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Health and Safety Policy
Last Review Date
April 2018
Approving Body
Executive Committee
Date of Approval
02nd May 2018
Date of Implementation
May 2018
Next Review Date
April 2021
Review Responsibility
Associate Director of HR & Corporate
Services
Version
2.0
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REVISIONS/AMENDMENTS SINCE LAST VERSION
Date of Review Amendment Details
December 2013 New Health & Safety Policy based on guidance documents and advice from the Health & Safety Executive to classify a Clinical Commissioning Group as an office environment and therefore a low risk environment. The policy will be supported by a range of operational procedures covering areas such as Display Screen Equipment, Portable Appliance Testing, First Aid, Personal Safety and Moving & Handling.
April 2018 The addition of the following Procedures Appendix A (Display Screen Equipment Procedure) Appendix B (Moving and Handling Procedure) Appendix C (Driving at Work Procedure) Appendix D (Control of Substances Hazardous to Health Procedure) Appendix E (First Aid Procedure) Updated legislation section The addition of reference to White Rose House- Section A 1.1 & Section B 1.4 Section 2 - Date change of the Policy Addition of the location of the H&S Poster in White Rose House
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CONTENTS
Page Definitions 4 Section A – Policy 5 1. Policy Statement, Aims & Objectives 5 2. Legislation & Guidance 5 3. Scope 6 4. Accountabilities & Responsibilities 6 5. Dissemination, Training & Review 7 Section B – Procedure 9 1. Overview
9
2. Policy Statement
9
Section C – Appendices 12 Appendix A – Display Screen Equipment Procedure 13 Appendix B – Moving and Handling Procedure 19 Appendix C – Driving at Work Procedure 26 Appendix D – Control of Substances Hazardous to Health Procedure
31
Appendix E – First Aid Procedure 37
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DEFINITIONS Term
Definition
CCG
Clinical Commissioning Group
HSE
Health & Safety Executive
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SECTION A – POLICY 1. Policy Statement, Aims & Objectives 1.1 NHS Doncaster Clinical Commissioning Group’s (CCG) Health and
Safety Policy outlines our commitment to effectively manage health and safety on a risk basis during our activities. NHS Doncaster CCG’s primary function is to commission healthcare services for the Doncaster population. NHS Doncaster CCG employs approximately 213 staff based primarily within Sovereign House and White Rose House in Doncaster. The CCG also are the host employer of a team of employees based within Sheffield CCG headquarters. NHS Doncaster CCG also supports other NHS organisations within South Yorkshire by providing hot desk capacity within Sovereign House as well as hosting multi agency meetings as required.
1.2 The aims of this procedural document are:
To set out how the organisation will approach and discharge its legal duties under the Health and Safety at Work Act 1974 and associated regulations to protect employees and third parties affected by the organisation’s activities.
1.3. To ensure continuous improvement, the organisation has a range of
key performance indicators (KPIs) which it uses for monitoring purposes:
No. Key Performance Indicator Method of Assessment
1. Monitoring of Health & Safety progress.
Quarterly Corporate Assurance Report.
2. Legislation & Guidance 2.1. The following legislation and guidance has been taken into
consideration in the development of this procedural document:
Health & Safety at Work Act (1974)
The Management of Health & Safety at Work Regulations 1999
The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013
The Safety Representatives and Safety Committees Regulations 1977
The Health & Safety (Consultation with Employees) Regulations 1996
The Control of Substances Hazardous to Health Regulations 2002
The Manual Handling Operations Regulations 1992
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The Health and Safety (Display Screen Equipment) Regulations 1992
Road Traffic Act 1991 3. Scope 3.1. This policy applies to those members of staff that are directly employed
by NHS Doncaster CCG and for whom NHS Doncaster CCG has legal responsibility. For those staff covered by a letter of authority / honorary contract or work experience this policy is also applicable whilst undertaking duties on behalf of NHS Doncaster CCG or working on NHS Doncaster CCG premises and forms part of their arrangements with NHS Doncaster CCG. As part of good employment practice, agency workers are also required to abide by NHS Doncaster CCG policies and procedures, as appropriate, to ensure their health, safety and welfare whilst undertaking work for NHS Doncaster CCG.
4. Accountabilities & Responsibilities 4.1. Overall accountability for ensuring that there are systems and
processes to effectively manage health and safety within the workplace lies with the Chief Officer. This accountability includes establishing the provision and maintenance of a safe working environment, the adoption and enforcement of safety policies, plans and procedures and the welfare and health support arrangements for all staff. In addition the Chief Officer is responsible for ensuring that sufficient resources are made available to meet the provision of health and safety legislation. Responsibility is also delegated to the following individuals:
Associate Director of
HR & Corporate Services
Has delegated responsibility for:
Overseeing Health & Safety within the organisation, including the review and maintenance of this procedural document and associated operational procedures.
Overseeing the production of the Corporate Assurance Report which includes Health & Safety reporting.
Ensuring that health and safety training is available to staff
Ensuring the provision of Competent Person advice to the organisation
Competent Person
Sourced from the Health and Safety Shared Service, hosted by Rotherham CCG, the Competent Person has delegated responsibility for:
Day to day responsibility for Health & Safety management
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across the organisation.
