile phone even with a hands free kit and a road traffic offence or
accident happens, the driver could be liable to face prosecution.

Research clearly shows that using hands-free phones while driving is
dangerous, as it is the mental distraction of the phone conversation that leads to
accidents.

The Trust stance on the use of mobiles is that they should be diverted to
voicemail when an employee is driving and managers should not call
employees at times they suspect they will be driving.

If they receive a call it should not be answered while they are driving. They must
find somewhere safe to stop and turn the engine off before answering the call.

If an employee who is driving needs to make a call they must park in a safe
place and turn their engine off.

Contact HR or See Trust’s Driving Policy (Under development) for further
information



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Security of mobile phones
Police indicate that the number of incidents of mobile phone theft is still
growing. Try to keep your mobile phone out of view as much as possible -
carrying it in your hands or on a belt clip is inadvisable.

Do not leave it on display in a parked car, and be aware of your surroundings
when using it in a public area. Most phone muggings take place when people
are using them and are unaware of what is going on around them.

3.19   Monitoring Performance
Managers responsible for setting their employees objectives must ensure that
they reflect health and safety risks and the actions they are required to take to
control the risks.

Managers are responsible for regularly reviewing accident statistics for their
department.

Managers should ensure that they review safety inspections carried out in the
area for which they are responsible.

3.20   Occupational Health
Alcohol / Drugs
The misuse of alcohol and drugs can lead to reduced productivity, taking time
off work, serious ill health and accidents at work. Misuse of illegal drugs is a
criminal offence.

For advice and information, please contact the Occupational Health Department
or HR

Display Screen Equipment (DSE) –
The DSE regulations require every employer to carry out a suitable and
sufficient analysis of all workstations used by DSE Users. Managers have the
responsibility to ensure these assessments are undertaken.

The three principle risks relate to: -
      Musculoskeletal disorders ( upper limb disorders)
      Visual Fatigue
      Mental Fatigue

The known health problems associated with DSE work can be prevented in the
majority of cases by good ergonomic design of the equipment, workplace and
job and by worker training and consultation.

Employees identified as DSE users will be expected to undertake an initial self
assessment of their workstation.

More information refer to the Display Screen Equipment Policy

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Hepatitis B
Hep B is a serious disease of the liver, which can cause liver damage, liver
cancer and even death, but many sufferers make a full and complete recovery.
Approximately 10 – 12 cases are reported every year in the North East Essex
area. Hep B can be contracted through:
      A sharps injury from an infected needle
      Wounds or bites received from an infected person, or
      Infected blood or body fluids coming into contact with the eyes,
       uncovered scratches or cuts.
You can protect yourself from Hepatitis B by:
   a) Keeping immunisations up to date
   b) Keeping wounds and cuts covered
   c) Wearing personal protection (e.g. gloves)
   d) Ensuring hand hygiene Washing hands before and after every patient
      contact
   e) Carefully disposing of sharps in the appropriate sharps box
   f) Never re-sheathing a needle, and
   g) Clearing up all spillages of blood or body fluids according to the infection
      prevention and Control guidelines, including disinfection.

A Hepatitis B vaccination programme is offered to all clinical and direct care
staff, although other staff e.g. Hospital Porters are also encouraged to
undertake immunisation programme.

Hepatitis C
The prevalence of Hepatitis C in North East Essex is less than 1%. The risk of
transmission of Hepatitis C is increased if:

      If the exposure is caused by a puncture wound, cut, scratch, or by a
       splash to the eye, mouth or onto broken skin and the patient/client is
       known to be Hepatitis C positive.
      The patient/client is/was an IV drug user, sex worker or originates from a
       country with a high prevalence of the Hepatitis C virus e.g. Egypt.

HIV
The incidence of HIV in North East Essex is very low. A significant exposure is:
      If the exposure is caused by a puncture wound, cut, scratch, or by a
       splash to the eye, mouth or onto broken skin and the patient/client is
       know or likely to be HIV positive.
      The substance exposed to is blood, serum, cerebro- spinal fluid, genital
       secretions or other body fluids including urine and gut secretions (but
       only if visibly blood stained). This also includes fresh tissue samples.

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The risk of HIV transmission is increased if:
      The patient/client is/was suffering from terminal HIV disease (AIDS)
      The patient/client is/was suffering from an initial HIV sero-conversion
       illness
      In the case of an accident involving blood or tissue samples, the samples
       originate from countries with a high prevalence of HIV e.g. sub-Saharan
       Africa, East and South East Asia, Central and South America, or are
       collected from a sample population with high risk factors for contracting
       HIV infection e.g. sex-worker, IV drug user, promiscuous sexual habits,
       or children of individuals from High risk populations
      The injury was deep, or caused by a hollow needle especially if just used
       for venous or arterial puncture, or there is visible blood on the device.

