Item 1129 16 … · Web view2015 – 2016. Annual Health & Safety . Board Report . Incorporating...

2015 – 2016Annual Health & Safety

Board Report Incorporating Annual

Health & Safety CommitteeSecurity and Occupational Health Reports

Prepared by Rod DewarHealth & Safety Advisor / EPRR Lead

Executive LeadBronwen Bishop Director of Strategic Development

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Table of Contents2015 – 2016 Annual Health & Safety Board Report.....................................................................................................................1

1. Executive Summary.........................................................................................................................................4

1.1 Format 4

1.2 Health & Safety Resource 4

1.3 Health & Safety Responsibilities 4

1.4 Radiation Protection 4

1.5 Estates Department 4

2. Purpose of the Report......................................................................................................................................5

2.1 Purpose 5

3. Legislative Framework for Health & Safety.......................................................................................................5

3.1 Legislative Framework 5

3.2 Statutory Duties 5

Table-1: Key Regulations – Oversight Responsibility: 6

4. Key Health & Safety Regulatory Areas..............................................................................................................7

4.1 Health & Safety Executive (HSE) 8

5. Trust Health & Safety Management System.....................................................................................................8

5.1 HSG-65 Health & Safety Management Model 8

6. Responsibilities................................................................................................................................................8

7. Safety Alerts..................................................................................................................................................10

Table-2: Safety Alerts received by Type and Qty 10

8. Health & Safety Training................................................................................................................................10

8.1 Health & Safety Training Arrangements 10

Table-3: Health & Safety Essential Training – 2015/16 Uptakes 10

9. The Health & Safety Committee.....................................................................................................................11

10. Datix Incident Reporting................................................................................................................................11

Table-4: Specific Datix Reported Incidents - Data by Financial Quarter 2015-16 12

Table-5: Detail for Staff RIDDOR Reported Incidents 13

Table-6: Detail for ‘Patient RIDDOR’ Reported Incidents 15

Table-7: Detail for ‘Visitor RIDDORs’ Reported Incidents 16

Table-8: Detail for Contractor RIDDOR Reported Incidents 16

Table-9: Personal Injury Claims - 01st April 15 to 31st March 2016 17

10.10 Radiation Safety 18

10.11 Datix Reported – Unintended Exposure to Radiation Incidents 19

Table-10: Datix Reported Unintended Exposure to Radiation - Detail by Quarter 2015/16 19

10.12 Datix Reported - Fire Safety Incidents 21

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10.13 Datix Reported – Pathology Incidents 22

10.14 Datix Reported - Abuse Incidents 22

10.15 Datix Reported – Control of Substances Hazardous to Health Incidents (CoSHH) 23

10.16 Datix Reported - Manual Handling Incidents 23

Table-11: Detail for Datix Reported Manual Handling Incidents - by Quarter 2015-16 24

10.17 Datix Reported – Contamination and Sharps Incidents 25

Table-12: Contamination SHARPS Incidents 2015-16 27

Table-13: Contamination Splash Incidents: 29

11. Key Developments during the Year................................................................................................................30

11.1 Memorandum of Understanding (MoU) - Health and Safety Executive (HSE) and Care Quality Commission (CQC). 30

11.2 RIDDORs in health and social care 30

11.3 Trust Updated Core HEALTH & SAFETY Policies Uploaded to Document Management System. 30

11.4 Trust Health & Safety Policies Due Review by June 2016 30

11.5 Trust E&FM New Issue Policies - Ratified and on DMS 2015 30

11.6 Trust E&FM Reviewed HEALTH & SAFETY Related Policies - Ratified and on DMS 2015. 30

11.7 Trust Changes to Responsibilities 2015-16 31

11.8 Trust Estates Department Reconfiguration 31

12. Summary of Health & Safety Priorities 2016-17..............................................................................................31

12.1 Estates Department 31

12.2 Training 31

12.3 Health & Safety Audit Programme 31

13. Appendix-1: Annual Security Report 2015-16.................................................................................................32

14. Appendix-2: Annual Occupational Health Service Report April 2015 to March 2016.......................................35

15. Appendix-3: Annual Health and Safety Work Plan 2016-2017.........................................................................46

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1. Executive Summary

1.1 FormatThis Annual Health & Safety Report details a number of Health and Safety metrics, in a format agreed by the Executive Lead for Health & Safety and the Health & Safety Committee.

1.2 Health & Safety ResourceFor the reporting period 2015/16, the Trust had in post one professionally qualified and experienced Health & Safety ‘Competent Person’ as required by Regulation-5; of the Management of Health & Safety at Work Regulations – 1999. For the whole reporting period this post was resourced at 0.6 WTE (3-days per week).

1.3 Health & Safety ResponsibilitiesThe Trust Health & Safety Policy details specific responsibilities for the implementation of Health & Safety within the Trust, including responsibilities for the Chief Executive Officer, nominated Executive Director for Health & Safety, Executive Directors and Senior Managers / Heads of Departments.

The Trust Health & Safety Advisor provides advice and guidance to the Trust on Health & Safety matters and maintains a watching brief on Health & Safety Legislation changes which will, or may, affect trust compliance with Health & Safety Legislation.

The Health & Safety Advisor is also responsible for reporting on Health and Safety matters to the Health & Safety Committee, Risk Management Committee, Quality & Governance Committee and the Trust Board.

1.4 Radiation ProtectionFor Radiation Incidents reported via the Datix Incident Reporting System, the Radiology department has specific processes and procedures in place to ensure that rapid local investigation takes place and where an incident meets set criteria; all external reporting requirements are met.