The provision of Health & Safety training.
The development of Health & Safety policies.
Ensuring completion of the relevant RIDDOR returns to the Health and Safety Executive.
Ensuring risk assessments are carried out as required.
Completing inspections and audits in consultation with Managers.
Attending any Health and Safety meetings as required.
Liaising with senior managers on health and safety issues.
Ensuring the promotion of organisational health and safety.
Maintaining audit and investigation reports.
Ensuring the analysis of incidents when required.
Supplying information for reports to the Audit Committee on health and safety subjects as required.
Monitoring and learning lessons from all accidents and injuries to staff or visitors and making recommendations for improvements.
Line Managers
Have delegated responsibility for:
Developing safe working practices and organisational arrangements for carrying them out.
Undertaking risk assessments, bringing them to the attention of the staff and reporting as required; subject to the provision of the appropriate training.
Investigation of accidents and incidents as appropriate.
Staff
Responsibilities of Staff (including all employees, whether full/part time, agency, bank or volunteers) are:
Follow the training received when using any work items provided by the organisation.
Take reasonable care of your own and other people’s health and safety.
Cooperate with the organisation on health and safety.
Report any areas where work practices or inadequate precautions may be putting anyone’s health and safety at serious risk.
Staff Side
Have responsibility for:
Understanding the policy and its application
Advising and supporting members
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5. Dissemination, Training & Review 5.1. Dissemination 5.1.1. The effective implementation of this procedural document will support
openness and transparency. NHS Doncaster CCG will:
Ensure all staff and stakeholders have access to a copy of this procedural document via the organisation’s website.
Communicate to staff any relevant action to be taken in respect of complaints issues.
Ensure that relevant training programmes raise and sustain awareness of the importance of effective complaints management.
5.1.2. This procedural document is located on the CCG website. A set of hardcopy Procedural Document Manuals are held by the Governance Team for business continuity purposes and all procedural documents are available via the organisation’s website. Staff are notified by email of new or updated procedural documents.
5.2. Training 5.2.1. All staff will be offered relevant training commensurate with their duties
and responsibilities. Staff requiring support should speak to their line manager in the first instance. Support may also be obtained through their HR Department.
5.3. Review 5.3.1. As part of its development, this procedural document and its impact on
staff, patients and the public has been reviewed in line with NHS Doncaster CCG’s Equality Duties. The purpose of the assessment is to identify and if possible remove any disproportionate adverse impact on employees, patients and the public on the grounds of the protected characteristics under the Equality Act.
5.3.2. The procedural document will be reviewed every three years, and in
accordance with the following on an as and when required basis:
Legislatives changes
Good practice guidelines
Case Law
Significant incidents reported
New vulnerabilities identified
Changes to organisational infrastructure
Changes in practice
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5.3.3. Procedural document management will be performance monitored to ensure that procedural documents are in-date and relevant to the core business of the CCG. The results will be published in the regular Governance Reports.
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SECTION B – PROCEDURE 1. Overview 1.1. NHS Doncaster CCG takes a risk-based approach to organisational
health and safety, assessing risks and reviewing the assessment on at least an annual basis using the Health & Safety Executive recommended format.
Step 1: Identify the hazards / risks
Step 2: Identify who might be harmed and how
Step 3: Identify any controls already in place
Step 4: Identify what further action is necessary
Step 5: Develop further actions as required to mitigate the identified risks
1.2. The policy statement in Section 2 is based on the recommended format
from the Health & Safety Executive (HSE) and comprises the health & safety policy of the organisation.
1.3. Responsibility is delegated to the Leads as listed overleaf. The individuals fulfilling those roles are detailed on the organisation’s website. NHS Doncaster CCG employs approximately 213 staff based primarily within Sovereign House and White Rose House in Doncaster. The CCG also are the host employer of a team of employees based within Sheffield CCG headquarters. NHS Doncaster CCG also supports other NHS organisations within South Yorkshire by providing hot desk capacity within Sovereign House as well as hosting multi agency meetings as required.
2. Policy Statement 2.1. The Policy Statement overleaf details the CCG’s actions against each
area of responsibility.
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This is the statement of general policy and arrangements for:
NHS Doncaster Clinical Commissioning Group
Overall and final responsibility for health and safety is that of:
Chief Officer
Day-to-day responsibility for ensuring this policy is put into practice is delegated to:
Associate Director of HR & Corporate Services, supported by the Competent Person
STATEMENT OF GENERAL POLICY
RESPONSIBILITY OF: ACTION / ARRANGEMENTS
To prevent accidents and cases of work-related ill health and provide adequate control of health and safety risks arising from work activities.
Associate Director of HR & Corporate Services supported by the Competent Person
NHS Doncaster CCG takes a risk-based approach to organisational health and safety, assessing risks and reviewing the assessment on at least an annual basis using the Health & Safety Executive recommended format.
A Health and Safety Premises Inspection is completed annually. An action plan from the inspection is developed by the Competent Person and monitored by the Associate Director of HR & Corporate Services with exceptions reported to the Audit Committee.
Ad hoc risk assessments are completed as required as situations arise. Risk assessments are reviewed every year or earlier if working habits or conditions change.
