Health and Safety Policy

HEALTH AND
SAFETY POLICY
Version 3.0
Purpose:
To advise and inform all Trust staff of the Trust Health and Safety Policy
For use by:
All Trust patients, visitors and staff, including contractors.

The Health and Safety at Work Act 1974
This document supports

compliance with:
All Statutory Instruments written under the above Act

Regulatory Reform (Fire Safety) Order 2005
This document supersedes:
TPO HS 001 version 2.0
Approved by:
Trust Management Team
Approval date:
17 September 2012
Ratified by
Trust Board
Date Ratified
27 September 2012
Implementation date:
1 December 2012
Review date
1 December 2015
In case of queries contact:

Responsible Officer
Health and Safety Advisor
Directorate and Department
Operations - Estates
Archive Date:
To be inserted by Information Governance Department when this document is

superseded. This will be the same date as the implementation date of the new
document.
Date document to be destroyed:
To be inserted by Information Governance Department when this document is

superseded.
Registered Document 1168

Health & Safety Policy v3.0 TPO HS 001
Page 1 of 18
Implementation Date 1 December 2012
Version and document control:

Version
number
1.0
Date of
issue
Dec 2006
2.0
Jan 2009
2.1
Author
Change Description
G Morgan
Feb 2012
Written in new format; allocated new number

Small amendments throughout, written to
new template. Final ratified document with
document reference
Reviewed, minor changes to responsibilities
2.2
Feb 2012
Minor amendments following consultation
G Morgan
3.0
Dec 2012
Approved and ratified document
G Morgan
G Morgan
G Morgan
This is a Controlled Document

Printed copies of this document may not be up to date. Please check the hospital
intranet for the latest version and destroy all previous versions.
Hospital documents may be disclosed as required by the Freedom of Information Act 2000.
Sharing this document with third parties

As part of the hospitals networking arrangements and sharing best practice, the hospital
supports the practice of sharing documents with other organisations. However, where the
hospital holds copyright to a document, the document or part thereof so shared must not be
used by any third party for its own commercial gain unless this hospital has given its express
permission and is entitled to charge a fee.
Release of any strategy, policy, procedure, guideline or other such material must be agreed
with the Lead Director or Deputy/Associate Director (for hospital -wide issues) or Directorate/
Departmental Management Team (for Directorate or Departmental specific issues). Any
requests to share this document must be directed in the first instance to the Director of
Operations.

Page 2 of 18
CONTENTS
1.
SECTION 1 INTRODUCTION ...................................................................................................... 5
1.1.
Policy Statement and Rationale ............................................................................................... 5
1.2.
Key Principles ............................................................................................................................ 5
1.3.
Background Information ........................................................................................................... 5
1.4.
Definitions .................................................................................................................................. 6
1.5.
Scope .......................................................................................................................................... 6
2.
SECTION 2 DUTIES AND RESPONSIBILITIES ......................................................................... 6
2.1.
Trust Board ................................................................................................................................ 6
2.2.
Chief Executive .......................................................................................................................... 7
2.3.
Chairs and General Managers of Business Units and Directors .......................................... 7
2.4.
Departmental Managers / Matrons ........................................................................................... 8
2.5.
Business Unit Heath and Safety Nominated Officer ................................................................ 8
2.6.
Director of Operations .............................................................................................................. 9
2.7.
Health and Safety Advisor ........................................................................................................ 9
2.8.
Fire Safety Adviser / Manager ................................................................................................. 10
2.9.
Security Advisor ...................................................................................................................... 10
2.10.
Non Clinical Risk Team ............................................................................................................ 10
2.11.
Occupational Health ................................................................................................................ 11
2.12.
Infection Control ...................................................................................................................... 11
2.13.
Risk Management Committee .................................................................................................. 11
2.14.
Union Health and Safety Representatives .............................................................................. 12
2.15.
Trust Safety Group .................................................................................................................. 12
2.16.
Individual Responsibilities ..................................................................................................... 12
2.17.
Any Other Persons on Trust Premises ................................................................................. 13
2.18.
Responsible Officer ................................................................................................................. 13
3.
SECTION 3 ARRANGEMENTS ................................................................................................. 13
3.1.
Key Related Hospital Policies ................................................................................................ 13
3.2.
Business Objectives ............................................................................................................... 13