For further information contact – Occupational Health

Needle stick injuries
All cuts and puncture wounds from contaminated objects must be encouraged
to bleed, washed at once with soap and water, and a wound dressing applied if
necessary.

Employees must inform their Line Manager at once and complete an Incident
Report Form. Line Managers will ensure that the Needle stick Protocol is
followed where necessary. See the Management of Needle stick and Sharps
Injuries

Work Related Stress
Stress is a natural response to excess pressure or demands. If managed
correctly pressure can be a positive thing, however the pressure is perceived as
excessive then this can lead to stress, which can be detrimental to Health and
productivity

A person’s ability to cope with stress will depend on their personality,
perceptions, life skills, training, support, knowledge and past experiences.
It follows, therefore, that a situation which is stressful to one person may not be
stressful to another, and a situation which is stressful to you today, may not be
so tomorrow.

Whilst being a difficult area to manage, the Trust has a duty to manage Stress,
line with all other Occupational Health and Safety issues. See the Trust Stress
Policy or contact HR Department

Smoking
Second hand smoke is both a public and workplace health hazard. The PCT
seeks to guarantee the right of all to breathe air free of tobacco smoke and to
comply with smoke-free legislation. Adequate signage will be displayed to
inform employees, patients, and visitors of the smoke-free status of the Trust.
The Trust has a Stop Smoking Co-ordinator who offers support for staff who
wish to give up smoking. This support includes one-to-one counselling and
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reduced cost nicotine replacement therapy. The Trust also offers in-house
training for staff who wish to become trained advisers. See Trust No Smoking
Policy

Counselling
If any employee feels that they need to talk to someone about any work related
issue requiring counselling or trauma debriefing, they should contact the
Occupational Health Department.

Working Time Regulations

Managers must ensure that they and their staff aware of the limits on working
time and the entitlements provided for in the Working Time Regulations 1998
(as amended). Human Resources can advise further and the link below gives
HSE guidance on the issue.

http://www.hse.gov.uk/contact/faqs/workingtimedirective.htm

3.22      Policy Review
The Health and Safety Group will review this policy annually. The Integrated
Governance Committee will approve amendments prior to issue.

3.23      Risk Assessment
The Integrated Governance Committee will be responsible for setting standards
in relation to the managing of risks. Executive Directors and managers are
responsible for overseeing the undertaking of the assessment process and
must ensure risk assessments are carried out for all appropriate situations.

Any assessment of risk that is undertaken must be reviewed:
   i)       If there are reasons to suspect that it is no longer valid
   ii)      If there is significant change in the matters to which it relates, or
   iii)     Annually, if sooner than i) or ii) above.

Where such a review is undertaken and changes to the assessment are
required these changes must be made. Action required resulting from a risk
assessment should be identified by the department or service area manager or
lead with the relevant Assistant Director / Director unless insignificant. Where
there are significant resource implications, the reporting mechanism is through
the Risk Management Team who will record the risk on the Risk Register to
raise with Health and Safety Group and Integrated Governance Committee.

All risk assessments must be sent to the relevant Department or Service
Manager for counter signature and copies retained within the department or
service area for access by the staff. Department and service area staff must be
made aware of the risk assessments and the steps taken to control those risks.
Where circumstances change and create new or altered risks, the
circumstances should be assessed prior to the change being implemented.

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Further information on risk assessments can be obtained from the PCT’s Risk
Management Team

Further guidance can be found in the Trust’s Risk Management Strategy and
Policy

3.24   Security
General
It is recognised by the Trust that a secure and safe environment for service users,
visitors and staff is essential to achieve a high standard of service to which the Trust is
committed and to meet statutory obligations imposed by current legislation and follow
best practice.

The Trust has appointed a Security Management Director and a Local Security
Management Specialist responsible for effective security arrangements

All employees should help to create a secure environment for themselves and
others by:
      Limiting the amount of personal property brought to work (including cash,
       credit cards etc)
      Locking all personal property away wherever possible
      Locking away all trust equipment/property wherever possible
      Wearing their ID badge
      Challenging (politely and courteously) any person not wearing an ID
       badge whose identity is not known
      Reporting any untoward activities or suspicious characters immediately
      Maintaining good key security, and
      Completing an Incident Report Form for any security breaches or
       hazards

Further guidance can be found in the Trust’s Security Policy

Violence
Everyone has a duty to behave in an acceptable and appropriate manner. Staff
have a right to work, as patients have a right to be treated, in an environment
that is properly safe and secure.

