Workplace (Health, Safety and Welfare) Policy TRUSTWIDE POLICY

Workplace (Health, Safety and Welfare Policy Version 3 1 March 2015

Workplace (Health, Safety and Welfare) Policy TRUSTWIDE POLICY

Version: 3.0

Policy Lead/Author & position: Assistant Director of Estates Health and Safety Advisor

Ward / Department: Non-Clinical Risk

Replacing Document: 2.0

Approving Committee / Group: Policy Development, Monitoring & Review Group

Date Approved/Ratified: October 2010

Previous Reviewed Dates: October 2013, March 2015

Date of Current Review: March 2015

Date of Next Review: October 2018

Relevant Standard(s): Nil

Target Audience All Staff Contractors


EQUALITY STATEMENT Barnet, Enfield and Haringey NHS Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. It takes into account the Equality Act (2010) including the Human Rights Act 1998 and promotes equal opportunities for all. This document has been assessed to ensure that no employee or patient receives less favourable treatment on the protected characteristics of their age, disability, sex (gender), gender reassignment, sexual orientation, marriage and civil partnership, race, religion or belief, pregnancy and maternity. Barnet, Enfield and Haringey Mental Health NHS Trust embraces the four staff pledges in the NHS Constitution and this policy is consistent with these pledges. This Trust is committed to safeguarding and promoting the welfare of children, young people and vulnerable adults and expects all staff and volunteers to share this commitment.

Consultation Record of Procedural Document Form

Name and Title of Individual Date Consulted

Health Safety and Welfare Committee April 2015

Name of Committee Date of Committee

Policy Development, Monitoring & Review Group March 2015

Version Control Summary

Version Date Section Author Comments

1.0 August 2010

Health and Safety Advisor

New Policy

2.0 October 2013

Flowchart Sections 10 and 12


Flowchart updated Updated to reflect other polices

3.0 March 2015

All sections Appendices


New Trust Header inclusion Appendix 1 2, and 3 now in Electrical Safety and Workplace Temperature Page Intranet page

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_132958.pdf


Table of Contents Section Page

1. Policy Statement 5

2. Introduction 5

3. Aims 5

4. Scope 5

5. Purpose and Outcome 6

6. Definitions 6

7. Duties 7

8. Workplace Minimum Standards 9

9. Training and Information 9

10. Incident Reporting 10

11. Monitoring Compliance and Effectiveness 10

12. Dissemination and Implementation 10

13. Trust’s Related Documentation 11

14. References 11

15. Appendices 13

Appendix 1: Workplace Minimum Standards 13

16. Equality Impact Assessment Tool 14


Workplace Safety Regulations flowchart

The regulations cover Workplace Minimum Standards:

Health and safety in the workplace Welfare facilities for people at work Maintenance of the workplace.

Health: 1. Ventilation 2. The temperatures

within indoor working environments

3. Suitable and sufficient lighting

4. Cleanliness and waste materials

5. Room Dimensions and space

6. Workstations and seating

Safety: 1. Maintenance of the

workplace 2. Conditions of floors and

traffic routes 3. Organisation of Traffic

Routes 4. Falls and falling objects 5. Transparent or

translucent doors, gates or walls and windows

6. Windows, skylights and ventilators

7. Doors gates and escalators

Welfare: 1. Washing

facilities 2. Sanitary

conveniences 3. Drinking water 4. Accommodation

and facilities for clothing

5. Facilities for rest and to eat meals

Health and Safety Audit of Areas in conjunction with team leader and

Union representatives

Implement Actions


1. Policy Statement 1.1 Barnet, Enfield and Haringey NHS Mental Health Trust (BEHMHT) recognises and

accepts its responsibility, to provide so far as is reasonably practicable, safe systems of work and a safe place of work, in accordance with The Health and Safety at Work Act, etc (1974) and The Workplace (Health, Safety and Welfare) Regulations 1992, its Approved Code of Practice and additional Guidance. The Trust aim is ensuring that workplaces meet the health, safety and welfare needs of all members of staff, including those with disabilities and those who are not employees but who access and use its premises and who may also be affected by its activities and undertakings.