To provide adequate training to ensure employees are competent to do their work.
Associate Director of HR & Corporate Services supported by the Competent Person and HR Manager
A Mandatory and Statutory training plan is in place for all staff including agency/bank staff.
Any contractors on site are managed by the building management company or via a facilities management contract.
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To engage and consult with employees on day-to-day health and safety conditions and provide advice and supervision on occupational health.
Associate Director of HR & Corporate Services supported by the Competent Person, HR Manager and Staff Side Representative.
Staff are routinely consulted on health and safety matters as they arise.
Staff are encouraged to feed any issues arising through line managers, Staff Brief and the Associate Director of HR & Corporate Services.
Access to Occupational Health services including physiotherapy and counselling is available.
The Competent Person provides Display Screen Equipment / Workstation assessments on request.
To implement emergency procedures – evacuation in case of fire or other significant incident.
Associate Director of HR & Corporate Services supported by the Competent Person
A Fire Policy is in place and subject to a review schedule.
Escape routes well signed and kept clear at all times.
Evacuation plans are tested from time to time and updated as necessary.
Fire Marshalls are in place.
First Aiders are in place.
To maintain safe and healthy working conditions, provide and maintain plant, equipment and machinery, and ensure safe storage/use of substances.
Associate Director of HR & Corporate Services supported by the Competent Person
Toilets, hand washing facilities and drinking water are provided. These facilities are maintained under contract. A space for eating refreshments is provided alongside access to boilers for hot drinks.
A system is in place for routine inspections and testing of equipment and machinery and for ensuring that action is promptly taken to address any defects.
Health and safety poster is displayed:
In the Ground Floor Open Plan office area in Sovereign House.
On the notice board adjacent to the lift on the first floor of White Rose House.
Posters are displayed within Sheffield CCG Headquarters in accordance with NHS Sheffield CCG’s health and safety policy.
First-aid box and accident book are located:
First aid boxes are signed and located on each floor of Sovereign House and Upper Floor of White Rose House. First aid boses are located within Sheffield CCG Headquarters in accordance with NHS Sheffield CCG’s health and safety policy.
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Accidents and ill health at work reported under RIDDOR:
An organisational incident reporting system is in place coordinated by the Governance Manager and linking into RIDDOR.
Signed: (Employer) Date: April 2018
Subject to review, monitoring and revision by:
Associate Director of HR & Corporate Services
Every: 12 months or sooner if work activity changes
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SECTION C – APPENDICES Procedures for the management of operational health, safety and security issues such as Control of Substances Hazardous to Health (COSHH), Portable Appliance Testing, First Aid and Manual Handling are developed as required based on the organisational risk assessment. These operational procedures will be approved by the Associate Director of HR & Corporate Services, stored on the Shared Drive and disseminated appropriately to staff.
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Appendix A
DISPLAY SCREEN EQUIPMENT (DSE) PROCEDURE
CONTENTS
1 Introduction 14 2 Definitions 14 3 Safe Working 15 4 Eye and Eye Sight Tests 16 5 Maintenance of Equipment 17 6 Training and Awareness 17 7 Assessment 17 8 Further Information 18
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1. INTRODUCTION
1.1. To comply with the Health and Safety (Display Screen Equipment) Regulations 1992, the CCG shall identify users of display screen equipment (DSE); and carry out an assessment of work stations, and, as far as reasonably practicable, introduce measures that will eliminate or minimise possible health effects.
1.2. In order to achieve this the CCG accepts that implementation of an effective and proactive DSE management procedure will enable it to work towards reducing risks to all persons who are affected by the organisations activities, including the reduction of potential or actual harm to the organisations employees, and to its services, property and financial resources.
1.3. This procedure covers everyone that is employed by the organisation including temporary staff that use display screen equipment.
2. DEFINITIONS
2.1. Regulation 1 of the DSE Regulations prescribe a number of definitions
which must be taken into consideration, as follows:
DSE: Any alphanumeric or graphic display screen, regardless of the display process involved and the term DSE covers both conventional display screens and other types such as liquid crystal or plasma displays used in flat panel screens, touch screens and other emerging technologies. The term DSE includes any portable DSE i.e. laptop and handheld computers, personal digital assistant devices and some portable communication devices.
DSE user: A “user” is defined as being an employee who habitually uses DSE equipment as a significant part of their job requirements.
Where it is clear that the use of DSE is more or less continuous on most days, the individual concerned should be considered as a user under the DSE Regulations. Where there is less continuous or less frequent use of DSE, other factors connected with the job must be assessed. It will generally be appropriate to classify the person concerned as a DSE user if they:
Normally use DSE for continuous or near-continuous spells of an hour or more at a time; and use DSE in this way on a more or less daily basis
Have to transfer information quickly to or from the DSE
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The performance requirements of the system demand high levels of attention and concentration by the user where for example, the consequences of error may be critical.
Workstation:
For all DSE the workstation, as defined, is the assembly including the screen, keyboard, other parts of the computer and its accessories (such as the mouse or other input device), the desk, chair and the immediate work environment. Some of these items are specifically mentioned in the DSE regulations, but anything else in the immediate work environment is also part of the workstation.