The PCT has a statutory obligation to ensure as is reasonably practicable, a
safe and secure environment for its staff. Violent, abusive behaviour and
criminal acts will not be tolerated. The risks of violence to staff must be
assessed and appropriate actions will be taken to protect staff, patients and
visitors.

Physical Violence is defined as: "The intentional application of force to the
person of another without lawful justification, resulting in physical injury or
personal discomfort.”
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Non-Physical Violence is defined as: “The use of inappropriate words or
behaviour causing distress and / or constituting harassment”.

All incidents of violence must be reported to the Line Manager and a Trust
Incident Report Form Completed. Assaults must also be reported to the Police.

The PCT provides a range of Conflict Resolution and Physical Intervention
training

Further guidance can be found in the Trust’s Policy for the Management of
Violence & Aggression (NEE.176)

Lone Working
Many of the Trust’s employees may find themselves designated as a Lone
Worker at times. The Trust recognises the importance of these employees
being afforded as safe a working environment as is reasonably practicable.

Lone workers, generally, come into three categories:
      Staff who normally work in the community, such as District Nurses,
       Health Visitors, Occupational Therapists and Physiotherapists
      Staff who are out based, such as Clinic Staff, Practice Staff and School
       Nurses, or
      Staff who travel between sites, such as Managers and Specialist Nurses

Line Managers of lone workers have a duty to:
   d) Undertake a suitable and sufficient risk assessment of the hazards to
      which the lone worker may be exposed
   e) Put control measures in place to reduce the risk, and
   f) Monitor the effectiveness of the control measures applied

Employees have a duty to:
   a) Follow all procedures and arrangements made for lone workers, and
   b) Report all incidents or near misses relating to lone working

Line Managers should undertake a Risk Assessment on all Lone Working
activities and decide who else should be included , for example people who are
first in or last out, those interviewing patients or members of the public in side
rooms and/or even staff who have to collect items from another part of the site.

Further guidance can be found in the Trust’s Lone Worker Policy




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3.25   Training and Training Records
All new permanent employees must attend the Corporate Induction Programme
at the earliest practicable time after commencing employment. This training
includes Health, Safety, Welfare, Fire, Security and Back Awareness.

All staff must attend Update Training every 2 years.

All employees must also receive local induction where they will be given
appropriate information, instruction and training to ensure that they are aware of
the general and site specific hazards, safe systems of work and departmental
rules of their particular workplace.

Managers are to identify the specific safety related training needs for the staff
they are directly responsible for and must make adequate arrangements for
staff to be able and actually attend. Once training needs have been recognised,
the managers should then contact the Training, Education and Development
Team who will book staff onto the courses.
Line Managers are also responsible for keeping records of all health & safety
training for all their members of their staff.

3.26   Waste
All staff should follow the guidelines as laid out in the Trust’s Environmental
Policy and comply with the segregation, handling and storage of waste as
advised.

      Household waste will be disposed of by using black plastic bags.
      Confidential waste should either be shredded or deposited in THICK
       WHITE woven plastic bags. See also the Trust’s Records Management
       Policy for further details
      Clinical Waste will be disposed of according to legislation and local
       procedures




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SECTION 4

                        KEY PERFORMANCE INDICATORS

This policy will be monitored to ensure that it is effective. The following
performance indicators will be used as part of that evaluation:

      Health & Safety Management System Audit (bi-annually)
      Health & Safety Audits
      Incident reporting
      Evidence of progression of Health & Safety related incidents, via the
       Commissioning Quality Analysis Group and H&S Group
      National Staff Survey findings
      A demonstrable reduction (over time) in the number of Health & Safety
       related incidents reported;

      H&S Training Records

      H&S Group attendance




SECTION 5

                        EQUALITY IMPACT ASSESSMENT

This document has been assessed for equality impact. The Health & Safety
Policy is applicable to every member of staff within the PCT irrespective of their
race, ethnic origin, nationality, gender, culture, religion or belief, sexual
orientation, age or disability.




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 APPENDIX A
          NORTH EAST ESSEX PCT HEALTH & SAFETY GROUP

                          LINES OF RESPONSIBILITY



                                          PCT
                                         BOARD




                                      INTEGRATED
                                      GOVERNANCE
                                       COMMITTEE
                                         (IGC)


                                                                         Commissioning
                                                                         Quality
                                                                         Analysis Group
                                   HEALTH & SAFETY
                                       GROUP




   1.1.2 ALL                       1.1.1 STAFF SIDE                   2.1.1 WORKING
    2 PCT                          HEALTH & SAFETY                           GROUPS
DIRECTORATES*                            REPS.                       (as appropriate)


 * The relevant Directors or their representatives attending the Health & Safety
 Group will be responsible for the presentation to that Committee of relevant
 comments and issues arising from their Committees, Working Groups or
 operational areas of responsibility.