2 Introduction: 2.1 The Regulations are amended by the Quarries Regulations 1999, the Health and

Safety (Miscellaneous Amendments) Regulations 2002, the Work at Height Regulations 2005, and the Construction (Design and Management) Regulations 2007 and set out general requirements in four broad areas:

Working environment; heating, cooling, ventilation (temperature), lighting, emergency lighting, room dimensions, suitability of workstations and seating

Safe access and egress; safe passage for, and segregation of pedestrians and vehicles, windows, floors, doors (their construction, any obstructions, slipping and tripping hazards), falls from height and falling objects

Facilities; toilets, washing, eating and changing facilities, clothes storage, seating in rest areas for workers and rest areas for pregnant women and nursing mothers

Housekeeping; including maintenance of the workplace, equipment and facilities cleanliness, removal of waste materials and security

2.1 It is essential that all Trust managers who work in, or are responsible for, or in control

of premises and those whose job it is to plan, commission, procure, install, operate, service, maintain and decommission the fabric and services of Trust buildings and premises become familiar with the requirements of the Workplace Regulations.

2.3 They are also required to assess the risks associated with workplaces long before they are commissioned and put into use. Wherever possible, standardisation of workplaces, and services should be considered. All this is necessary so that it is ascertained at the earliest opportunity whether the working environment to be used by Trust personnel and others is suitable and fit for its intended purpose and use; whilst also providing value for money.

3 Aim 3.1 This policy demonstrates the Trust’s commitment to reducing accidents and exposure

to hazards in the workplace. The policy aims to define what the requirements of the Workplace Regulations are and to inform managers and staff as to their roles and responsibilities to comply with them.

4 Scope 4.1 The Workplace Health, Safety and Welfare Regulations apply to a very wide range of

workplaces and environments such as toilets, wards, offices, kitchens, plant rooms,


theatres, yards, loading bays, roofs, confined spaces, outside areas, etc.

They also apply to common parts of shared buildings (lobbies, staircases, roads, corridors, etc), private roads & paths, courtyards, balconies, restaurants, rest areas, temporary work sites (but not construction sites). They affect all staff employed by the Trust and its requirements are also relevant to bank, temporary staff, volunteers, young workers, and contractors working on Trust business.

5 Purpose and Outcome 5.1 The purpose of this policy is to enable managers and staff to comply with the

Workplace (Health, Safety and Welfare) Regulations by identifying hazards, assessing the risks, controlling, managing and mitigating those risks so far as is reasonably practicable and maintaining suitable workplaces where work activity can be undertaken in a safe and efficient manner.

5.2 The outcome of this policy is to

Comply with the Workplace Health, Safety and Welfare Regulations and with requirements of Higher Technical Memorandums, The Disability Discrimination Act, Building Regulations, Environmental Health Regulations, Fire Codes of Practice, Safety Alerts, etc.

Minimise avoidable and foreseeable accidents within the workplace so far as is reasonably practicable

6 Definitions 6.1 Workplace: means any premises or part of premises which are not domestic

premises and are made available to any person as a place of work and includes: a) any place within the premises to which such persons have access while at work;

and b) any room, lobby, corridor, staircase, road, or other place used as a means of access or egress from the workplace or where facilities are provided for use in connection with the workplace; other than a public road.

Traffic Route means a route for pedestrian traffic, vehicles or both and includes any stairs, staircase, fixed ladder, doorway, gateway, loading bay or ramp.

So Far as Is Reasonably Practicable means that the degree of risk in a particular activity or environment can be balanced against the time, trouble, cost and physical difficulty of taking measures to avoid the risk. If these are so disproportionate to the risk that it would be unreasonable for the persons concerned to have to incur them to prevent it, they are not obliged to do so. The greater the risk, the more likely it is that it is reasonable to go to substantial expense, trouble and invention to reduce it. But if the consequences and the extent of the risk are small, insistence on great expense would not be considered reasonable.

