Organisational Health and Safety Policy Statement
January 2024
The Provide Community Board is committed to improving the Health, Safety and Welfare of all our employees, contractors of services, as well as those seconded, locum bank and agency staff, volunteers, patients and members of the public who use our facilities or services.
People are a key resource in any organisation. Implementation of this policy will assist in reducing accidents and ill health, thereby contributing to reduce losses and liabilities for the organisation. Health and Safety will therefore be given equal priority in relation to other key objectives.
Legislation defines the minimum action any organisation is required to achieve. Provide Community will strive to implement a higher standard and improve on safety performance year on year. Provide Community accepts that accidents and ill health are not necessarily the fault of the individual employee and will require all accidents to be investigated to determine the root and underlying causes to prevent them reoccurring.
The organisation will maintain an effective system of safety communication ensuring employees can contribute to policy implementation by reporting and, where possible, eliminating hazards.
The organisation has a Property, Health and Safety Steering Group which allows effective consultation with employees through their representatives. Provide Community also appoints a Health, Safety, Fire and Security Manager to co-ordinate health and safety activities across the organisation.
We are committed to ensuring that all employees are competent to undertake their roles and responsibilities and will ensure adequate financial and physical resources are provided. Additional expert advice will be sought where necessary. Line managers are required to identify hazards, carry out suitable and sufficient risk assessments, implement and maintain measures introduced to reduce the level of risk to both employees and non-employees who may be affected by our activities.
This health and safety policy statement of intent shall be reviewed and amended annually, or as dictated by significant changes to legislation and/or Provide Community policies or adverse conditions, whichever is the sooner
Mark Heasman
Robert Parkinson
Group Chief Executive Group Chair
1. Introduction
Provide Community will manage health and safety using the process of risk management which includes the identification of hazards, assessment of risks and introduction of control measures. To ensure this Provide Community will:
• Implement a systematic approach to safety. This includes following any standards published by the Health & Safety Executive, NHS or Department of Health which identify priorities and set objectives whereby risks are eliminated or minimised by the correct selection and design of facilities, equipment and processes;
• Provide and maintain safe and healthy working conditions, adequate welfare facilities, safe means of access and egress and take account of all statutory requirements;
• Provide information, operational policies and procedures, training, instruction and supervision to enable employees to perform their work safely and efficiently;
• Make available all necessary safety devices and protective equipment and provide instruction in their use;
• Maintain a constant and continuing interest in health, safety and welfare matters by consulting and involving employees or their representatives. Liaise with other employers upon its sites insofar as the activities of these employers affect the health, safety and welfare of the Trust’s staff, students’ visitors and patients; and where the activities of the Trust may affect the activities of the other employers;
• Keep and maintain accurate records of accidents, incidents and injuries via Datix/Access
• Monitor and evaluate the application of Trust Health & Safety related policies and procedures.
2. Purpose
Provide Community has a legal obligation and a moral responsibility to ensure the health, safety and welfare of its staff, Patients and visitors in its facilities and associated services. This document sets out management and employee responsibilities and procedures relating to health and safety. It is an organisational and individual responsibility that they are implemented
3. Definitions
Datix web – Provide Community approved Incident Report Form
Access – Provide Care Solutions Incident reporting form
HSE – Health and Safety Executive
CCG – Clinical Commissioning Group
4. Duties
Group Chief Executive
The Group Chief Executive is ultimately responsible for health and safety within Provide. He will ensure that health and safety management is effective within the
organisation, adequate resources are provided, and the organisation has competent H&S advice. However, the day-to-day health and safety management function is delegated to Executive Directors.
Senior Management Team
Under the leadership of the Group Chief Executive, each Group Chief Officer will be responsible for the overall implementation of the Health and Safety Policy within their specific services. They will ensure arrangements are in place for the effective planning, organisation, control, monitoring and review of preventative and protective measures in line with organisations policy.
The Group Chief Officers will delegate their direct responsibility for implementation of the Health and Safety Policy, but will remain ultimately accountable to the Board and the Group Chief Executive for the safety performance of their services.
Responsibility will be delegated through the management structure for each Directorate. Responsibility at this level will be delegated with reference to both professional responsibilities and environmental responsibilities under the Health and Safety Policy.