Page 3 of 18
3.3.
Non Compliances .................................................................................................................... 14
3.4.
Dignity and Respect Charter .................................................................................................. 14
3.5.
Equality Impact Assessment .................................................................................................. 14
3.6.
Consultation ............................................................................................................................. 14
4.
SECTION 4 TRAINING AND EDUCATION ............................................................................... 15
4.1.
Training Needs Analysis (TNA) .............................................................................................. 15
4.2.
Training Prospectus ................................................................................................................ 15
4.3.
Training..................................................................................................................................... 15
5.
DEVELOPMENT AND IMPLEMENTATION INCLUDING DISSEMINATION .............................. 15
5.1.
Development and Implementation ......................................................................................... 15
5.2.
Dissemination .......................................................................................................................... 16
6.
SECTION 6 MONITORING COMPLIANCE AND EFFECTIVENESS ....................................... 16
7.
SECTION 7 CONTROL OF DOCUMENTS INCLUDING ARCHIVING ARRANGEMENTS ..... 16
8.
SECTION 8 SUPPORTING COMPLIANCE AND REFERENCES ............................................ 16

Page 4 of 18
1.
SECTION 1 INTRODUCTION
1.1.
Policy Statement and Rationale
1.1.1.
The Ipswich Hospital NHS Trust (hereinafter referred to as the Trust) is committed
to providing and maintaining a safe and healthy work place and to provide suitable
resources, information, training and supervision on health and safety to staff
patients, contractors and visitors.
1.1.2.
The Trust aims to do all that is reasonably practicable to manage non clinical risk.
1.1.3.
It is the policy of the Trust to do all that is reasonably practicable to prevent personal
injury and damage to property on the Trust premises.
1.1.4.
The overall objective of this policy is to ensure that there is a hospital wide
approach to the development, management and implementation of health and
safety policies and procedures that are communicated to and available to all staff.
1.2.
Key Principles
The Trust Board of the Ipswich Hospital NHS Trust recognises that it is its duty:-
1.2.1.
To meet the standards required by current legislation relating to health and safety in
the workplace.
1.2.2.
To provide sufficient information and training to enable staff to comply with Health and
Safety statutory requirements, Trust Health and Safety rules, and all Codes of Practice
and procedures relevant to their job responsibilities.
1.2.3.
To ensure that all employees work in a manner which follows all accepted rules and
procedures, takes reasonable care of the health and safety of themselves and others
who may be affected by his or her acts or omissions, and co-operates with
management in the implementation of health and safety matters.
1.2.4.
To provide adequate publicity and information on health and safety.
1.2.5.
To provide safe access and egress to and from the workplace.
1.2.6.
To ensure that all equipment, plant and tools provided are safe and maintained in a
safe condition.
1.2.7.
To carry out suitable and sufficient risk assessments in the workplace and to reduce
identified risks to an acceptable level, and to try to identify and minimise such risks at
the planning stage of new equipment or buildings.
1.2.8.
Where necessary to provide health surveillance and monitoring for staff.
1.2.9.
To provide sufficient and suitable first aid facilities for all employees.
1.2.10.
Where appropriate, to provide suitable personal protective equipment.
1.2.11.
To provide, where appropriate, fire prevention and fire fighting equipment and to
instruct all employees in fire escape procedures.
1.2.12.
To provide the means to report, investigate and analyse accident and illness data and
to work towards the elimination of accidents at work.
1.3.
Background Information
1.3.1.
This Health and Safety Policy Statement is an essential document for all workforces
employed by The Ipswich Hospital NHS Trust (hereinafter referred to as the Trust).

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1.3.2.
This policy is issued in accordance with Section 2(3) of the Health and Safety at Work
Act 1974, all Statutory Instruments written under the Act and the Regulatory Reform
(Fire Safety) Order 2005
1.3.3.
This Health and Safety Policy represents a definitive statement of The Ipswich
Hospital NHS Trust's current requirement in all activities with regard to Health and
Safety and the Environment.
1.3.4.
The Trust operates on the principle that health and safety has equal status with any
other quality or business objective. Furthermore, we strongly believe that a safe
working environment at all levels of the Trust contributes to our overall efficiency
and success. This policy, together with safe operating procedures will help to
achieve the desired standards of safety throughout the Trust.
1.4.
Definitions
1.4.1.
RIDDOR.
The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations
1.4.2.
COSHH
The Control of Substances Hazardous to Health Regulations.
1.5.
Scope
1.5.1.
This Health and Safety Policy is an essential document for all workforces employed
by the Ipswich Hospital NHS Trust.
1.5.2.
It applies with equal force to agency and temporary staff, to contractors and any
other person working on or visiting the Trust premises.
2.
SECTION 2 DUTIES AND RESPONSIBILITIES
2.1.
Trust Board
The Trust Board is responsible for:
2.1.1.
Providing strong and active leadership and active commitment.
2.1.2.
Receiving and considering assurance reports that health and safety requirements
are being met and related policies are being followed.
2.1.3.
Establishing effective downward communication system and management

structures.
2.1.4.
Ensuring integration of health and safety management with business decisions.
2.1.5.
Accessing and following competent advice.
2.1.6.
Ensuring effective worker involvement through engaging staff in the promotion and
achievement of safe and healthy conditions, effective upward communication and
providing high quality training