Workstation: means any area set aside for an individual to perform a work related task.

Risk: For the purposes of the policy ‘risk’ is defined as the chance or probability that a person will be harmed or experience an adverse health effect if exposed to a hazard

Safety material – Means materials that are inherently robust such as


polycarbonate, glass blocks, glass which if it breaks, breaks safely or annealed glass of a suitable thickness.

Suitable Conditions – Means the provision of adequate access, a firm level surface in a safe position and adequate tying or fixing positions.

7 Duties 7.1 The Chief Executive 7.1.1 The Chief Executive has overall responsibility to provide a safe working environment,

ensuring compliance with the requirements of The Health and Safety at Work etc, Act 1974, Workplace (Health Safety and Welfare) Regulations 1992 and the requirements of this policy. He also has overall responsibility for the safety of any patient, visitor or contractor whilst they are on Trust premises.

7.2 Directors 7.2.1 All Directors have Corporate responsibility to provide a safe working environment and

shall ensure adequate arrangements and resources are provided to implement the requirements of this policy, all safety Regulations, and any associated safe systems of work; and apply this within their respective Directorate.

7.3 Assistant Directors / Team Leads / Service Managers/ Heads of Department 7.3.1 They are responsible for ensuring that Local Managers and other

managerial/supervisory staff aware of their own responsibility for health and safety within their managed areas. Also; they must ensure that funding is available to provide any necessary peripheral equipment, procedures and ongoing training and supervision where a risk assessment has identified such control measures as being necessary.

7.4 Line Managers / Charge Nurses / Senior Staff on Duty 7.4.1 Line managers, supervisors or persons responsible for other workers have the

responsibility to:

Undertake or facilitate a risk assessment as per the workplace and manage the identified actions; in addition, take to account specific risk assessments such as those related with pregnancy or nursing mothers or disability access at work.

Ensure that the workplaces for which they are responsible are suitable and fit for its intended purpose and use

Ensure that when new premises, or work procedures are introduced, they obtain input from the end user and take heed of their needs and concerns: i.e. their staff and their safety representative

Ensure that the workplace is spacious, suitable and sufficient for the work activity which needs to be undertaken

Ensure that all workplaces are subject to thorough examination, maintenance and inspection by competent persons; on a planned basis

Ensure that work regimes are planned, organised and carried out in accordance with the requirements of the Regulations and this Policy and that safe systems of work are set and followed

Ensure that whatever workplace is used, managers must ensure that it continues to operate safely & correctly throughout the lifetime of its use

Plan preventative maintenance includes inspections, cleaning, disinfecting,


examination, replacement, repair and testing. This scheme will vary depending on the type of work being undertaken

Understand and undertake their supervisory responsibilities with regard to ensuring employees use and operate within the workplace for the purpose for which it was designed and installed

Ensure hat the possible consequences to the health of an employee arising from the inappropriate use the workplace and its facilities is avoided

That they understand their obligations under common law towards the employee and the potential for civil claims and subsequent compensation payments

Provide Local Induction, Information, Instructions and Training to staff with regard to the workplace to enable them to operate within the workplace safely

Maintain training records on what training has actually been provided to their staff

Ensure contractors and self-employed persons assess the hazards and risks and make provision to protect themselves and others in respect of their own work activities

Place measures to deal adequately with emergency situations and have clear and unobstructed means of escape

Ensure that persons gaining work experience, temporary or ‘young’ workers are entitled to the same provisions and requirements of this policy as if they were full time employees

Ensure that local plans are put in place (e.g. business continuity, disaster recovery and emergency plan, adverse weather plan-heat wave and winter - ) and that they are managed as necessary

7.6 Employees 7.6.1 All employees have a responsibility to:

Take reasonable care of their own health and safety and that of others who may be affected by what they do or do not do

Use the workplace provided for them in accordance with their managers’ or supervisors’ training & instructions

Undertake a visual inspection of the workplace to ensure there are no obvious hazards before commencing work

Take all reasonable care of working environment provided for them and to report any defects or loss as soon as possible

Not interfere with or misuse anything provided for their or others’ personal protection or safety

Comply with the requirements of this policy

Report any untoward activity, incidents or defects relating to the workplace which they believe is likely to endanger the safety of themselves or others

Not use personal equipment within the Trust that has not been approved by the Trust

Report to their manager any medical symptoms associated with or being caused by their workplace

7.6.2 The requirements this Policy applies to all Trust staff whilst they are working or

engaged in Trust business. If any employee believes that their workplace is unsafe they must seek further instructions from their line manager. Disciplinary action can be


taken against staff for not using their workplace in a safe manner or for misusing it.