Directors
Directors are ultimately responsible for health and safety within their services. They may delegate this function on a day-to-day basis to their Assistant Directors. They will ensure sufficient resources are available to implement both the Corporate and Service health and safety plans and will review progress on a regular basis. They will set a good example to all employees by their actions, including obeying safety alarms and signs. They will also deal with hazards they identify and ensure where reasonably practicable they are removed.
Assistant Directors
Assistant Directors are responsible for producing detailed health and safety plans for their service area to ensure the aims and objective laid down in Corporate and Departmental Statements of Intent are achievable. Where required these will form an integral part of the service ‘Business Plan’.
Any plan must ensure the involvement of all employees through consultation at team meetings.
To assist in the effective planning and implementation of the policy Managers will seek specialist advice where necessary and co-ordinate the advice where more than one specialist views are sought.
They will keep up to date in changes to health and safety legislation, standards and good practice relevant to their service and management practices. They will ensure risk assessments are undertaken for all significant and high-risk activities their employees are exposed to and ensure any identified control measures are implemented so risks are as low as reasonably practicable.
Line Managers
Line Managers are responsible for implementing the health and safety policies, procedures and plans.
They will identify and make available all necessary resources to ensure the plans can be completed within the specified target date. This can include, but not be limited to people’s time, equipment and finance.
They will regularly inform their manager on progress towards completing the plan including any areas where targets will not be met. Additionally they will work with the Health, Safety, Fire and Security Manager to review the health and safety plan, standards, procedures and safe systems of work.
Line managers will ensure that all employees within their services are competent to undertake their duties and responsibilities and ensure employees at all levels are able to discuss and participate in health and safety activities.
The Head of health, Safety and Compliance
The Head of health, Safety and Compliance is responsible for the development and formulation of health and safety policies for consideration.
They will assist in promoting a positive health and safety culture by ensuring the health and safety message including the policy is widely communicated within the organisation.
They will maintain adequate information systems on relevant legislation and safety management practice.
The Head of health, Safety and Compliance will draft a Monthly Health and Safety Report for the organisation which will then be sent to the Property. Health and Safety Committee for ratification.
The Head of health, Safety and Compliance will assist managers to complete risk assessments and identify hazards by providing advice on suitable control measures and levels of risk. They will assist the organisation to implement health and safety plans by monitoring the effectiveness of control measures, undertaking and reviewing active monitoring to enable effective benchmarking to take place. They will interpret legislation and inform the organisation of its implications.
The Head of health, Safety and Compliance will maintain procedures for reporting, recording, investigation and analysis of accidents, incidents and cases of work-related ill health, review the health and safety management system on a regular basis.
They will also act as the competent person for the organisation when it comes to matters relating to health & safety, fire and security and establish professional relationships at all levels within the organisation as well as external organisations such as the HSE, CCG and Fire and Rescue Service.
Facilities Managers
Facilities Managers are responsible for carrying out the site quarterly health and safety audits. They will produce a plan to improve the health and safety management system based on the audit findings, accidents investigations, absence statistics and other management information.
They will represent their sites at the Property, Health and Safety meeting and act as the focal point for the flow of health and safety information into and out of their sites.
Employees
Employees are responsible for ensuring they take reasonable care of their own health and safety and that if other employees, contractors and members of the public who may be foreseeably affected by what they do or do not do.
Employees must co-operate with the organisation and any authoritative body to ensure they comply with any duties and responsibilities imposed on them.
Employees must ensure they do not intentionally or recklessly interfere with or misuse anything that has been provided for the purpose of health, safety or welfare.
Employees must not use any machinery, transport, equipment or substance without receiving suitable and sufficient information and training they must ensure any machinery equipment or substance is used as directed in the training.
Employees must inform their line manager of any work situation which has the potential for serious or imminent danger to health and safety and also inform the line manager if any control device is not working correctly or is not adequately controlling the risk.