3. SAFE WORKING
3.1. Common health hazards associated with working with DSE are:
upper limb disorders (including pains in the neck, arms, elbows, wrists, hands and fingers) often referred to as Repetitive Strain Injury (RSI)
backache
fatigue and stress
temporary eye strain (not damage)
headaches 3.2. The causes may not be obvious and can be due to a number of other
factors however there is sufficient evidence available on the importance of environmental and ergonomic issues that reduce and in some instances eliminate the hazards. Furniture and equipment adjusted incorrectly can result in discomfort and can even lead to disability in extreme circumstances. Poor work design can cause or aggravate these conditions. Unnecessary discomfort can be avoided by adopting the following simple precautions:
Adjust furniture and equipment so that you are comfortable when working
Where possible, take the opportunity to vary activities, breaking up long periods of DSE activity and ensure scheduled breaks are away from the workstation
Use your entitlement to eye and eyesight tests
Report symptoms of discomfort or ill health as soon as you become aware of them
Inform your line manager of your training needs
Do not tamper with electrical equipment - ask IT for assistance
3.3. Display Screen Equipment has made a significant contribution to working life and can be used in complete safety where a few common sense measures are taken. The four most important steps are to:
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Adjust furniture and equipment to suit your needs - do not adjust your own posture to suit the workstation
Avoid adopting a static posture and avoid (where possible) prolonged DSE work without a change of activity
Always report problems with your furniture, equipment or health as soon as these arise to your line manager
Follow the guidance in the appendices
3.4. In accordance with regulation 4 of the DSE regulations all users shall be provided with appropriate rest breaks/time away from the DSE in relation to the number of hours the user works. Whilst it is the CCG’s duty to provide appropriate breaks it is the user responsibility to ensure these are away from their work station.
4. EYE AND EYE SIGHT TEST
4.1. In accordance with regulation 5 of the DSE regulations the employee (user) is entitled to request an appropriate eye and eyesight test. An appropriate eye and eyesight test means a sight test as defined by the Opticians Act Legislation and includes a test of vision and an examination of the eye.
4.2. The CCG will offer reimbursement for any eye and eyesight test when:
DSE users request a test
Any individual who is to be recruited or relocated within the CCG to be a user requests a test
Any user requires and requests an update test
Any user notices a change in their eyesight, visual discomfort or eyestrain
The intervals between tests should be as recommended by their optician but reimbursement will not normally exceed two years.
4.3. In order to receive reimbursement the user must:
Be defined as a user under the requirements of this policy
Have completed an documented a self-assessment of their work station
Submit a request to their manager prior to the eyesight test (via email) to be acknowledged by the manager
Obtain a signature from the optician on receipt of the eyesight test
Obtain an official receipt for the cost of the eyesight test from the opticians
Submit the official receipt via expenses for reimbursement, remembering to keep a copy for their own records
Please note that the CCG will not be liable for the cost of the basic DSE eyesight test or the cost of any necessary DSE Special Corrective Appliances
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(see below) if the request has not been acknowledged by the manager prior to the eye sight test.
4.4. The CCG will reimburse up to £21.31 for a sight test if the individual is not automatically entitled to free NHS sight tests. This figure was equivalent to the NHS sight test fee payable to optometrists from 1st April 2012. The maximum reimbursement will be revised annually in line with national amendments to this fee.
If the result of the sight test indicate that special corrective appliances are required for the work being done the CCG will reimburse the cost of the lenses and a basic frame. If normal corrective appliances can be used then reimbursement will not apply. Should the employee wish to ‘enhance’ the appearance of the spectacles for cosmetic purposes they will be required to meet the additional cost.
5. MAINTENANCE OF EQUIPMENT
5.1. General day to day maintenance of all DSE will be the responsibility of the
user; i.e. any defects or problems must be reported to management, as soon as possible.
The user must not put themselves at risk by continuing to operate a defective piece of equipment. If the equipment is of an electrical nature, it must be isolated and removed from use, and reported to the IT department.
6. TRAINING AND AWARENESS
6.1. In accordance with regulations 6 & 7 of the DSE regulations; all staff will receive awareness of this procedure through their local Health and Safety induction process. Guidance on how to set up your workstation can be found in appendix 1.
7. ASSESSMENT
7.1. Regulation 2 requires that a ‘suitable and sufficient’ assessment must be made of all workstations utilised by users. Therefore all DSE users are required to assess their own workstation using the standard DSE assessment form which is available on the CCG web site. An e learning package is available to support this process.
7.2. On completion of the assessment and effective implementation of
suitable control measures to reduce any risk of injury and/or ill health, the assessment form should be returned to the Associate Director of HR & Corporate Services.
7.3. Where it is not possible to reduce the level of risk and there remains a significant risk of injury and/or ill health, a request by a line manager should be made to the health and safety team, in order that a further risk assessment can be carried out. An assessment will need to be reviewed if there is any reason to suspect that it is
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no longer valid or there is a change to the matters to which the assessment relates.
8. FURTHER INFORMATION
8.1. A copy of the DSE Self-Assessment and information regarding setting up your workstation can be found on the NHS Doncaster CCG intranet pages.