The Trust employs the services of a qualified Radiation Protection Advisor (RPA) based at the Bristol Royal Infirmary and on site Radiation Protection Supervisors (RPS). All Radiation incidents are fully investigated by the Radiology Manager and Trust RPS, with advice and guidance provided by the RPA, all Radiation Incidents are also reviewed by the Radiation Protection Committee.

1.5 Estates DepartmentThe ‘Director of Strategic Development’ took over executive responsibility for the Estates Department from 1st June 2015 and took steps to implement Health & Safety recommendations to ensure the department has in place the required, policies, risk assessments, safe systems of work, documentation and training required, in order to fulfil its Health & Safety Statutory Duties.

Work to ensure the Estates Department has in place all statutory competencies required was ongoing throughout the reporting period. Subject to delivery of an agreed training plan designed to ensure that members of Estates Staff undertake required competency training and are formally appointed.

Throughout the reporting period, the Trust Health & Safety Advisor supported Estates Managers in the delivery of required Health & Safety policies and procedures.

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2. Purpose of the Report

2.1 Purpose2.1.1 The purpose of this report is to provide assurance to the Board regarding the Trusts Health & Safety

Systems and Processes for the year 1 April 2015 to 31 March 2016.

2.1.2 This report enables the Trust Board to demonstrate effective, active leadership and commitment, detailing the ‘downward’ communication systems and management structures in place to enable integration of positive health and safety management.

3. Legislative Framework for Health & Safety

3.1 Legislative Framework3.1.1 The ‘Health and Safety at Work Act -1974’ provides the legislative framework for the Health, Safety

and Welfare of persons at work. The Act is an ‘enabling act’ detailing the Health and Safety requirements for people at work, in all occupations. It also details protection for the wider public where they may be affected by the activities of people at work.

3.1.2 The ‘Act’ includes; Health & Safety Regulations, Approved Codes of Practice, Guidance Notes and Directives. The Trust is required to comply with all elements of the act and non-compliance may result in an offence being committed under the Act and may constitute a criminal offence leading to prosecution, resulting in a fine and/or a term of imprisonment.

3.1.3 Under the Corporate Manslaughter and Corporate Homicide Act - 2007; an offence will be committed where failings by an Organisation’s Senior Management, are a substantial element in any gross breach of the duty of care owed to the organisation’s employees or members of the public, which results in death.

3.1.4 The maximum penalty is an unlimited fine and the court can make a publicity order, requiring the organisation to publish details of its conviction and fine.

3.2 Statutory Duties3.2.1 Whilst the Trust is ‘vicariously liable’ for the acts and omissions of its staff, trust employees also

have a duty under the ‘Health & Safety at Work Act – 1974’; ‘To take reasonable care to avoid injury to themselves and others and to co-operate with the Trust

as their employer and others, in meeting the statutory requirements’

3.2.2 Failure to comply with any Health & Safety Regulations that apply to the Trust, may lead to Enforcement Action by the Health & Safety Executive in the form of Improvement or Prohibition Notices, the Fire Authorities are also empowered for enforcement action, under the Fire Safety Order.

3.2.3 The Trust has a statutory duty to ensure compliance with a significant number of current Health & Safety Regulations, as detailed at Table-1 below.

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Table-1: Key Regulations – Oversight Responsibility:Regulation Oversight

1. The Health and Safety at Work Act - 1974 H&S Committee2. The Management of Health and Safety at Work Regulations – 1999 (MHSWR) H&S Committee3. The Workplace (Health, Safety and Welfare) Regulations – 1992 (WHSWR) H&S Committee4. The Manual Handling Operations Regulations - 1992 (amended – 2002) H&S Committee5. The Provision and Use of Work Equipment Regulations -1998 (PUWER) H&S Committee6. Health and Safety (First Aid) Regulations -1981 H&S Committee7. Reporting of Injuries, Diseases & Dangerous occurrences Regulations - 1985 (RIDDOR) H&S Committee8. The Control of Substances Hazardous to Health Regulations - 2002 H&S Committee9. Health and Safety (Display Screen Equipment) Regulations - 1992 H&S Committee10. The Personal Protective Equipment Regulations - 2002 H&S Committee11. Health and Safety (Sharp Instruments in Healthcare) Regulations - 2013 H&S Committee12. Control of Noise at Work Regulations - 2005 H&S Committee13. The Ionising Radiation (Medical Exposure) Regulations - 2000 H&S Committee14. Ionising Radiations Regulations - 1999 H&S Committee15. Lifting Operations and Lifting Equipment Regulations -1998 H&S Committee16. Health and Safety (Consultation with Employees) Regulations - 1999 H&S Committee17. Safety Representatives and Safety Committees Regulations - 1977 H&S Committee18. The Work at Height Regulations - 2005 H&S Committee19. The Health and Safety (Training for Employment) Regulations - 1990 H&S Committee20. The Health and Safety (Safety Signs and Signals) Regulations - 1996 H&S Committee21. The Regulatory Reform (Fire Safety) Order - 2005 H&S Committee22. Liability (Compulsory Insurance) Act - 1969 H&S Committee23. Electricity at Work Regulations - 1989 H&S Committee24. Chemicals (Hazard Information and Packaging for Supply) Regulations - 2002 H&S Committee25. Construction (Design and Management) Regulations - 2007 H&S Committee26. Gas Safety (Installation and Use) Regulations - 1994 H&S Committee27. Dangerous Substances and Explosive Atmospheres Regulations - 2002 H&S Committee28. Disability Discrimination Act (DDA) - 2005 H&S Committee29. The Health and Safety (Offences) Act - 2008 Trust Board Secretary30. The Corporate Manslaughter and Corporate Homicide Act - 2007 Trust Board Secretary

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4. Key Health & Safety Regulatory Areas

Table-3

Asbestos Management

(Control of Asbestos Regulations 2012)