7.7 Estates and Facilities and Project Managers 7.7.1 Are responsible for ensuring that if a contractor is to undertake work on Trust

premises, it is to be carried out in consideration of the requirements of the Workplace Regulations, and this policy.

As with any type of work activity, managers and workers are likely to come across ‘one-off’ instances and/or sudden or unexpected changes in their working environment; this may require a dynamic risk assessment and a review of work activity and procedures by the operators. Managers must have flexible arrangements to accommodate these changing requirements.

7.8 Contractors 7.8.1 In some specific situations it is essential that contractors comply with the requirements

of this section. Contractors must:

Comply with the Workplace Regulations and subsequently, the requirements of this Policy

Supply the Trust with copies of the following documents: o Risk assessments o Method statements o Full operating instructions o Safe systems of work o Emergency and rescue procedures o Document and report to the Trust any untoward incidents o Provide any guarantees, warranties or any other documentation relevant to

the safe operation of or use of the workplace

7.9 Non-Clinical Risk Team 7.9.1 The non-clinical risk team will provide advice and guidance on safety within the

workplace and work procedures to be used. The H&S Manager can propose changes to this Policy as and when new legislation or regulations are introduced and intervene to prevent poor health and safety practice or procedures, as necessary.

8 Workplace Minimum Standards 7.1 The following headings relate directly to the specific Workplace Regulations and they

reflect the main requirements of the Approved Codes of Practice, however, there is much more Guidance accompanying the Regulations which is not detailed here. A summary of these is provided in Appendix 1.

Health:

1. Ventilation 2. The temperatures within indoor working environments 3. Suitable and sufficient lighting 4. Cleanliness and waste materials 5. Room Dimensions and space 6. Workstations and seating


Safety:

1. Maintenance of the workplace 2. Conditions of floors and traffic routes 3. Organisation of Traffic Routes 4. Falls and falling objects 5. Transparent or translucent doors, gates or walls and windows 6. Windows, skylights and ventilators 7. Doors gates and escalators

Welfare:

1. Washing facilities 2. Sanitary conveniences 3. Drinking water 4. Accommodation and facilities for clothing 5. Facilities for rest and to eat meals

9 Training and Information 9.1 It is mandatory that all staff attend staff induction. During this training staff are made

aware of the Risk Management Policies and Procedures including the importance to keep a safe working environment and the requirement to receive training. Also, staff must undertake local induction.

10 Incident Reporting 10.1 All incidents are to be reported in accordance with the Incidents Management Policy

and using the on-line DATIXWEB reporting system. Serious harm to an employee’s health may require the Head of Non-clinical Risk or the Health and Safety Advisor to complete a RIDDOR report form.

11 Monitoring Compliance and Effectiveness 11.1 Internal 11.1.1 The effective monitoring of this policy will be through review of working practices in all

Trust areas, annual safety audits documentation from all departments, monitoring of incidents throughout the Trust and Incident Management Process.

11.1.2 The content of the Policy will be monitor by the Health, Safety and Welfare Committee, which meets quarterly and will be reviewed on an ongoing process and updated at least every three years or in the light of legislation or other relevant changes.

11.1.3 Non-Clinical Risk Management will monitor the Policy for compliance through health and safety audit process on yearly bases.

11.2 External


11.2.1 The Health and Safety Executive have the capability and responsibility to monitor

health and safety throughout the NHS. Their Inspectors have the right of entry to property or premises at any time and are empowered to obtain information by interviewing any persons, taking photographs, removing documentation and take possession of any article or substance.