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Appendix B
MOVING AND HANDLING PROCEDURE CONTENTS: Page 1 Introduction 20
2 Risk Assessment 20
3 Principles of Handling 22
4 Good Handling Techniques for Lifting 22
5 Training 25
6 Further Information 25
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1. INTRODUCTION 1.1. NHS Doncaster Clinical Commissioning Group (CCG) thereafter known
as the CCG acknowledges a duty of care to the health, safety and welfare of staff and acknowledges that preventing harm to staff is an important health and safety issue.
1.2. The Manual Handling Operations Regulations 1992 (amended 2002)
are based upon established principles of good occupational health and safety practices and apply to a wide range of manual activities including lifting, lowering, pushing, pulling or carrying; the load may be either inanimate, such as a box or a trolley, or animate, such as a person or an animal.
1.3. In line with these regulations, employers are required to make an
assessment of the risks to health, which arise from the manual handling of loads, in the circumstances of their own particular workplace. Where risks are identified as a result of such an assessment, employers must establish what measures are necessary to eliminate or adequately control the risk of injury due to manual handling and what further precautions may need to be taken.
Manual handling is defined by the Health and Safety Executive as any: “transporting or supporting of a load (including the lifting, putting down, pushing, pulling, carrying or moving thereof) by hand or bodily force”.
2. RISK ASSESSMENT 2.1. HSE guidance on the manual handling regulations details a clear
hierarchy of measures to be used when managing manual handling tasks. Firstly hazardous manual handling operations should be avoided where possible. Where this is not possible, risks should be assessed, taking into consideration the following factors:
Task (What does it entail?)
Holding loads away from the body?
Strenuous pushing or pulling?
Holding loads away from the body?
A work rate imposed by a process?
Large vertical movement? Insufficient rest or recovery time?
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Long carrying distances? Repetitive handling? Individual (Person carrying out the task)
Require unusual capability, e.g. above average strength or agility?
Endanger those with a health problem or learning/physical disability?
Endanger pregnant women or young persons?
Call for special information or training?
Load (What you are moving?) Is the load:
Heavy or bulky? Harmful, e.g. sharp or hot?
Difficult to grasp? Awkwardly stacked?
Unstable or likely to move unpredictably
Too large for the handler?
Environment (What the surrounding area is like you are about to travel through?)
Restrictions on posture? Variations in floor levels?
Bumpy, obstructed or slippery floors?
Gusts of wind or other strong air movements?
Hot/cold/humid conditions? Poor lighting conditions?
Restrictions on movements from clothes or Personal protective equipment (PPE)?
2.2. Appropriate measures should be taken to eliminate or reduce the risk
as far as is reasonably practicable. 2.3. There is a statutory requirement on all employers to assess the health
and safety risks to their employees and others (public, visitors, and contractors) that may be affected by their work. Manual handling risk assessments will be carried out in accordance with the CCG’s risk assessment procedure as appropriate to the task; an action plan will be developed in accordance with manual handling procedures.
2.4. Manual handling risk assessments shall be undertaken for all areas
within the CCG where potential manual handling hazards have been identified or after a manual handling incident which resulted in an injury or near miss.
2.5. Risk assessments will be reviewed in the following circumstances:
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routinely every 12 months
where there are significant changes i.e. to /equipment/staffing
where a manual handling incident has occurred
when there has been a change in legislation which would have an impact on the manual handling risk assessment process
3. PRINCIPLES OF HANDLING 3.1. These principles should be applied to any handling situation whether a
person, object or animal. Stop / avoid
Lifting whenever possible
Stooping
Twisting and stooping when supporting, lifting or carrying a load
A prolonged hold (or lift)
Wearing restrictive clothing and unsafe footwear
Lifting loads above chest height 4. GOOD HANDLING TECHNIQUE FOR LIFTING Think before lifting / handling.
Plan the lift. Can handling aids be used? Where is the load going to be placed? Will help be needed with the load? Remove obstructions such as discarded wrapping materials. For a long lift, consider resting the load midway on a table or bench to change grip.
Adopt a stable position.
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The feet should be apart with one leg slightly forward to maintain balance (alongside the load, if it is on the ground). The person should be prepared to move their feet during the lift to maintain their stability.
Start in a good posture.
At the start of the lift, slight bending of the back, hips and knees is preferable to fully flexing the back (stooping) or fully flexing the hips and knees (squatting).
Get a good hold.
Where possible the load should be hugged as close as possible to the body. This may be better than gripping it tightly with hands only.
Keep the load close to the waist.
Keep the load close to the body for as long as possible while lifting. Keep the heaviest side of the load next to the body. If a close approach to the load is not possible, try to slide it towards the body before attempting to lift it.
Don’t flex the back any further while lifting.
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This can happen if the legs begin to straighten before starting to raise the load.
Avoid twisting the back or leaning sideways,
Especially while the back is bent. Shoulders should be kept level and facing in the same direction as the hips. Turning by moving the feet is better than twisting and lifting at the same time.
Keep the head up when handling.
Look ahead, not down at the load, once it has been held securely.
Move smoothly.
The load should not be jerked or snatched as this can make it harder to keep control and can increase the risk of injury.
Don’t lift or handle more than can be easily managed.
There is a difference between what people can lift and what they can safely lift. If in doubt, seek advice or get help.
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Put down, and then adjust.