Medical Gas

Systems

EU Pharmacopeia Regulations

Ventilation - LEV Testing

HTM

Control of Substances Hazardous to

Health Regulations 2013

EH40/2005

Contractors

Construction Design Management

(CDM) Regulations 2015

MHSW Regulations

Diathermy & Surgical Smoke

Control of Substances Hazardous

to Health Regulations 2012

HSE Guidance

Waste

Controlled Waste (England and Wales) Regulations 2012

HSE Guidance

High Voltage Systems Authorisation

Process

HTM 06-03

Medical Air Quality Compliance

HTM 02-01 A & B

Lifting Equipment And Handling Including

Hoists

Lifting Operations and Lifting

Equipment Regs 1998 (LOLER)

Falls From Windows

(HSE Info 5) Falls from windows or

balconies in health and social care

MHRA Safety Alert

EFA/2012/001

Equipment Safety – Medical

Equipment

Provision & Use of Work

Equipment Regs 1998 (PUWER)

Lifting Operations and Lifting

Equipment Regulations (LOLER)

Workplace Violence

EU Directive HSE

Management of Health And Safety @Work Regs 1999

Local Security Management Services

Low Voltage Systems (Electrical)

HTM-06-03 Elec.

Medical Gas

HTM 02

Compliance and Authorisation of

Processes

MHRA

Pressure Systems

Pressure Systems Safety Regulations -

2000

Patient Handling Including Bariatric

Manual Handling Operations

Regulation -1992

Fire Safety

Regulatory Reform (Fire Safety)

Order- 2005

HTM05-01

Workplace Transport Safety - HSE Guidance

Safe Site

Pedestrians

Car Parks

Road Speed Limits

PAT Testing

HTM 06 Electricity at Work-1989

Water Safety

Control of Legionella -2012 (L8.)

Quality, Safety & Environmental

Management

Implementation of Premises

Assurance Model (PAM)

COSHH

Control of Substances Hazardous

to Health Regs -2013

Infection Prevention

DoH Infection Prevention

Guidelines

Personal Protective equipment

Regulations 2002

Fire Alarm Testing

Regulatory Reform (Fire Safety) Order -2005

HTM 05-01

Air Conditioning Plant.

Control of Legionella -2012 (L8.)

Slips, Trips And Falls

HSE Guidance INDG225

Cytotoxic drugs

COSHH

HSE Guidance Safe Handling of

Cytotoxic Drugs in the Workplace

Sharps injuries

EU Directive compliance

Health and Safety (Sharp

Instruments in Healthcare)

Regulations -2013

First Aid

Health and safety (First Aid)

Regulations -2013

Health & Safety Information & Training

The Health & Safety At Work Act 1974

The Management of Health & Safety at Work

Regulations -1997

Safety Representatives and Safety Committees

Regulations - 1977

The Health and Safety (Consultation with Employees)

Regulations 1996 Health and Safety (Training for

Employment) Regulations - 1990

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4.1 Health & Safety Executive (HSE) 4.1.1 Under the ‘Health and Safety (Fees) Regulations - 2012’, a breach of Health & Safety Law now

results in liability for costs submitted by the HSE; including inspection, investigation and enforcement action; the intervention fee hourly rate for 2016 is set at £129.

4.1.2 The HSE continues to implement measures aimed at reducing the burden of unnecessary regulation upon organisations, while maintaining the UK’s health and safety performance.

5. Trust Health & Safety Management System

5.1 HSG-65 Health & Safety Management Model5.1.1 The Trust currently uses the Health & Safety Executive (HSE) - HSG-65 guidance ‘Managing for

Health and Safety’ model to manage the delivery of Health and Safety.

6. Responsibilities

6.1 Trust Health & Safety Policy - ResponsibilitiesFull details of responsibilities for the management of Health & Safety within Weston Area Health NHS Trust, are detailed in the Trust Health & Safety Policy.

6.1.1 Trust Chief Executive The Chief Executive is responsible for the establishment and maintenance of an effective policy for Health & Safety at Work.

6.1.2 Trust Executive Lead for Health & SafetyA nominated Executive Director holds delegated responsibility for overseeing the management of Health & Safety.

The Director of Strategic Development fulfilled this role from June 2015.

6.1.3 Trust Executive Lead for Fire Safety A nominated Executive Director has delegated responsibility for overseeing the management of Fire Safety within the Trust.

The Director of Strategic Development fulfilled this responsibility for the period of this report; 2015-16.

6.1.4 Trust Executive Lead for SecurityA nominated Executive Director has delegated responsibility for overseeing the management of Security within the Trust.

The Director of Operations fulfilled this responsibility for the period of this report; 2015-16.

6.1.5 Trust Executive DirectorsAll Executive Directors are responsible for effective implementation of the Trust Health & Safety Policy by members of staff for whom they are managerially or professionally accountable.

6.1.6 Trust Associate Director of Governance and Patient ExperienceAssociate Director of Governance and Patient Experience Ensures that appropriate governance arrangements for Health & Safety are in place and are a robust part of the Trusts overall governance arrangements.

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6.1.7 Trust Head of Governance and Patient ExperienceLine manages the Trust Health & Safety Advisor.

6.1.8 Trust Health & Safety AdvisorAssumes the role of Health & Safety ‘competent person’ for the Trust and provides advice and guidance to Trust Directors and Managers for implementation of day to day delivery of Health and Safety within the Trust, resourced at 0.6 WTE (3 days per week) during this reporting period.