Property, Health and Safety Group
The Property Health and Safety Group will:
• Establish corporate standards in health and safety that will meet existing and expected legislation and assist in achieving the organisations wider aims
• Produce and update the corporate health and safety policy document that will enable minimum standards to be enhanced, as necessary, to reflect local circumstances in individual sites
• Promote a positive partnership between the Executive, management, staff and trade unions to ensure the health, safety and welfare of all employees in the organisation
Fire Marshalls
Fire Marshalls will ensure that their designated areas are clear of people when the fire alarm sounds.
The Fire Marshall will, on hearing the fire alarm proceed to the fire panel to determine whether it is a false alarm.
Refer to HSPOL17 Fire Safety Policy for further information
They will wait for all marshalls to report into them that the building is clear of people and liaise with the Fire and Rescue Service on their arrival.
First Aiders
First aiders will ensure their training remains in date and that their first aid kit is suitably stocked.
They will provide first aid to injured people within their scope of competence and complete a Datix/Access incident form for any aid given.
Refer to HSPOL09 First Aid at Work Policy for further information
5. Consultation and Communication
The Health and Safety Policy applies to all staff employed or on behalf on Provide Community including:
• Permanent staff
• Temporary staff
• Students
• Agency staff
• Contractors and Subcontractors
6. Monitoring
Regular monitoring and audit of health and safety is essential to ensure that the arrangements in place for managing health and safety are effective and compliant with relevant statutory provisions. Provide Community will use a variety of mechanisms to monitor and audit the health & safety arrangements.
7. Organisational Chart – Health and Safety
Policy Makers
Board
Planners
Senior Management Team
Quality & Safety Committee
Property, Health and Safety Group
Implementers
Assistant Director’s & Line Managers
Specialists
Operations and Estates team etc
Employees
8. Arrangements
Annual Health and Safety Plan
Good planning enables an organisation to anticipate the need for action, prioritise and justify resources necessary to meet identified need. The organisation will produce an annual plan by April each year which lays the framework for the organisation’s safety plans.
Property, Health and Safety Group
The Property, Health and Safety Group will be formulated to allow consultation of health and safety issues. The Group will consist of representatives of both Senior Management and Trade Union Representatives (where possible)
Meetings will be held at least quarterly to discuss accident trends and reduction strategies; safety audit reports, Health and Safety Executive reports and monitoring of health and safety training.
Communication
Provide will ensure the effective communication of health and safety information by ensuring its dissemination to all relevant sections within and external to the organisation.
Any communication generated will be in a suitable form for its intended audience.
Health and safety will be a regular item on team agendas. Articles regarding health, safety and wellbeing will be published and communicated with the assistance of the Communication Team.
Health and Safety Training
It is a moral and legal requirement to ensure that employees are competent to undertake any task required of them.
Training can take many forms and can include formal classroom-based training, on the job training, on-line training and observation-based learning.
It will be provided to employees on their induction into the organisation. Training will be updated if processes, safe work procedures or equipment changes, if their role and responsibilities change and refresher training will also be given at regular intervals as necessary or required by legislation.
The Learning & Development Strategy Group will review the mandatory training program each year and services will identify individuals that need to attend and schedule their training over the program.
Training requirements can be identified by several means including auditing, inspection, accident investigation, risk assessment and personal development review (PDR).
Auditing
Sites will undergo a health and safety audit once each three years to identify strengths and weaknesses and make recommendations for year-on-year improvements. The audit will be used to enable benchmarking in progressive years within each site.
Fire
Provide will ensure that evacuation procedures exist and are tested in all sites that our staff occupy.
Regular checks will be undertaken to ensure fire routes are kept clear and alarms tested to ensure staff can hear them. Fire-fighting equipment will be provided and maintained.
Fire risk assessments will be carried out for all premises where employees work. These risk assessments will be regularly reviewed and in line with The Regulatory Reform (Fire Safety) Order 2005
Refer to HSPOL17 Fire Safety Policy for further information
Risk Assessments
All hazards (other than those deemed insignificant) will be assessed prior toemployees being exposed.
Identified control measures will be introduced to reduce risks to a level as low as reasonably practical. Control measures will be monitored to ensure they continue to reduce risks. Tasks which are deemed high risk will not be carried out until the risk is reduced.
Refer to HSSOP02 Risk Assessment Procedure for further information
Accidents/Incidents
All employees must report accidents, incidents and near misses that occur to them in the undertaking of their role as a Provide Employee.