If precise positioning of the load is necessary, put it down first, and then slide it into the desired position.
5. TRAINING All staff employed by the CCG are required to undertake mandatory manual handling (object) training upon joining the CCG and every three years thereafter 6. FURTHER INFORMATION
A copy of the Manual Handling of loads risk assessment checklist can be found on the NHS Doncaster CCG intranet pages.
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Appendix C
DRIVING AT WORK
PROCEDURE
CONTENTS
1 Introduction 27
2 Consequences 27
3 Risk Assessment 28
4 Hazards 28
5 Lease Cars 30
6 Monitoring and Review 30
7 Further Information 30
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1. INTRODUCTION
1.1. NHS Doncaster Clinical Commissioning Group (CCG) covers a large geographical area, some of it rural, to provide a comprehensive range of services. This inevitably means employees will be expected to drive during the course of their employment therefore this Standard Operating Procedure (SOP) relates to all CCG employees who are required to drive as part of their role. Managing Driving at Work is becoming an important issue for employers who expect employees to drive as part of their employment.
1.2. The Health & Safety at Work etc Act 1974 requires the
employer to safeguard their employees and others affected by their undertakings. This applies to employees who are required to drive as part of their employment. This procedure outlines how NHS Doncaster CCG will fulfil its statutory duties under the Road Traffic Act 1988 & 1991, Road Safety Act 2006 and the Management of Health and Safety at Work Regulations 1999.
2. CONSEQUENCES
2.1. The Sentencing Advisory Panel has introduced new sentencing guidelines for motorists who cause death by dangerous driving. Anybody convicted of killing by dangerous driving would normally face a prison sentence of between 2 - 14 years. Disciplinary action could also be taken by the CCG for any employee found deliberately in breach of the guidance contained within this procedure.
2.2. Mobile phones
Staff are liable to receive an automatic fixed penalty notice if they are found to be using a hand-held phone while driving or riding, leading to 6 penalty points on their licence and a fine of £200. The rules also apply if they are stopped at traffic lights or queuing in traffic. The phone should be switched to voice mail and the calls retrieved when it is practical and safe to stop the vehicle.
2.3. Substances
It is illegal for staff to drive if they are unfit to do so because they are under the influence of legal or illegal drugs. If the police stop a member of staff who they think is under the influence of drugs they can conduct a ‘Field Impairment Assessment’. This is a series of tests such as asking the individual to walk in a
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straight line and checking the size of their pupils. Individuals deemed unfit to drive because of taking drugs will be arrested and will have a blood test at a police station. If the test shows they have taken drugs the individual could be charged with a crime. Drivers do not have to be on illegal drugs to be unfit to drive - many prescription or over-the-counter drugs can also impair their ability to drive. If staff are taking legal drugs and are not sure they should talk to their doctor, pharmacist or healthcare professional before driving. Persons convicted of drug driving are liable for:
a minimum 1 year driving ban
a fine of up to £5,000
a criminal record
Their driving licence will show they have been convicted for drug driving. This will last for 11 years. The penalty for causing death by dangerous driving is a prison sentence of up to 14 years.
3. RISK ASSESSMENT
3.1. Where employees are required to drive as part of their employment with the CCG then a dynamic risk assessment should be carried out for the task of driving. Risk assessments should take account of the following:
The journey, including the item(s)/passenger(s) to be transported, inclement weather;
The vehicle, road worthiness and well maintained;
The driver, all staff should make reasonable provision for foreseeable events: punctures, breakdowns etc. And the necessity to communicate their circumstances to their manager should the need arise.
3.2. This assessment should also take into account the number
of hours the employee is expected to drive, distractions and fatigue. Ample time should always be allocated for travelling between venues for appointments. The risk assessment may be a generic risk assessment for a department, team, service, or specific staff where employees’ driving tasks are similar.
4. HAZARDS
There are four main factors that can affect driving activity, these are:
Substances:
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Under no circumstances should any member of staff drive while under the influence of alcohol, illegal substances or prescribed medication which may affect their ability to drive. Staff should always read the information provided.
Distractions: The Highway Code requires drivers to avoid distractions when driving. This includes loud noises, reading, inserting a cassette or CD, tuning a radio, arguing with passengers or other road users, eating or drinking, using in-car technologies and using mobile phones. Road Vehicles (Construction and Use) Regulations 1986 prohibits people from driving a car on the road if they cannot have proper control of the vehicle or have a full view of the road and traffic ahead. Employees of the CCG when driving must at all times remain in full control of the vehicle and must not attempt any task that distracts them from the operation of driving. When used properly, phones in cars can have many benefits. They can provide valuable security and help in an emergency. However, in the course of their employment with the CCG, irrespective of who owns the vehicle or the mobile phone, staff should under no circumstances operate a hand held mobile phone while driving. This includes the sending or receiving of text messages or photo messaging. Staff with access to a mobile phone whilst in the course of their employment should follow the following procedure when driving:
Place the mobile phone in the standby mode. If you receive a call, a text or photo messages whilst driving do not answer the phone. If you need to answer or use the phone find a safe place to park, (remember you cannot pull over on the hard shoulder of the motorway except in an emergency) turn off the engine and answer/use the phone.