6.1.9 Trust Fire Safety ManagerThe Head of Estates and Facilities reports to the Executive Director with responsibility for Health & Safety and has delegated responsibility under ‘HTM05-01: Fire code: Fire Safety in the NHS’ as the nominated Trust Fire Safety Manager, with responsibility for ensuring effective delivery of Fire Safety measures throughout the Trust, by compliance with the requirements of both the Fire Safety Order and HTM05-01.

6.1.10 Trust Fire Safety AdvisorsFire Safety Advisors are contracted in to support the Fire Safety Manager and ensure appropriate fire safety guidance is provided to the Trust Fire Safety Manager, including provision of Fire Risk Assessments and Fire Safety / Evacuation Training, currently resourced at 0.4 WTE (2 days per week).

6.1.11 Trust Manual Handling / DSE AdvisorSpecialist advice for reported Manual Handling and Display Screen Equipment (DSE) issues is provided by a member of the Trust Training Team undertaking Trustwide ‘Health & Safety induction and Statutory Mandatory training’.

6.1.12 Trust Associate Directors/Senior Managers/Heads of Department/Ward Managers Senior Managers/Heads of Department/Matrons/Ward Managers (Nursing) are responsible for implementing Health & Safety measures for the areas under their immediate control; e.g. Health and Safety of employees and that contractors and other people (patients and visitors) comply with the Trust’s Health and Safety Policy.

6.1.13 Trust Quality & Governance CommitteeA Committee of the Trust Board, with responsibility to review all aspects of the Trust’s quality and clinical governance and for ensuring that the Trust meets all its duties and obligations under the NHS Constitution, plus all other statutory, regulatory and best practice requirements. The committee is also responsible for the review of all aspects of the risk management process regarding clinical, quality and safety and obtaining assurance on all aspects of the Trust’s declarations and its registration by the Care Quality Commission.

6.1.14 Trust Health & Safety CommitteeAn essential part of the Trusts governance arrangements for Health & Safety, the committee monitors the delivery within the Trust of Health & Safety, Fire Safety and Security and associated policies and procedures.

6.1.15 Health & Safety Representatives The Trust encourages all departments to have a nominated Health & Safety Representative. Health & Safety Representatives assist management in the promotion and improvement of Health and Safety and their role is clearly defined by the ‘Safety Representatives and Safety Committees Regulations -1977’ and the ‘Health and Safety (Consultation with Employees) Regulations - 1999’

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7. Safety Alerts

7.1 Safety Alerts are managed by the Head of Governance, appropriate department managers are informed, action due dates are tracked and reporting deadlines are met.

7.2 Table-2 below details the type and quantity of safety alerts received by the Trust in the reporting period 2015/16.

Table-2: Safety Alerts received by Type and QtyAlert Type Full Title Qty

MDA Medical Device Alert 30EFN Estates Facilities Notice 49EFA Estates Facilities Alert 05DH Department of Health Notice 01NHS/PSA NHS Patient Safety Alert 10

Total Alerts Received from 01-04-15 to 31-03-16 0Alerts closed = 19 with actions & 75 no action required 94Total Alerts Open - Qty-1 within deadline 01Total Alerts Outstanding at 31-03-16 0

8. Health & Safety Training

8.1 Health & Safety Training Arrangements8.1.1 As a key element of the Trusts implementation of its Health and Safety Policy, mandatory training

packages are delivered to members of staff by the Trust Training Team, in order to promote Health & Safety awareness and competency.

8.1.2 For 2015/16, the Trust continued to deliver induction and refresher mandatory training in: Fire Safety. Health and Safety. Infection Control. Moving & Handling. Conflict Resolution.

8.1.3 Training Uptake for 2015-16 reported by the trust Training department is detailed in Table-3 below; The Trusts compliance target for Core Essential Training is set at 90%:

Table-3: Health & Safety Essential Training – 2015/16 Uptakes

Topic

Apr-15%

May-15%

Jun-15%

Jul-15%

Aug-15%

Sep-15%

Oct-15%

Nov-15%

Dec-15%

Jan-16%

Feb-16%

Mar-16%

Last 3 months

% Change

FireSafety

79.27 79.03 81.81 79.00 82.70 83.00 81.60 80.40 80.10 78.90 79.40 77.80 1.1

Health & Safety

86.71 87.00 88.10 88.80 89.30 88.60 88.30 88.70 89.80 88.50 88.10 87.20 1.3

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Infection Control 86.76 87.00 88.00 88.40 89.20 88.40 88.20 88.60 89.70 88.30 88.20 87.40 0.9

Moving & Handling 86.85 87.10 88.20 88.90 89.10 88.40 88.10 88.50 89.60 88.30 87.80 87.10 1.2

Conflict Resolution 59.50 59.09 60.80 59.20 63.60 64.00 65.60 66.20 66.60 68.00 68.40 69.20 1.2

8.1.4 For the final 3-months of the reporting period, Fire Safety; Health & Safety; Infection Control; and Moving & Handling training compliance, were on a downward trend. However, Conflict Resolution compliance was on an upward trend rising to 69.20% in March 2016 from a low of 59.2% in July 2015; however compliance for this subject remains more than 20% below the Trust 90% target.

8.1.5 Whilst operational pressures have contributed to this position, it was also clear that members of staff were also failing to attend training when they were available to do so. For this reason disciplinary action was undertaken for members of staff who were more than 6 months out of date with essential training; this appeared to have a positive impact on compliance levels for the latter part of 2015.

9. The Health & Safety Committee

9.1 During this reporting period, the Trust Health and Safety Committee met quarterly under the chairmanship of the Director of Strategic Development as the Executive Lead for Health & Safety, with the Committee Secretariat provided by the Trust Datix Administrator, who is part of the Quality Improvement Team.