Line Managers will ensure that all accidents, incidents and near misses they are aware of are recorded on the Datix or Access Incident Reporting System.
Working in conjunction with the Health, Safety, Fire and Security Manager, the Line Managers will carry out an initial investigation of the incident and in serious cases or cases which had the potential to be a major incident will undertake a formal accident investigation and where necessary convene an accident investigation panel.
Refer to the following documents for further information;
QSPOL01 Incident Reporting and Management Policy
HSSOP02 Risk Assessment Procedure
CPOL17 Medical Devices Policy
Alcohol and Drug Misuse
The misuse of alcohol and drugs can lead to accidents, incidents or serious ill-health and can be illegal.
Employees must not attend for duty (including driving to and from work) under the influence of alcohol or illegal drugs; this is likely to lead to disciplinary action.
Further advice, support and information can be obtained from Occupational Health.
Refer to HSPOL11 Managing Alcohol and Drug Abuse Policy for further information
First Aid
The organisation will ensure that there are sufficient trained first aiders to provide first aid to employees and members of the public on our sites through undertaking risk assessment.
As a minimum an appointed person will be nominated to provide assistance and call the Emergency Services.
Arrangements for cover during absence and leavewill be determined by thefirst aider’s line manager or site co-ordinator.
All necessary equipment will be provided, and refresher training given at appropriate intervals.
Any first aid treatment given will be recorded on Datix or Access Reporting portal.
Refer to HSPOL09 First Aid at Work Policy for further information
Active Monitoring of Estates
Where reasonably practical all building, and activities will be monitored in line with control measures identified through risk assessment.
Active monitoring can be in the form of inspections, site surveys or sampling. Where formal monitoring is required, this will be recorded.
To comply with the Health & Safety at Work Act 1974 and the Occupiers’ Liability Act 1957 all buildings occupied by Provide staff and members of the public are maintained to provide a safe place to work, receive treatment and to visit.
Buildings include the building structure (roof, walls, and windows), floors and stairs, internal walls, partitions, doors and door furniture.
Fixed plant includes lighting, heating, ventilation systems, piped medical gases etc.
It is important that all defects, faults or failures of buildings or fixed plant are reported as soon as possible to the facilities management helpline.
Refer to HSPOL17 Fire Safety Policy, EFPOL03 Water Safety Policy and QSPOL01 Incident Reporting and Management Policy for further information
Contractors
In properties where Provide is a tenant, the landlord will take the lead on agreeing and approving risk assessments and method statements for works being undertaken.
The landlord or landlords’ representative (e.g. Facilities Management) will be required to supply the relevant Service Lead, Locality Manager or Integrated Team Leader and Health & Safety, Resilience and Security Manager with copies of Risk Assessments and Method Statements for agreement and approval prior to specific works taking place.
In other properties, Provide, in line with the Construction (Design and Management) Regulations 2015 (CDM Regulation’s), will act as landlord and take responsibility for agreeing and approving contractors, their risk assessments and method statements prior to any works being carried out.
Working in conjunction with our Estates Team, approved contractors will also produce risk assessments and method statements where any works may affect Provide, its undertakings, employees, patients or visitors and provide this information to the Service Lead / Line Mangers and the Health, Safety, fire and Security Manager for agreement and approval prior to any works being carried out.
EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 1: ‘Screening’
Name of project/policy/strategy (hereafter referred to as “initiative”):
HSPOL08 Health and Safety at Work Policy
Provide a brief summary (bullet points) of the aims of the initiative and main activities:
To provide a healthy safe environment for all staff, patients, contractors, volunteers and members of the public.
To ensure the organisation complies with all health & safety legislation.
Project/Policy Manager: Head of Health Safety and Compliance Date: November 2023
This stage establishes whether a proposed initiative will have an impact from an equality perspective on any particular group of people or community – i.e. on the grounds of race (incl. religion/faith), gender (incl. sexual orientation), age, disability, or whether it is “equality neutral” (i.e. have no effect either positive or negative). In the case of gender, consider whether men and women are affected differently.