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2.2.
Chief Executive
2.2.1.
The Chief Executive has overall responsibility for all matters of health and safety and
for ensuring mechanisms are in place for the overall implementation, monitoring and
revision of this policy.
2.2.2.
The Chief Executive is ultimately responsible for safety throughout the Trust. It is his
duty, so far as is reasonably practicable:2.2.2.1.
To ensure that the Health and Safety requirements and standards are met.
2.2.2.2.
To review all significant Trust reports on health and safety including those
concerning accidents and reportable incidents.
2.2.2.3.
To monitor the management of the Trust's Health and Safety Policy, and ensure all
recommended corrective actions are implemented.
2.2.2.4.
To set priorities against identified problems and decide upon the allocation of
resources with respect to these problems.
2.3.
Chairs and General Managers of Business Units and Directors
2.3.1.
Chairs and General Managers of Business Units and Directors are responsible for
the effective implementation of this policy within their area of responsibility including
overall management of any potential risks and development of safe systems of
work to manage any identified risks.
2.3.2.
They are responsible for monitoring compliance and effectiveness of this policy
under the Health and Safety Performance Management and Assurance Framework.
2.3.3.
Chairs and General Managers of Business Units and Associate Directors are
accountable for the safety of their work force, and the activities in their charge, and
are expected to promote a high degree of health and safety awareness amongst all
work forces. This involves the following key responsibilities:
2.3.3.1.
Ensuring managers within their Business Unit understand their responsibilities

to complete suitable and sufficient risk assessments for all equipment within
their area of responsibility.
2.3.3.2.
Providing sufficient resources to complete the risk assessments and implement

identified control measures.
2.3.3.3.
To ensure the Trusts Health and Safety Policies are effectively implemented within
their areas of responsibility.
2.3.3.4.
To monitor and co-ordinate the implementation and production of effective and up

to date Health and Safety Policies and Procedures within their areas of
responsibility.
2.3.3.5.
To set Health and Safety objectives for Managers in their areas of responsibility.
2.3.3.6.
To ensure all valid risks are identified and placed onto the Risk Register.
2.3.3.7.
To monitor any accidents/incidents to ensure that the event is properly reported

and investigated and that prompt action is taken to avoid a recurrence.
2.3.3.8.
To ensure distribution of Health and Safety information, hazard notices and safety
bulletins as issued by the non clinical risk team.

Page 7 of 18
2.4.
Departmental Managers / Matrons

Department Managers and Matrons are responsible for the safety of their staff, and
the activities in their charge, and are expected to manage health and safety as part of
their working priorities. This involves the following key responsibilities:-
2.4.1.
To ensure the compliance of their department with the Trust Health and Safety policy
on a day to day basis.
2.4.2.
To maintain a specific, up-to-date departmental policy which clearly indicates the

Health and Safety responsibilities of managers, supervisors and staff
2.4.3.
To ensure that all staff receive induction and on-going training in all aspects of health,
safety and environmental care relevant to their work.
2.4.4.
To monitor all departmental activity on an on-going basis to ensure full compliance

with the letter and spirit of the law relating to health and safety
2.4.5.
To ensure that suitable and sufficient risk assessments are carried out in the
workplace and to reduce identified risks to an acceptable level, and to try to identify
and minimise such risks at the planning stage of new equipment or buildings.
2.4.6.
To establish safe systems of work for all activities within their areas of responsibility.
2.4.7.
To ensure that all incidents or accidents are properly reported, and that, in the case of
a serious accident, full co-operation is provided so that a thorough investigation can be
carried out to identify the cause and to avoid a recurrence.
2.4.8.
To ensure that any recommended corrective action resulting from an incident or

accident is implemented as soon as is reasonably practicable.
To ensure that all departmental staff:-
2.4.9.
Are made aware of any health, safety or environmental hazards within their areas of
responsibility.
2.4.10.
Know their individual responsibilities and quality targets relating to health and safety.
2.4.11.
Carry out their work according to statutory safety obligations, Trust standards and
specific departmental health and safety requirements.
2.4.12.
To meet individual Health and Safety objectives set by their Director.
2.5.
Business Unit Heath and Safety Nominated Officer