9.2 Representation and reports to this committee were made by the following: Director of Strategic Development - Executive Lead for Health & Safety. Health & Safety Advisor / EPRR Lead. Health & Safety Representatives (Union and non-union). Head of Estates & Facilities. Local Security Management Specialist (LSMS). Security Manager - Estates. Fire Safety Advisor - Estates. Training Manager. Occupational Health Nurse. Infection Control Nurse (when required). Pathology Laboratory Saftey Representative. Radiography Manager. Directorate General Manager

9.3 Although not a statutory requirement ‘Safety Representatives’ also have a committee, normally scheduled to meet 14-days before each Health and Safety Committee meeting.

10. Datix Incident Reporting

10.1 The Datix Incident Reporting System is overseen by the Head of Governance and Patient Experience and administered daily by the Datix Administrator.

10.2 Incidents are logged onto Datix in accordance with the Trust’s Incident Management Policy. The Datix system is used by staff to report both clinical and non clinical safety incidents.

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10.3 The Datix system received an upgrade to its capabilities in October of 2015, part of the upgrade included changes to reporting fields, groups and sub groups, to better capture data and adding the functionality for automatic feedback to be given to the incident reported once the incident has been finally approved by the incident manager.

10.4 The Datix administrator quality checks each submitted Datix incident to ensure data is accurate for uploads to the National Reporting Learning System (NRLS) and also that an appropriate Incident Handling Manager is allocated to investigate each incident, complete the Datix and feedback to the individual raising the incident.

10.5 The Quality Improvement Team review and assess each Datix submitted for the Trust via the daily SitRep and determine the level of investigation:

A local investigation; RIDDOR investigation; Medication Root Cause Analysis. Pressure Ulcer Root Cause Analysis; Serious Incident Requiring Investigation.

10.6 Each incident is assigned a handler responsible for investigation and identification of actions.

Table-4: Specific Datix Reported Incidents - Data by Financial Quarter 2015-16

Specific Datix Reported Incident Categories Qtr-12015/16

Qtr-2 2015/16

Qtr-3 2015/16

Qtr-4 2015/16

Annual Totals

RIDDOR Reportable 9 6 10 9 34Security 13 11 10 9 43Radiation 3 4 7 3 17Fire Related 6 5 1 1 13Pathology 14 4 2 6 26Abuse 82 66 26 34 208Manual Handling 1 2 2 0 5Contamination and SHARPS (Splash Blood Saliva) 11 16 17 17 61Quarter Totals 139 114 75 79 407407

10.7 Reporting of Injuries, Diseases & Dangerous Occurrences Regulations - 2013 (RIDDOR) 10.7.1 The ‘Reporting of Injuries, Diseases & Dangerous Occurrences Regulations – 2013’ is a complex

regulation applying a single set of reporting requirements to ‘all work activities’ in the United Kingdom.

10.7.2 The main purpose of the regulation is to generate statutory notification to the Health and Safety Executive (HSE) and to Local Authorities (also referred to as ‘Enforcing Authorities’) for: Specified Injuries: are reportable by the Trust if they arise ‘out of or in connection with work’

Reportable diseases, infections and ill health: are reportable by the Trust if they arise ‘out of or in connection with work’

Reportable Lost-time accidents to employees: are reportable by the Trust if they arise ‘out of or in connection with work’

Over-seven-day incapacitation of a worker: are reportable if they result in an employee or self-employed person being away from work; or unable to perform their normal work duties; for more than seven consecutive days as the result of their injury, statutory 15 days to complete and submit each report.

Over-three-day injuries: The Trust is required to record accidents, (but not report them), where they result in a worker being incapacitated for more than three consecutive days, the use of the Datix Incident Reporting System to record the event is sufficient.

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10.7.3 All reported Datix incidents are investigated by an allocated Incident Handler and the Datix Incident Reporting System allows the assigned investigating manager, to directly report any incident classed as ‘RIDDOR reportable’ to the ‘HSE RIDDOR Website’.

10.7.4 All reported RIDDOR’s (other than for an absence in excess of 7-days), whether to staff or patients, are subject to an SBAR investigation. Any fractured NOF is subject to a Serious Incident Requiring Investigation (SIRI) undertaken by the investigating manager or a manager agreed by the Head of Governance.

10.8 RIDDOR Reported Incidents by Quarter

13/14 Q1

13/14 Q2

13/14 Q3

13/14 Q4

14/15 Q1

14/15 Q2

14/15 Q3

14/15 Q4

15/16 Q1

15/16 Q2

15/16 Q3

15/16 Q4

0

2

4

6

8

10

12

54

2

54 4

3

9 9

6

109

Table-5: Detail for Staff RIDDOR Reported Incidents

Submitted Staff RIDDOR’s

Area

Ambulance Entrance

Ashcombe Birth

Centre

Cheddar Ward

Draycott Unit

Harptree Ward

Kewstoke Ward

Patients Home

Physio OT

StoreSAU Total

1. Fall - Absent +7 days Bruised Arm

1 1

2. Fall - Absent +7 days Bruised Bottom

1 1

3. Fall - Absent +7 days Bruised Chest

1 1

4. Fall - Absent +7 days Dislocated Shoulder

1 1

5. Bed Rail Dropped - Absent +7 days Fracture Finger

1 1

6. Fall - Absent +7days Strained Back

1 1

7. Lifting Couch - Absent +7days Strained Back

1 1

8. Lifting - Absent +7days Strained Shoulder

1 1

9. Fall - Absent +7days Swollen Knee

1 1

10. Slip - Absent +7 days Twisted Ankle

1 1

Total 1 2 1 1 1 1 1 1 1 10

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10.8.1 Analysis of submitted ‘Staff RIDDOR’s’ detailed above:

Sn:

AboveDetail Causes Action Taken

1.