You can use hands-free phones, sat navs and 2-way radios when you are driving or riding. But if the police think you are distracted and not in control of your vehicle you could still get stopped and penalised.
Fatigue:
The Highway Code recommends that drivers should take a 15-minute rest break every two hours. Employees need to examine work schedules in advance to ensure that they will not be pressured by time. Drivers must report to their line manager if they feel unfit to drive. Drivers must report unreasonable scheduling issues as soon as they arise. Line Managers must respond to any such reports with urgency. Employees must not drive under the influence
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of fatigue caused by lack of sleep or after long working hours as this could be classed as neglect.
Neglect (maintenance):
Regardless of whether the vehicle is under a CCG lease agreement or owned by the driver, it is the driver’s responsibility to ensure that the vehicle is in a roadworthy condition in accordance with the road traffic act 1991 e.g. tyres must be replaced when tread depth reaches a minimum of 1.6 mm. A valid MOT certificate (for those cars over three years old) should be seen by managers when checking credentials. Managers must ensure that appropriate arrangements are in place for maintenance of lease cars and lease vehicles used by multiple drivers.
5. LEASE CARS The CCG participates in a salary sacrifice scheme whereby staff who meet the necessary criteria can lease a car through NHS Fleet Solutions Ltd. Staff taking advantage of this scheme should read the NHS Fleet Solution brochure in conjunction with this policy.
6. MONITORING AND REVIEW
This SOP will be reviewed every three years and in accordance with any changes to relevant legislation, good practice guidelines or after a significant accident / incident has been reported.
7. FURTHER INFORMATION
A copy of the Staff Handbook for drivers, Driver incident recording form and annual employee private vehicle check can be found on the NHS Doncaster CCG intranet pages.
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Appendix D
CONTROL OF SUBSTANCES HAZARDOUS TO
HEALTH REGULATIONS 2002 (COSHH)
PROCEDURE
CONTENTS
1 Introduction 32
2 Scope 32
3 Definitions 33
4 Material Safety Data Sheets 34
5 Control measures 34
6 COSHH Assessments 35
7 Training requirements 35
8 Further Information 36
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1. INTRODUCTION NHS Doncaster Clinical Commissioning Group (CCG) acknowledges its responsibilities under the Control of Substances Hazardous to Health Regulations 2002 (COSHH) and the importance of providing a working environment which is safe and healthy for all employees, contractors, visitors and members of the public. The CCG will ensure that the exposure to hazardous substances is prevented or, if this is not reasonably practicable, adequately controlled by assessing the risks, implementing appropriate control measures and ensuring that appropriate advice and training is given to users the risks of exposure to hazardous substances can be reduced. It is recognised that failure to comply with COSHH Regulations and the approved codes of practice (L5) constitutes an offence and is subject to penalties under the Health and Safety at Work etc. Act 1974. 2. SCOPE This procedure applies to all staff and other persons working on CCG premises who come into contact with hazardous substances used by the CCG. The CCG is responsible for ensuring contractors have carried out relevant COSHH assessments by including this as a requirement in the service specification. The regulations require the employer to:
identify substances which have the potential to cause harm
not carry out any work which is liable to expose any employees to harmful substances unless they have made a “suitable and sufficient” assessment of the risks created by that work
ensure that where there is any work which exposes employees to harmful substances, the employee shall receive such information, instruction and training as is suitable for him/her to know the risks created by such exposure, and what precautions that should be taken
ensure that exposure to harmful substances is prevented or, where this is not reasonably practicable, adequately controlled
ensure that control measures (e.g. engineering controls) personal protective equipment or other facilities are provided and that reasonable steps are taken to make sure they are properly used and staff are adequately trained in its purpose and its use
ensure that such control measures are maintained in an efficient state, in efficient working order and in good repair and in the case of PPE in clean condition
ensure that assessments of risk involving harmful substances are reviewed regularly and forthwith if:
There is a reason to suspect that the assessment is no longer
valid,
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or There has been significant change in the work to which the
assessment relates. 3. DEFINITIONS Control of Substances Hazardous to Health Regulations 2002 – COSHH Hazardous Substance - Any substance (or preparation) that is:
very toxic, toxic, corrosive, harmful or irritant
a substance for which the health and safety executive has approved an occupational exposure limit
a micro-organism or biological agent
any substance (or preparation) which is a carcinogen or possible carcinogen, mutagen or teratogen
dust at substantial airborne concentration
a substance which creates a hazard to the health of any person, which is comparable with the hazards, created by those substances mentioned above
This definition excludes a risk to the health of a person to whom the substance is administered in the course of medical treatment. (Medical treatment means medical examination or treatment, which is conducted under the direction of a registered medical practitioner.)