 * *Minutes of the Health & Safety Group will be submitted to every Board
 meeting




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APPENDIX B


                     Principal Health & Safety Contacts
PCT Risk Management Team
(Health & Safety, Fire, Security, Manual Handling):
Head of Risk Management                       01206 286847
Assistant Risk Manager                        01206 286845
Risk Management Administrator                 01206 286849

Occupational Health:
Occupational Health Manager                   01206 851436
Specialist Practitioner

Estates and Facilities:
Assistant Director                            01206 286861

Facilities and Portering:
Carillion                                     01255 201530

Senior HR Advisor:                            01206 286938

Infection Control Team:                       01206 286779


Health & Safety Executive (HSE):

HSE Info line, Caerphilly Business Park, Caerphilly, CF83 3GG
                                              0845 345 0055




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APPENDIX C
Monthly Departmental Inspection Report

Department …..……………………………………… Date………………………..

                                       Yes     No        Proposed action   Action taken
                                                       to be taken       and date taken
Health & Safety Policy:
Is it accessible by all staff?
Has the sign-off sheet been signed
by all staff?
Risk Assessments:
Have Risk Assessments been
completed?
Are they accessible to all staff?
Are they reviewed on a regular
basis?
COSHH folder:
Is it accessible by all staff?
Has it been signed by all staff?
Are they reviewed on a regular
basis?
Hazardous Substances:
Are all containers clearly marked?
Are all substances stored
appropriately?
First Aid:
Is FA box stocked as per Trust list?
Is a FA notice displayed?
Are named First Aiders current?
Needles (if appropriate):
Are sufficient boxes provided?
Are all boxes correctly assembled?
Are boxes changed when ⅔ full?
Are temporary closures activated?
Waste:
Is domestic waste stored correctly?
Is clinical waste stored correctly?
Portable Electrical Equipment:
Have all been tested during last 12
months?
Are all plugs and leads in good
condition?
Fire:
Do all fire doors open & close
freely?
Are emergency evacuation routes
clear at all times?
Have extinguishers and hoses
been tested in last 12 months?
Are Fire Alarm call points
accessible & clear?
Are completed evacuation notices
displayed?

NEE168                                                                                 34
Version 7 April 2010
Policy Owner: Head of Risk Management
Approved by: First Approved by Health and Safety Group
Review date: July 2011
Display Screens:
Have all ‘users’ been identified &
trained?
Is lighting adequate for ‘users’?
Cleanliness:
Are toilets & bathrooms clean?
Are floors & walls clean?
Is hot water, soap and towels freely
available?
Lighting:
Is lighting adequate in all areas?
Do all light fittings work, and are
they clean?
Storage:
Are heavy items stored in
appropriate places?
Are all shelves accessible?
Are gangways and corridors free of
obstructions?
Windows / Ventilation:
Do all windows look in good
condition?
Do windows open to a maximum of
4 inches?
Are window restrictors in place?
Is ventilation reasonable?

Inspection carried out by
(name)………………………..(signature)…………………………….

Action Points addressed by
(name)……………………..(signature)…………………………….


1   Departmental Inspection Report - Guidance

Departmental Inspection should be completed at least every 8 weeks in clinical areas
and at least every 12 weeks in non-clinical areas.

The Inspection should be completed by members of staff of that department, preferably
on a rotational basis, so that a “fresh pair of eyes” are looking at the issues each time
e.g. for changes to employee profiles, new starters, changed circumstances.

The inspection should address each of the areas listed overleaf (if applicable) and if
found to be acceptable, then a tick put in the appropriate box. If any condition or
situation is deemed to be unacceptable, then a cross should be placed in the
appropriate box with a comment added into the ‘Proposed action to be taken’ box.

If there are no action points arising, Report can be filed into appropriate section of H&S
Folder.

If there are any action points requiring attention, then Report must be forwarded to Line
Manager for action. Line Manager should enter details of what action is to be taken in
the “Action taken and date taken’ box and then file report in the appropriate section of
the H&S Policy. Any items of significance should be raised with the Risk Management
team.
NEE168                                                                                 35
Version 7 April 2010
Policy Owner: Head of Risk Management
Approved by: First Approved by Health and Safety Group
Review date: July 2011

								
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