Member of staff fell in corridor

Not taking appropriate personal care, rushing and falling, whilst going to attend a birth.

No additional hazards present.

Upon her return to work the member of staff was reminded of the need to be aware of the risk posed by rushing and not paying attention to the surroundings.

2.


Not taking appropriate personal care, rushing and falling.



3.





4.

Member of staff fell in at Emergency Department Ambulance Entrance

Not taking appropriate personal care, by ignoring the wet weather at that time.

The staff member slipped as soon as she came off the carpeted entrance onto the tiled floor.

1. Upon return to work the member of staff was reminded of the need to be aware of hazards caused when wet weather is happening.

2. Housekeeping staff place additional ‘wet floor signage’ on all hospital entrances when weather is wet

5.

Member of staff fractured finger

Not paying appropriate attention when lowering a bed rail and so not taking appropriate personal care.

Upon her return to work the member of staff was reminded of the need to be aware of the risks involved when operating bed rails, and the need to be vigilant.

6.





7.

Member of staff strained back whilst moving a birthing couch on their own

Not analysing the Manual Handling task and the risk of moving it by themselves.

Upon her return to work the member of staff was reminded of the need to ‘assess’ a Manual Handling task and use of safe Manual Handling techniques.

8. Member of staff suffered a strained shoulder

Carrying too many items from the Occupational Therapy store to place of use.

Upon her return to work the member of staff was reminded of the need to ‘assess’ a Manual Handling task and use of safe Manual Handling

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techniques.

9.





10.

Member of staff twisted their ankle

Unfamiliar surroundings (patients home) uneven path leading from house.

Upon her return to work the member of staff was reminded of the need to be vigilant and to consider ‘hazards and risk’ when working in unfamiliar surroundings away from base.

Incident Themes Arising for Submitted ‘Staff RIDDOR’s’:

The common theme that emerges above is lack of awareness shown by the members of staff involved for:

The task in hand.

The surroundings.

The prevailing conditions.

The hazard and risks present.

Areas for Improvement:

Hazard and risk awareness training during induction and statutory / mandatory training sessions.

Regular scheduled department and team Health & Safety talks by Managers and Supervisors.

Table-6: Detail for ‘Patient RIDDOR’ Reported Incidents

Submitted Patient RIDDOR’s

Area

Cheddar Ward

Day Case Unit

Draycott Unit

Harptree Ward

Hutton Ward

Kewstoke Ward MAU

Recovery Main

Theatre

Steepholm Ward

Stroke Unit

Uphill Ward Total

1. Bed Rail Amputation Finger Tip

1 1

2. Fall Fracture Clavicle 1 1

3. Fall Fracture Elbow 1 1

4. Fall Fracture Lower Limb 1 1 1 1 4

5. Fall Fracture Lower Limb 1 1

6. Fall Fracture NOF 1 2 1 2 1 77. Fall Fracture

Pubic Rami 1 1

8. Fall Fracture clavicle 1 1

9. Fall Fracture Upper Limb 1 1

10. Fall Fracture Left Arm 1 1

11. Fractured Wrist 1 1 2

Total 1 1 1 2 5 3 2 1 1 2 2 21

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10.8.2 Analysis of submitted ‘Patient RIDDOR’s’ detailed above, shows:

Sn: Detail Causes Action Taken

1.

Amputation of a little finger at the first joint

Failure of a bed rail mechanism on a loan bed not previously used by the Trust.

The bed rail failed when the recovering patient moved their arm and hit the rail.

All beds of this type were immediately removed from service and a Serious Incident Investigation undertaken by the trust.

The Hire Company informed the Trust that the manufacturer was redesigning the bed rail mechanism.

The trust reviewed and amended its policy on the acceptance into use of hire beds

2.

The remaining Twenty (20) Patient RIDDOR reportable incidents were all falls causing fractures;

Falls caused to patients who were, not accompanied whilst mobilising and :

In addition to statutory reporting to the HSE RIDDOR site, each incident was investigated by an assigned Trust clinical lead. Note: Fractured NOF triggers a SIRI investigation.

Note: RCA for all other Incidents involving a broken bone (except fingers and toes)

Incident Themes Arising for Submitted ‘Patient RIDDOR’s’:

1. Unsteady whilst mobilising and not seeking assistance going to the bathroom.

2. Unsteady whilst mobilising and not using walking aids.

3. Slipping on urine, water, or over own feet or slippers.


Housekeeping (reporting / cleanup of water or urine on the floor)

Enhanced communication to staff for patients assessed as at risk from falls.

Table-7: Detail for ‘Visitor RIDDORs’ Reported Incidents

Visitor RIDDORs Submitted Hospital Grounds Car Park Outside Main Entrance Total

1. Fracture Foot 1 1

2. Fracture NOF 1 1

Total 1 1 2

10.8.3 Analysis of submitted ‘Visitor RIDDOR’s’ detailed above, shows:

Table-8: Detail for Contractor RIDDOR Reported Incidents

Contractor RIDDORs Submitted Physio Department Total

1. Fracture Foot 1 1 1

Total 1 1

10.8.4 Analysis of submitted ‘Contractor RIDDOR’s ‘detailed above, shows:

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Sn: Detail Causes Action Taken

1.

Fractured foot, contractor (part of a team refurbishing the Physiotherapy Department)

Caused when the contractor stepped off a ladder and slipped on a piece of pipe left on the floor/ Contractor had too many tradesmen working on different areas of the project at the same time, (e.g. walls, ceilings, floors, and electrics) in order to meet short completion deadlines

Discussion with the Contractor to understand why there were so many contractors in the working area, working on different elements of the project.