Routes of Entry - The method by which, substances could enter the body:
Inhalation
Ingestion
Absorption (through skin contact)
Injection (needle puncture)
WEL - Workplace Exposure Limits (WEL's). The health and safety commission has established workplace exposure limits for a number of substances hazardous to health which are intended to prevent excessive exposure to specific hazardous substances. A WEL is the maximum concentration of an airborne substance, to which an employee may be exposed by inhalation, averaged over a reference period of time, referred to as a time weighted average (TWA),Two time periods are used:
Long term (8) hours
Short Term (15 Minutes)
Substances that have been assigned a WEL are subject to the requirements of COSHH. These Regulations require employers to prevent or control
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exposure to hazardous substances. Under COSHH, control is defined as adequate only if:
the principles of good control practice are applied
any WEL is not exceeded
exposure to asthmagens, carcinogens and mutagens are reduced as low as is reasonably practicable 4. MATERIAL SAFETY DATA SHEET
Material Safety data sheets (MSDS) provide information on chemical products that help users of those chemicals to make a risk assessment. They describe the hazards the chemical presents, and give information on handling, storage and emergency measures in case of accident. A MSDS is not a COSHH assessment. The assessor should use the information it contains to carry out a COSHH assessment. 5. CONTROL MEASURES Using chemicals or other hazardous substances at work puts people’s health at risk. The law requires employers to control exposure to hazardous substances to prevent ill health. They must protect both employees and others who may be exposed by complying with the COSHH Regulations. Control measures must be determined by the level of risk to health and must take into account:
elimination and/or use of alternative, less hazardous substances and materials where possible
modification of the use or process to eliminate, isolate or reduce exposure
elimination and/or reduction of numbers of people exposed to the hazardous substance
the outcome of any environmental monitoring, as appropriate, which has been undertaken by a competent person
the provision, maintenance and use of any control equipment required
prepare plans and procedures to deal with accident, incidents and emergencies
ensure employees are properly informed, trained and supervised
the use of personal protective equipment (PPE) to reduce or control exposure to hazardous substances/materials. PPE should be regarded as a ‘last resort’ in providing protection from exposure to substances hazardous to health
Failure to comply with the identified control measures may result in disciplinary action.
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Managers are responsible for ensuring that PPE, as required, is suitable for its intended purpose, appropriately maintained, cleaned, inspected, stored and replaced as required. Employees are required to use PPE provided in accordance with the training they have been given and report any faults/defects or concerns regarding PPE to their manager. 6 COSHH ASSESSMENTS:
gather information about substances hazardous to health in your area of work i.e. establish an inventory of substances used
identify workers likely to be exposed, but note also that account should be taken of non-employees who may be exposed, as far as reasonably practicable
collate relevant information from material safety data sheets and / or other sources of information
evaluate the risk for each substance is the risk significant, insignificant or not significant due to effective control measures
determine how any risks present can be prevented or controlled
for existing controls, determine whether these are adequate and maintained in an efficient state, working order and good repair
ensure sufficient information, instruction and training is provided to staff and that training needs are identified and met
record the COSHH assessment
review the COSHH assessment biennially or sooner if circumstances change e.g. incident occurs, change in process, change in legislation
at the date of review if no further action is required the assessment should be re-signed and dated
The COSHH register must be available where any hazardous substances are used and kept in a place that is accessible to all staff. It must include:
a list of all relevant substances used in the CCG including safety data sheets for each of those substances
a COSHH assessment for the use of those substances
a supply of COSHH assessment forms
relevant COSHH documents (leaflets, information, correspondence etc.)
Sources of further information and support. 7 TRAINING REQUIREMENTS The CCG will ensure that employees receive the necessary level of training for them to fulfil their individual responsibilities identified in this procedure. Employees must be informed of:
the substances they work with
the findings of COSHH assessments
precautions to be taken to protect themselves and others
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how to use PPE
results of any health surveillance
emergency procedures to be followed 8 FURTHER INFORMATION A copy of the COSHH Risk Assessment form and information regarding Hazard Symbols, Pictograms and Hazard / Precautionary statements can be found on the NHS Doncaster CCG intranet pages.
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Appendix E
FIRST AID PROCEDURE
1. If an incident/injury occurs that requires first aid assistance please
contact reception on 01302 566300. Ask for a first aider to attend, give the location of the injured party, and brief details of the injury. Reception will contact a first aider in the building who will attend.
2. Procedure for Reception Staff:
Reception is the point of contact for first aid for the organisation.
First aiders will make you aware every morning whether they are in the building and what extension number you can get hold of them on.
If you receive a call requesting first aid assistance, you need to take details of the location of the injured party and brief details of the injury.
You then need to contact a first aider, ask them to attend and pass the details over. If a first aider is not present, please call the CHC team and ask for a nurse to attend the injured person.
3. Procedure for first aiders:
On arriving in the building please let reception know you are in the building and what is the best number to contact you on.
You may receive requests direct from staff or via reception to attend to injuries, if you receive a request it is up to you to pass or play, please do not refuse to attend, take the request and either attend yourself or pass immediately to another first aider who can attend ensuring there is no delay.
If reception contacts you with a request to attend an injury, it is your responsibility to accept the call and either pass or play, if you are unavailable to attend for whatever reason it is up to you to find another first aider to attend the injury without delay.
On completion of the incident please complete an incident report form and inform facilities of any consumables from the first aid box that need replacing.
4. Procedure for restocking first aid boxes:
The facilities team is responsible for ensuring that the first aid boxes are fully stocked and correct stock rotation is in place ensuring that nothing goes out of date.
The facilities team will check the contents of all first aid boxes on the 1st of the month, or earlier if an incident occurs and consumables have been used.