Each business unit will identify a Nominated officer who will:
2.5.1.
Act as the principle point of contact for health and safety and non clinical risk issues.
2.5.2.
Attend Trust Safety Group meetings.
2.5.3.
Manage Business Unit risk and Health and Safety policies, procedures and guidelines.
2.5.4.
Undertake such training as required to ensure competence in health and safety.
2.5.5.
Appoint such persons as required to assist them in risk assessments and health and
safety compliance and arrange suitable training.
2.5.6.
Ensure risk assessments required by safety legislation are carried out and reviewed
regularly.
2.5.7.
Ensure identified risks are eliminated or reduced as far as reasonably practicable.
2.5.8.
Ensure residual unacceptable risks are placed on the Trust Risk register.
2.5.9.
Inform immediately the Trust Health and Safety Advisor of any RIDDOR reportable

Page 8 of 18
incidents.
2.5.10.
Report immediately, using the Trust incident reporting system, any defect or failure of
a medical device for reporting to the Medicines and Healthcare products regulatory
agency.
2.5.11.
Develop safe systems of work for all significant risks which cannot be eliminated.
2.5.12.
Together with staff safety representatives carry out regular risk and health and safety
inspections of all areas with in their Business Unit.
2.6.
Director of Operations
The Director of Operations is the designated Director with responsibility for health
and safety, fire safety and security management matters. This involves the following
key responsibilities:-
2.6.1.
To ensure the reporting to the Risk Management Committee of significant non

clinical risks identified by the Business Units / Department risk assessments or
following major changes in working practices or methods.
2.6.2.
To establish and implement a performance management and assurance framework

for all health and safety issues and to ensure its for managing its compliance and
effectiveness.
2.6.3.
To provide regular reports, including an annual report to the Trust Board via the
Risk Management Committee and Trust Management Team on compliance with
health and safety legislation and standards.
2.7.
Health and Safety Advisor

The Trust Health and Safety Advisor has the following key responsibilities:
2.7.1.
To advise and assist managers on health and safety matters in order to ensure
compliance with current and proposed safety legislation.
2.7.2.
To co-ordinate all accident and incident reporting, and monitor to ensure that thorough
investigations are conducted and suitable recommendations made to avoid a
recurrence.
2.7.3.
To identify and participate in health and safety training.
2.7.4.
To ensure that all Trust Health and Safety documentation complies with legal
requirements, and to monitor safety documentation and policies.
2.7.5.
To arrange suitable audit and inspection of the health and safety performance of each
Business Unit and report the findings to the Risk Management Committee.
2.7.6.
To act as the responsible person" under the Reporting of Diseases, Injuries and
Dangerous Occurrences Regulations 1995.

Page 9 of 18
2.8.
Fire Safety Adviser / Manager

The Trust Fire Safety Adviser / Manager has the following key responsibilities:-
2.8.1.
To advise and assist managers on Fire Safety matters in order to ensure compliance
with current and proposed fire safety legislation.
2.8.2.
To identify and participate in Fire Safety Training.
2.8.3.
To liaise with Suffolk Fire Service to ensure that existing buildings and new building
projects and alterations comply with current Fire Safety legislation in conjunction with
other Estate Officers.
2.8.4.
To co-ordinate fire procedures in the case of an emergency, and liaise with the Fire
Service to ensure that potential damage to people and property is minimised.
See Trust Fire Safety Policy for further details
2.9.
Security Advisor
The Security Advisor has the following key responsibilities:-
2.9.1.
To act as the designate Local Security Management Specialist (LSMS).
2.9.2.
To assist the Director of Operations in ensuring implementation of the Security

Policy and give advice to the Trust Board, Departments, Managers and individuals
on all security-related matters.
2.9.3.
To advise and assist managers on Security matters in order to ensure compliance with
current and proposed legislation and standards.
2.9.4.
To ensure the security of the Trust's premises, so far as is reasonably practicable.
2.9.5.
To identify and participate in Security Training.
2.9.6.
To ensure that security incidents are responded to promptly, the necessary

investigations are undertaken and documented, and liaison is maintained with the
proper authorities.
2.9.7.
To report all incidents of physical violence against members of staff to the NHS
Protect.
2.9.8.
To record details of all reported incidents of non-physical assaults against members

of staff and provide advice on appropriate action.
2.9.9.
To liaise with outside agencies such as the Police, Prison Service, NHS Counter
Fraud and Security Management Service, etc, to further the interests of the Trust
2.9.10.
To advise on the arrangements for the personal safety of employees.