Estates managers and the H&S Advisor put in place an action with the Contractor to ensure work was better planned with

Incident Themes Arising for Submitted ‘Contractor RIDDOR’s’:

1. Unrealistic deadline for safe completion of the work was agreed by the Contractor.


The Head of Estates initiated a programme to ensure that contractors are not subject to ‘unrealistic’ completion deadlines, which inevitably lead to safety issues.

Contractor in this incident recognises that they should not have accepted an unrealistic completion deadline on the grounds of safety.

Table-9: Personal Injury Claims - 01st April 15 to 31st March 2016

Date of Claim Date of Incident Incident Claimant Claim Status Compensation(Excluding Legal Costs)

18-05-2015 05-05-2015 Slip - Water On Floor Staff Settled £4,195

15-09-2015 12-07-2015 Slip - Tree Sap And Water Outside ED Public Settled £,1000

14-10-2015 17-03-2015 Trip Patient Withdrawn Nil22-03-2015 31-12-2015 Amputation - Tip of Finger Patient Ongoing Estimated £25,000

10.9 Datix Reported - Security Related Incidents

13/14 Q1

13/14 Q2

13/14 Q3

13/14 Q4

14/15 Q1

14/15 Q2

14/15 Q3

14/15 Q4

15/16 Q1

15/16 Q2

15/16 Q3

15/16 Q4

02468

10121416

7

10

15

910

1211

1213

1110

9

10.9.1 Challenges that currently face the NHS, Weston Area Health NHS Trust and the wider community, create unprecedented and constant security risks. These risks require a variety of measures to safeguard valuable assets required to deliver an effective service; measures include protecting the property belonging to the Trust, protecting our staff, safeguarding and protecting our patients and managing the visitors to our sites.

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10.9.2 Types of Security related incidents reported via the Datix Incident Management System include:

Vandalism. Alarm Management. Cark Park Incidents. Loss of keys. Intruders. Trespass. Proven / Alleged theft. Bomb Threats. Public order incidents etc...

10.9.3 For this reporting period Strategic Security Management was delivered by the Trust accredited Local Security Management Specialist (LSMS), providing advice and guidance for delivery of a safe and secure environment for staff, patients and visitors. The LSMS reported to the Director of Operations for this reporting period.

10.9.4 Day to day Physical Security Measures are led by an appointed Estates Manager and include:

Access Control. CCTV. Security Officers (Contracted in).

10.10 Radiation Safety10.10.1 Radiation Safety Policy

Relevant radiation risk assessments and local rules were reviewed and updated where appropriate.

10.10.2 Radiation Protection Adviser (RPA)The role of Radiation Protection Advisor to the Trust is assigned to I. S. Negus, of University Hospitals Bristol NHS Foundation Trust.

10.10.3 Radiation Protection Supervisors (RPS)All Radiation Incidents reported, are investigated and followed up, with all externally reportable incident reporting completed by a Trust Radiation Protection Supervisor (RPS) and the Radiation Protection Advisor (RPA), signed off by the Care Quality Commission.

10.10.4 Ionising Radiation (Medical Exposures) Regulations - 2000 (IRMER)No regulatory changes to report, however a revision by 2018 is expected by the RPA.

10.10.5 Types of Radiation related incidents reported via the Datix Incident Management System include: Equipment failure or malfunction. Exposure of a pregnant woman. Unnecessary or incorrect exposure.

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10.11 Datix Reported – Unintended Exposure to Radiation Incidents

13/14

Q1

13/14

Q2

13/14

Q3

13/14

Q4

14/15

Q1

14/15

Q2

14/15

Q3

14/15

Q4

15/16

Q1

15/16

Q2

15/16

Q3

15/16

Q4

0123456789

2 21

32

01

8

34

7

3

Table-10: Datix Reported Unintended Exposure to Radiation - Detail by Quarter 2015/16Date / Datix No: / Description / Learning Outcome Patient Staff Total

15/04/2015 - DW22254 Patient incorrect area X-rayed - right side - not leftLearning Outcomes/Action: Discussed with lead consultant, as issue was a result of registrar actions, X-ray forms to be double checked with senior doctor and with patient and on arrival to Radiology department. To be discussed with all members of staff in orthopaedic outpatients department. If required patients limbs to be marked by registrar before sending for scans.

1 1

19/06/2015 - DW23318 Member of cardiac team not wearing lead gown - unnecessarily exposedLearning Outcomes/Action: Discussion with member of staff who was affected.Better communication needed between both members of staff. More Lead aprons need to be available or reduction in non essential staff to accommodate number available. 2 physiologists required to attend the implant, only one was needed at less critical times of the procedure. At the time of incident the second Physiologist was need but no lead aprons were available.

1 1

26/06/2015 - DW23437 Patient given unnecessary second x-rayLearning Outcomes/Action: Patient requested by two separate ED nurse practitioners. Radiographer failed to check history. Radiographer spoken to. Alert put onto system for requested to know if the patient examination has already been requested by a colleague.

1 1

06/07/2015 - DW23643 Patient given unnecessary second x-rayLearning Outcomes/Action: The Radiographer strongly suspected that the patient had already been x-rayed, discussed it with the patient. The patient denied the event. So re-x-rayed. The Radiographer was informed that the electronic evidence must be checked in these cases.

1 1

07/08/2015 - DW24102 Patient given x-ray to area not requested.Learning Outcomes/Action: Radiographer failed to identify the correct patient. Discussion with Radiographer about their practice. See DW24536.

1 1

24/08/2015 - DW24356 Patient given unnecessary radiation dose -misinterpretation of x-ray request.Learning Outcomes/Action: Exam booked in incorrectly (clerical staff informed) Radiographer failed to check clinical information. 3rd incident by same Radiographer. Spoken to by manager to reiterate the importance of carrying out the basic checks for identifying a patient and justifying a request. I have appointed her a mentor and have made the senior staff aware that she may need to check requests with them. Radiation incident reported to RPA.