12 Dissemination and Implementation 12.1 This document will be made available to all Trust staff on the Trust Intranet and

through line management cascade. Staff should be referred for printing (if necessary to the current version on the trust intranet). This policy supersedes all previous policy implementation. This policy provides legal guidance to managers and staff of the workplace whilst on Trust business.

12.2 Should there be any conflict between this policy and its guidance and any other Trust document or policy then Health and Safety legislation will take precedence.

13 Trust Related Documentation 13.1 Health & Safety Policy and other relevant health and safety documentation

Fire Safety Policy Waste Management Policy First aid at work Policy Lone Working Policy Security Policy Manual Handling Policy Infection Control Policies People and organisational Development Policies Non-smoking Policy

14 References 14.1 The Health and Safety at Work, etc Act 1974. London: Stationery Office.

www.opsi.gov.uk

Workplace health, safety and welfare. Workplace (Health, Safety and Welfare) Regulations 1992. www.opsi.gov.uk

The Health and Safety (Training for Employment) Regulations 1990. London: Stationery Office. www.opsi.gov.uk

The Personal Protective Equipment Regulations 1992. London: Stationery Office. www.opsi.gov.uk

The Provision and Use of Work Equipment Regulations 1998. London: Stationery Office. www.opsi.gov.uk

The Management of Health and Safety at Work Regulations 1999. London: Stationery Office. www.opsi.gov.uk

The Work at Height Regulations 2005. London: Stationery Office. www.opsi.gov.uk

Manual Handling Operations Regulations 1992 (as amended) London: Stationery Office. www.opsi.gov.uk

Construction (Design and Management) Regulations 2007. London: Stationery Office. www.opsi.gov.uk


The Workplace (Health, Safety and Welfare) Regulations 1992. London: Stationery Office. www.opsi.gov.uk

The Health and Safety (Safety Signs and Safety Signals) Regulations 1996. London: Stationery Office. www.opsi.gov.uk

The Reporting of Injuries Diseases and Dangerous Occurrences Regulations 1995. London: Stationery Office. www.opsi.gov.uk

Control of Substances Hazardous to Health 2002 (COSHH) (as amended) www.opsi.gov.uk

Health & Safety (Display Screen Equipment) Regulations 1992. www.opsi.gov.uk.

The Regulatory Reform (Fire Safety) Order 2005 http://www.opsi.gov.uk/si/si2005/20051541.htm

Health and Safety Executive, Lighting at Work, HS (G) 38, 1998.

Health and Safety Executive. Thermal comfort in the workplace: Guidance for employers HSG 194 (1999).

Health and Safety Executive (2002). New and expectant mothers at work: A guide for employers HSG 122 (Second edition)


15. APPENDICES: APPENDIX 1: Summary of Workplace Minimum Standards http://staff.beh-mht.nhs.uk/Downloads/Documents%20and%20templates/Non%20Clincial%20Risk/Health%20and%20Safety/Workplace%20Minimun%20Standards.pdf

http://staff.beh-mht.nhs.uk/Downloads/Documents%20and%20templates/Non%20Clincial%20Risk/Health%20and%20Safety/Workplace%20Minimun%20Standards.pdf




16. EQUALITY IMPACT ASSESSMENT FORM AND MONITORING FORM

Name of the policy/service development, strategy or plan being analysed: LIFTING OPERATIONS AND LIFTING EQUIPMENT (LOLER) POLICY

Name and job title of the manager responsible for carrying out this analysis: Health and Safety Advisor

Please summarise your policy/service development, strategy or plan

Barnet, Enfield and Haringey NHS Mental Health Trust (BEHMHT) recognises and accepts its responsibility, to provide so far as is reasonably practicable, safe systems of work and a safe place of work, in accordance with The Health and Safety at Work Act, etc (1974) and subordinate legislation

What are the main objectives or intended outcomes of the policy/service development, strategy or plan?