See Trust Security Policy for further information
2.10.
Non Clinical Risk Team

The non clinical risk team comprises of the Health and Safety Advisor, the Fire
Safety Manager and the Security Advisor.

Page 10 of 18
2.11.
Occupational Health
The Ipswich Hospital NHS Trust will arrange for the Occupational Health Service:-
2.11.1.
To provide an independent advisory service on any health related matter, which may
be affecting work or staff health and wellbeing.
2.11.2.
To advise managers as required on fitness to work issues at pre employment stage,

following sickness absence and at any other times where health issues may be
involved.
2.11.3.
To advise managers as required about the likely duration of absence of employees

who may be absent from work owing to health problems.
2.11.4.
To advise managers and employees as required on fitness to undertake restricted or

alternative duties.
2.11.5.
To advise managers and individuals as required about areas of support for health
related problems, which may be affecting employment including guidance on ill health
retirement and rehabilitation services.
2.11.6.
To carry out appropriate health surveillance programmes according to managers local

risk assessment outcomes (including those assessments under COSHH and other
regulations)
2.12.
Infection Control
It is the responsibility of the Director of Infection Prevention and Control to:-
2.12.1.
Oversee local control of infection policies and their implementation.
2.12.2.
Lead on the development and implementation of infection prevention and control

strategy.
2.12.3.
Lead on the development and implementation of infection prevention and control

policies and other approved documentation.
2.12.4.
Manage the hospitals Infection Control Team.
2.12.5.
Assess the impact of all existing and new policies and plans on infection and
making recommendations for change.
2.12.6.
Produce an annual report on the state of healthcare associated infection in the

organisation(s) for which he/she is responsible and releasing it publicly.
2.12.7.
Comply with the Health and Social Care Act

For further information about duties and responsibilities for infection prevention and
control see the Infection Prevention and Control Policy.
2.13.
Risk Management Committee
2.13.1.
The Risk Management Committee will act as the Governance Group for health and
safety and for monitoring compliance and the effectiveness of this policy.
2.13.2.
Health and safety sub groups such as the Fire Policy Group, Medical Gases
Committee etc. will all report to the Risk Management Committee via the Health
and Safety Advisor.

Page 11 of 18
2.14.
Union Health and Safety Representatives
2.14.1.
Trade Union Representatives appointed under the Safety Representatives and

Safety Committees Regulations and by the Management of Health and Safety at
Work Regulations must be consulted with regard to the introduction of any measure
which will substantially affect the health & safety of employees.
2.14.2.
Such consultation will allow safety representatives to assist management in

developing control measures.
2.14.3.
Consultation and communication with Safety Representatives will take place via the
Trust Safety Group.
2.15.
Trust Safety Group
2.15.1.
The Trust Safety Group provides a forum within the Trust where managers and staff
representatives meet to discuss Health and Safety issues of concern and advise
the Risk Management Committee on all matters regarding health, safety, welfare
and environment in line with statute legislation.
2.16.
Individual Responsibilities
All staff, regardless of their position, have a duty to themselves, to all other colleagues,
and to any others who may be affected by their actions, to work in a safe manner. In
particular, all members of the workforce must:-
2.16.1.
Abide by all Trust health and safety requirements and statutory Health and Safety at
Work obligations.
2.16.2.
Avoid any actions that might constitute a danger to themselves or others.
2.16.3.
Bring to the notice of Managers, Supervisors, or the Estates department, any defective
equipment or potential health and safety hazard or any practice likely to cause an
incident or accident.
2.16.4.
Report all accidents to their supervisor or manager, whether injury is sustained or not
and record it onto DATIXWeb.
2.16.5.
Observe all procedures laid down concerning processes, materials or substances.
2.16.6.
Avoid improvisation, which could create an unnecessary risk to their personal safety or
to the safety of others.
2.16.7.
Dress sensibly and safely for their particular working environment, using the safety
equipment and personal protective equipment provided for the task being undertaken;
2.16.8.
Comply with all written and verbal instructions given to them to ensure their safety and
the safety of others.
2.16.9.
Maintain all tools and equipment in good condition, and report any defects to their
Supervisor/Manager as they occur.
2.16.10. Attend as requested, any training courses designed to further the needs of Health and
Safety.
2.16.11. Observe the Fire Evacuation Procedures, and be familiar with the position of their
departmental fire equipment, fire exits, fire routes and designated fire assembly points;