Q1. Who will benefit from this initiative? Is there likely to be a positive impact on specific groups/communities (whether or not they are the intended beneficiaries), and if so, how? Or is it clear at this stage that it will be equality “neutral”? i.e. will have no particular effect on any group.
Neutral
Q2. Is there likely to be an adverse impact on one or more minority/under-represented or community groups as a result of this initiative? If so, who may be affected and why? Or is it clear at this stage that it will be equality “neutral”?
Neutral
Q3. Is the impact of the initiative – whether positive or negative - significant enough to warrant a more detailed assessment (Stage 2 – see guidance)? If not, will there be monitoring and review to assess the impact over a period time? Briefly (bullet points) give reasons for your answer and any steps you are taking to address particular issues, including any consultation with staff or external groups/agencies.
Neutral
Guidelines: Things to consider
Equality impact assessments at Provide take account of relevant equality legislation and include age, (i.e. young and old,); race and ethnicity, gender, disability, religion and faith, and sexual orientation.
The initiative may have a positive, negative or neutral impact, i.e. have no particular effect on the group/community.
Where a negative (i.e. adverse) impact is identified, it may be appropriate to make a more detailed EIA (see Stage 2), or, as important, take early action to redress this – e.g. by abandoning or modifying the initiative. NB: If the initiative contravenes equality legislation, it must be abandoned or modified.
Where an initiative has a positive impact on groups/community relations, the EIA should make this explicit, to enable the outcomes to be monitored over its lifespan. Where there is a positive impact on particular groups does this mean there could be an adverse impact on others, and if so can this be justified? - e.g. are there other existing or planned initiatives which redress this?
It may not be possible to provide detailed answers to some of these questions at the start of the initiative. The EIA may identify a lack of relevant data, and that data-gathering is a specific action required to inform the initiative as it develops, and also to form part of a continuing evaluation and review process.
It is envisaged that it will be relatively rare for full impact assessments to be carried out at Provide. Usually, where there are particular problems identified in the screening stage, it is envisaged that the approach will be amended at this stage, and/or setting up a monitoring/evaluation system to review a policy’s impact over time.
EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 2:
(To be used where the ‘screening phase has identified a substantial problem/concern)
This stage examines the initiative in more detail in order to obtain further information where required about its potential adverse or positive impact from an equality perspective. It will help inform whether any action needs to be taken and may form part of a continuing assessment framework as the initiative develops.
Q1. What data/information is there on the target beneficiary groups/communities? Are any of these groups under- or over-represented? Do they have access to the same resources? What are your sources of data and are there any gaps?
N/A
Q2. Is there a potential for this initiative to have a positive impact, such as tackling discrimination, promoting equality of opportunity and good community relations? If yes, how? Which are the main groups it will have an impact on?
N/A
Q3. Will the initiative have an adverse impact on any particular group or community/community relations? If yes, in what way? Will the impact be different for different groups – e.g. men and women?
N/A
Q4. Has there been consultation/is consultation planned with stakeholders/ beneficiaries/ staff who will be affected by the initiative? Summarise (bullet points) any important issues arising from the consultation.
N/A
Q5. Given your answers to the previous questions, how will your plans be revised to reduce/eliminate negative impact or enhance positive impact? Are there specific factors which need to be taken into account?
N/A
Q6. How will the initiative continue to be monitored and evaluated, including its impact on particular groups/ improving community relations? Where appropriate, identify any additional data that will be required.
N/A
Guidelines: Things to consider
An initiative may have a positive impact on some sectors of the community but leave others excluded or feeling they are excluded. Consideration should be given to how this can be tackled or minimised.
It is important to ensure that relevant groups/communities are identified who should be consulted. This may require taking positive action to engage with those groups who are traditionally less likely to respond to consultations, and could form a specific part of the initiative.
The consultation process should form a meaningful part of the initiative as it develops, and help inform any future action.
If the EIA shows an adverse impact, is this because it contravenes any equality legislation? If so, the initiative must be modified or abandoned. There may be another way to meet the objective(s) of the initiative.
Further information:
Useful Websites www.equalityhumanrights.com Website for new Equality agency www.employers-forum.co.uk – Employers forum on disability www.efa.org.uk – Employers forum on age © MDA 2007 EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage One: ‘Screening’