Aim: The aim of this policy is to define what Lifting Operations and Lifting Equipment is and to inform managers and staff as to their roles and responsibilities with respect to LOLER. This policy demonstrates the Trust’s commitment to reducing accidents and exposure to hazards in the workplace.

Objective: It is to enable managers and staff to comply with Health and Safety Regulations by identifying hazards, assessing the risks, controlling, managing and mitigating those risks so far as is reasonably practicable and introducing suitable and sufficient lifting equipment and safe systems of work.

Intended outcomes: To Comply with the LOLER Regulations, minimise the misuse or inappropriate use of lifting equipment and minimize avoidable accidents or incidents relating to lifting operations and lifting equipment

1. Please indicate the expected impact of your proposal on people with protected characteristics

Characteristics Significant +ve Some +ve Neutral Some -ve Significant -ve

Age:

Disability:

Ethnicity:

Gender re-assignment:

Religion/Belief:

Sex (male or female)

Sexual Orientation:


Marriage and civil partnership

Pregnancy and maternity

The Trust is also concerned about key disadvantaged groups even though they are not protected by law

Substance mis-users

The homeless

The unemployed

Part-time staff

2. Consideration of available data, research and information

Key questions (supports EDS Goals)

Evidence sources

2.1 What evidence, data or information have you considered to determine how this change/development/plan contributes to delivering better health outcomes for all?

Joint strategic needs assessments for LB Barnet, Enfield and Haringey. London Health Observatory data NHS Protect Annual Report 2011-12 2011 census data 2012 Equality and Diversity report

2.2 What evidence, data or information have you considered to determine how this change/development/plan contributes to improving patient access and experience?

More diverse communities and also includes information about legislation which is more person centred in nature such as the Human Rights Act, the Mental Capacity Act and the Equality Act which takes into consideration Equality and Diversity practice. The Equality Act 2010

2.3 What evidence, data or information have you considered to determine how this change/development/plan contributes to delivering empowered, engage and well supported staff?

2012 Equality and Diversity report Trust’s Safeguarding Adults and children’s policies and procedures Local protocols and operational policies Healthcare Provides handbook Contractors equal impact assessment, included in their terms and conditions

2.4 What evidence, data or information have you considered to determine how this change/development/plan contributes to delivering inclusive leaders at all levels?

2012 Equality and Diversity report Trust’s Safeguarding Adults and children’s policies and procedures Local protocols and operational policies

3. It is Trust policy that you explain your proposed development or change to people who might be affected by it, or their representatives. Please outline how you plan to do this.

Group Methods of engagement


Service managers Comments on draft copy sent to all service line management teams and corporate service teams.

Staff side Comments on draft copy sent to all staff side representatives

Service user/ Community representatives

Comments on draft copy sent to selection of service user and community group representatives.

4. Equality Impact Analysis Improvement Plan

Negative impacts identified

Actions planned By who

None

6. Sign-off and publishing

I have conducted this equality Impact analysis in line with Trust guidance

Name: Maritza Perilla-Gibney Position: Health and Safety Advisor

Signed: Dated: 11 of March 2015

Approved by:

Name:

Signed: Dated:

Sign:

Date:

MONITORING COMPLIANCE WITH AND EFFECTIVENESS OF PROCEDURAL DOCUMENTS FORM

1. How will the document

be monitored?

(please circle as

appropriate)

Audit Review X Other, please specify;

Methodology:

The Equality Delivery system is an NHS-wide performance

management process for stakeholders to assess who the trust is

doing in this area of work across all its responsibilities as a service

provider and employer.

2. What is the process for

reviewing results of

monitoring?

Stakeholders are invited to grade the Trust’s performance and the

grades are made publically available.

3 Report to: Trust board and the general public

4. Who is responsible for

conducting the

monitoring?

(please circle as

appropriate)

Group / Committee Individual

Name / Title (also include position of individuals):

Ad hoc meetings of stakeholders once a year


5. How often will the

document be

monitored?

(please circle as

appropriate)

Monthly 6 Monthly 3 Yearly Other, please specify;

Comments:

6 Responsibility for action

planning after review