Page 12 of 18
2.17.
Any Other Persons on Trust Premises

Any other person, whether directly employed by the Trust or not, shall:-
2.17.1.
Observe Trust safety rules and instructions given by persons enforcing the Trust
Safety Policy;
2.17.2.
Not work on the Trust premises, unless the relevant safety rules are read, understood
and accepted;
2.17.3.
Not work on the Trust Premises, unless, where appropriate having suitable and
sufficient insurance against risk;
2.18.
Responsible Officer
2.18.1.
The Responsible Officer for this policy is the Health and Safety Advisor, who is
responsible for monitoring compliance with the contents of this document and for
reviewing it after three years.
2.18.2.
The Health and Safety Advisor will carry out audits to monitor the compliance of
business units.
3.
SECTION 3 ARRANGEMENTS
3.1.
Key Related Hospital Policies
3.1.1.
This policy is supported by a number of separate policies, procedures and guidance

covering specific aspects of risk management and health and safety. All these
documents are available to staff on the hospitals intranet and some can be
accessed from the hospitals website.
3.1.2.
A number of organisations e.g. hotel services, the Renal Unit etc. occupy part of the
Trust premises under lease arrangements. Whilst they operate under their own
health and safety policies and procedures they are obliged to follow this document
as far as is necessary for the Trust to achieve compliance and provide specialist
services.
3.1.3.
Where appropriate, regular meetings are held with representatives of these

organisations to ensure coordination and cooperation in health and safety
management.
3.1.4.
Where agency or other temporary members of staff are employed, they must
adhere to all aspects of this policy. It must be a condition of their employment that
they have the same training and competencies as other staff and receive sufficient
induction training at departmental level to ensure they can work safely.
3.2.
Business Objectives
3.2.1.
Health and safety issues will be considered throughout the process of setting
business objectives for the Trust and individual business units. The Business
Planning processes will also ensure that consideration is given to considering the
health and safety implications of introducing any new processes, new working
practices or new personnel, including the identification of the required resources to
safely manage the issue in question.

Page 13 of 18
3.2.2.
Consideration will be given to health and safety implications when procuring goods
or services or undertaking capital developments or refurbishment of existing
premises to prevent the introduction of health and safety hazards.
3.3.
Non Compliances
3.3.1.
Where significant non compliance of health and safety is identified, e.g. from audit
or untoward incidents, they will be resolved, where possible, by local management
at business unit or department level.
3.3.2.
Where these issues cannot be resolved locally, they must be reported to the Risk
Management Committee for agreement as to how these issues are to be managed
in accordance with the Trusts Risk Management Strategy and Organisational
Framework
3.3.3.
Significant health and safety non compliances or issues identified by risk

assessment will be put to Risk Management Committee for consideration and
inclusion on the Trust risk register.
3.4.
Dignity and Respect Charter

The Charter has been considered and there are no dignity and respect concerns in
the implementation of this policy.
3.5.
Equality Impact Assessment
3.5.1.
This policy applies equally to all staff, patients, visitors, contractors and the public.
3.5.2.
An equality impact assessment has been completed for this document
3.6.
Consultation
3.6.1.
This document was forwarded for comment to the following:
3.7
Director of Operations.
Business Unit General Managers
Head Matrons
Risk Management Committee members
Trust Safety Group members
Health and Safety Governance

The Trust Board receive assurance regarding Health and Safety via the Risk
Management Committee, who are in turn informed by the Trust Safety Group.

Page 14 of 18
4.
SECTION 4 TRAINING AND EDUCATION
4.1.
Training Needs Analysis (TNA)
4.1.1.
The non clinical risk team will work with the Training and Education Department to
ensure an annual training need analysis of all Health and Safety training required
to ensure compliance with this policy This TNA identifies the level of training
required by each staff group which acts as a baseline for identifying TNA for all
individual members of staff.
4.1.2.
This TNA will be published on the hospitals intranet.
4.1.3.
All new employees will attend Trust Welcome (induction) where basic Health and
Safety, Security, Personal Safety and Fire Safety information is given. Detailed
induction training takes place within each department and is based on a training
needs analysis
4.1.4.
Where appropriate staff may be given specialist health and safety training. For
example Institute of Occupational Safety and Health accredited Managing Safely
course is available to managers with a health and safety role
4.2.
Training Prospectus
4.2.1.
In addition the non clinical risk team will compile information on the training to be
held each year and forward details to the Education and Training Department for
inclusion with the hospitals training prospectus. This will also be placed on the
hospitals intranet.
4.3.
Training
4.3.1.
It is the responsibility of all line managers to ensure that their members of staff
receive mandatory training in line with the TNA. Each member of staff is also
personally responsible for attending training courses and for carrying out their
duties in accordance with the training given. Full information is given in the
hospitals Mandatory Training Policy including;
4.3.1.1.
Duties and responsibilities for managers, staff and contractors.
4.3.1.2.
The arrangements for staff to receive training.
4.3.1.3.
The recording of training received on the hospitals electronic staff record

system and the availability of records.
4.3.1.4.
The process for following up those staff who fail to attend mandatory training.
4.3.1.5.
Linking mandatory training with annual staff appraisals.
5.
DEVELOPMENT AND IMPLEMENTATION INCLUDING DISSEMINATION
5.1.
Development and Implementation
5.1.1.
The Trusts Health and Safety Advisor has consulted with those referred to in
paragraph 3.6 in compiling this policy through forwarding a draft to them for
comment.
5.1.2.
The policy will be approved by the Audit Committee and ratified by the Trust Board.

Page 15 of 18
5.2.
Dissemination
5.2.1.
Once this policy has been approved and ratified it will be brought to the attention of
staff via the following:
5.2.1.1.
The policy will be e-mailed to all Senior Managers, including Head Matrons
referring them to their responsibilities under this policy
5.2.1.2.
The policy will be placed on the Trust intranet
5.2.1.3.
A broadcast will be issued to all staff via e-mail.
5.2.1.4.
5.2.1.5.
As part of the Trusts induction process, all health and safety, security and fire
safety policies must be brought to the attention of all new members of staff.
The policy will also be implemented thorough the health and safety training
identified in Section 4.
6.
SECTION 6 MONITORING COMPLIANCE AND EFFECTIVENESS
6.1.
The Trust Board are assured of health and safety standards by compliance with the
Institute of Directors and Health and Safety Commission guidance document.
Leading health and safety at work
6.2.
Compliance with and the effectiveness of this policy will be monitored by the Health
and Safety Performance Management and Assurance Framework.
7.
SECTION 7 CONTROL OF DOCUMENTS INCLUDING ARCHIVING

ARRANGEMENTS
7.1.
Once ratified by the Trust Management Team, the Responsible Officer will forward
this policy to the Information Governance Department for a document registration
number to be assigned and for the policy to be recorded onto the central hospital
master index and central document library of current documentation.
7.2.
In order that this document adheres to the hospitals Record Management Policy,
the Responsible Officer will arrange for staff to be advised when this document is
superseded and for arranging for this version to be removed from the hospitals
intranet. The Responsible officer will also advise the Information Governance
Department who will ensure that this document is removed from the current index
and library, archived and retained for 10 years from the archive date.
8.
SECTION 8 SUPPORTING COMPLIANCE AND REFERENCES
8.1.1.
Health and Safety at Work Act 1974.
8.1.2.
Corporate Manslaughter and Corporate Homicide Act 2007
8.1.3.
Health and Safety (Offences) Act 2008.
8.1.4.
Compressed Acetylene Order 1947
8.1.5.
Confined Spaces Regulations 1997
8.1.6.
Construction (Design and Management) Regulations 2007

Page 16 of 18
8.1.7.
Control of Asbestos Regulations 2006
8.1.8.
Control of Lead at Work Regulations 2002
8.1.9.
Control of Noise at Work Regulations
8.1.10.
Control of Substances Hazardous to Health (Amendment) Regulations 2003
8.1.11.
Control of Substances Hazardous to Health (Amendment) Regulations 2004
8.1.12.
Control of Substances Hazardous to Health Regulations 2002
8.1.13.
Control of Vibration at Work Regulations 2005
8.1.14.
Electricity at Work Regulations 1989
8.1.15.
Fire Precautions (Factories, Offices, Shops and Railway Premises) Order 1989 Fire
Precautions Act 1971 (Modifications) (Revocation) Regulations 1989
8.1.16.
Gas Safety (Installation and Use) Regulations 1998
8.1.17.
Gas Safety (Management) Regulations 1996
8.1.18.
Gas Safety (Rights of Entry) Regulations 1996
8.1.19.
Health and Safety (Consultation with Employees) Regulations 1996
8.1.20.
Health and Safety (Display Screen Equipment) Regulations 1992
8.1.21.
Health and Safety (Enforcing Authority) Regulations 1998
8.1.22.
Health and Safety (Fees) Regulations 2007
8.1.23.
Health and Safety (First-Aid) Regulations 1981
8.1.24.
Health and Safety (Miscellaneous Amendments) Regulations 2002
8.1.25.
Health and Safety (Repeals and Revocations) Regulations 1995
8.1.26.
Health and Safety (Repeals and Revocations) Regulations 1996
8.1.27.
Health and Safety (Safety Signs and Signals) Regulations 1996
8.1.28.
Health and Safety (Training for Employment) Regulations 1990
8.1.29.
Health and Safety at Work etc Act 1974 (Application to Environmentally Hazardous
substances) Regulations 2002
8.1.30.
Health and Safety Information for Employees (Modifications and Repeals)

Regulations 1995
8.1.31.
Health and Safety Information for Employees Regulations 1989
8.1.32.
Ionising Radiations Regulations 1999
8.1.33.
Management of Health and Safety at Work and Fire Precautions (Workplace)

(Amendment) Regulations 2003
8.1.34.
Management of Health and Safety at Work Regulations 1999
8.1.35.
Management of Health and Safety at Work (Amendment) Regulations 2006
8.1.36.
Manual Handling Operations Regulations 1992
8.1.37.
Notification of Cooling Towers and Evaporative Condensers Regulations 1992
8.1.38.
Personal Protective Equipment Regulations 1992
8.1.39.
Pressure Systems Safety Regulations 2000
8.1.40.
Provision and Use of Work Equipment Regulations 1998

Page 17 of 18
8.1.41.
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995
8.1.42.
Safety Representatives and Safety Committees Regulations 1977
8.1.43.
Work at Height Regulations 2005
8.1.44.
Work at Height (Amendment) Regulations
8.1.45.
Workplace (Health, Safety and Welfare) Regulations 1992
8.1.46.
Regulatory Reform (Fire Safety) Order 2005
Note
The above list is of HSE enforced legislation at the time of approval of this document. This
list may not be exhaustive; current legislation can be found on the Office of Public Sector
Information webpage.

Page 18 of 18

Health and Safety Policy

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HEALTH AND

For use by:

All Trust patients, visitors and staff, including contractors.

This document supports

All Statutory Instruments written under the above Act

This document supersedes:

TPO HS 001 version 2.0

Trust Management Team

In case of queries contact:

Health and Safety Advisor

Directorate and Department

To be inserted by Information Governance Department when this document is

Date document to be destroyed:

To be inserted by Information Governance Department when this document is

Registered Document 1168

Version and document control:

Written in new format; allocated new number

Minor amendments following consultation

Approved and ratified document

This is a Controlled Document

Sharing this document with third parties

Registered Document 1168

SECTION 1 INTRODUCTION ...................................................................................................... 5

Policy Statement and Rationale ............................................................................................... 5

Key Principles ............................................................................................................................ 5

Background Information ........................................................................................................... 5

SECTION 2 DUTIES AND RESPONSIBILITIES ......................................................................... 6

Trust Board ................................................................................................................................ 6

Chief Executive .......................................................................................................................... 7

Chairs and General Managers of Business Units and Directors .......................................... 7

Departmental Managers / Matrons ........................................................................................... 8

Business Unit Heath and Safety Nominated Officer ................................................................ 8

Director of Operations .............................................................................................................. 9

Health and Safety Advisor ........................................................................................................ 9

Fire Safety Adviser / Manager ................................................................................................. 10

Security Advisor ...................................................................................................................... 10

Non Clinical Risk Team ............................................................................................................ 10

Occupational Health ................................................................................................................ 11

Infection Control ...................................................................................................................... 11

Risk Management Committee .................................................................................................. 11

Union Health and Safety Representatives .............................................................................. 12

Trust Safety Group .................................................................................................................. 12

Individual Responsibilities ..................................................................................................... 12

Any Other Persons on Trust Premises ................................................................................. 13

Responsible Officer ................................................................................................................. 13

SECTION 3 ARRANGEMENTS ................................................................................................. 13

Key Related Hospital Policies ................................................................................................ 13

Business Objectives ............................................................................................................... 13

Registered Document 1168

Non Compliances .................................................................................................................... 14

Dignity and Respect Charter .................................................................................................. 14

Equality Impact Assessment .................................................................................................. 14

SECTION 4 TRAINING AND EDUCATION ............................................................................... 15

Training Needs Analysis (TNA) .............................................................................................. 15

Training Prospectus ................................................................................................................ 15

DEVELOPMENT AND IMPLEMENTATION INCLUDING DISSEMINATION .............................. 15

Development and Implementation ......................................................................................... 15

SECTION 6 MONITORING COMPLIANCE AND EFFECTIVENESS ....................................... 16

SECTION 7 CONTROL OF DOCUMENTS INCLUDING ARCHIVING ARRANGEMENTS ..... 16

SECTION 8 SUPPORTING COMPLIANCE AND REFERENCES ............................................ 16

Registered Document 1168

Policy Statement and Rationale

To provide adequate publicity and information on health and safety.

To provide safe access and egress to and from the workplace.