1 1

07/09/2015 - DW24535 Patient sent from ED for Chest x-ray, already received chest x-ray.

Learning Outcomes/Action: Ensure that fully documented in notes when patients have attended tests and communicated fully.

1 1

04/11/2015 - DW25590 Patient given unnecessary repeat CXR. Learning Outcomes/Action: Requested a second time by F1 Dr who did not understand the appearances

on the CXR – artefact not pathology. This is well understood by Radiology – and is regularly disseminated

1 1

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to the F1 staff group. Feedback given to the Dr concerned.05/12/2015 - DW26138 Incorrect imaging request post operative. Learning Outcomes/Action: Incident reported by Radiographer who upon x-raying patient felt that the

clinical indications for the test were incorrect. Liaison with the ortho team confirmed that the original information was correct but confusing and incomplete. Learning point on post op findings for Radiographers – Disseminated. Examination continued and completed.

1 1

07/12/2015 - DW26177 Wrong scan performed - CT chest instead of for stones Learning Outcomes/Action: Incorrect protocol selected on the scanner resulting in wrong scan- low dose

scan. Staff involved informed and spoken to. Error made in a busy environment.1 1

08/12/2015 - DW26209 Ortho consultant requested left hip x-ray, Pelvis was x-rayed, actually wanted shoulder.Learning Outcomes/Action: The request was incorrectly written out by the orthopaedic team. The failsafe of the Radiographer checking all the details did not happen which ended up in the incorrect

body part being examined. Radiographer spoken to. Orthopaedics informed of error.

1 1

10/12/2015 - DW26270 Informed patient had a left hip replacement, no brace visible, wrong sticker on the form, no lateral

image performed. Learning Outcomes/Action: Ortho team to put in place measures for the investigation of assigned Datix

submitted

1 1

12/12/2015 - DW26389Required left foot and ankle views – actually imaged the right foot and right ankle. Learning Outcomes/Action: The Radiographer concerned spoken to about the incident – care and

attention required in future. Modified views were required for this patient and the Radiographer made a mistake in how he orientated the patient in the room which led to the incorrect foot being x-rayed.

1 1

13/12/2015 - DW26400Request was for a CT Abdomen and pelvis, the ct scan performed included the chest in error. Learning Outcomes/Action: Human error in busy/pressured environment. CT Radiographers to be

reminded of the importance of identifying the correct examination protocol. CT LEAD INFORMED – for notification at staff meeting.

1 1

03/01/2016 - DW26720CXR requested patient imaged who then said that they were imaged earlier in the evening for the same thing. Learning Outcomes/Action: ED patient very busy ED. Patient initially assessed in corridor where paper

copy request was made. Later reassessed in cubicle and 2nd request made on electronic system: two made independently with no communication between them. All requests are electronic Now and Radiographer reminded to check previous imaging history as a failsafe.

1 1

16/02/2016 - DW27443Abdomen scanned in error. Ct chest and upper abdomen requested with IV contrast Learning Outcomes/Action: Reported to RPA. The staff member involved wrote a reflective statement on

the incident. Lone working and under pressure with patient uncooperative: Postpone challenging patient in the future when more members of staff are available to avoid error.

1 1

22/03/2016 - DW28179Patient x-rayed the right side the patient had pain on the left - card read left. Learning Outcomes/Action: Ortho team to put in place measures for the investigation of assigned Datix

submitted1 1

Total 16 1 17

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10.12 Datix Reported - Fire Safety Incidents

13/14

Q1

13/14

Q2

13/14

Q3

13/14

Q4

14/15

Q1

14/15

Q2

14/15

Q3

14/15

Q4

15/16

Q1

15/16

Q2

15/16

Q3

15/16

Q4

0

5

10

15

20

2525

2 3

7

13 2

5 6 5

1 1

10.12.1 The types of Fire Safety Incidents reported via the Datix Incident Management System include; 1. Fire alarm activation (real, fault or malicious)2. Incorrect use of fire escapes.3. Smoking in non-smoking areas.4. Non-attendance of estates at alarm calls.5. Breaches in fire safety; e.g. trolleys blocking hospital street or fire exits.6. Incorrectly ‘held open’ fire doors.7. Incorrectly stored gas cylinders.8. Excessive fire loading etc.

10.12.2 The Trust Fire Safety Manager ‘contracts in’ Fire Safety Advisors (FSA), with one day per week assigned to Fire Safety Training and one day per week assigned to completion of Trust Fire Risk Assessments.

10.12.3 The high number of incidents reported in Qtr-1 2013/14 was a result of a newly appointed FSA raising fire safety issues on Datix, mostly clutter on hospital streets. The work undertaken by the FSA’s in the intervening period has resulted in less clutter and less incidents reported on Datix.

10.12.4 Individual actions identified by Fire Risk Assessment are assigned by the Fire Safety Advisor, to the Ward / Department Manager or the Estates and Facilities Department for completion.

10.12.5 Fire Risk Assessments’ are also emailed for information to the Fire Safety Manager, Directorate Managers and Health & Safety Advisor. The Fire Safety Manager continues to work with the Trust Fire Safety Advisors to improve monitoring, reporting and escalation of identified Fire Risk Assessment actions.

10.12.6 All buildings /departments have a current fire risk assessment. The annual fire safety risk inspections for Trust buildings /departments begin in January each year, however actions raised by the 2015/16 inspections, are very similar to those found in 2014/15. The Fire Safety Advisors and the Fire Safety Manger are working to ensure that local managers undertake the actions assigned to them in a timely manner.

10.12.7 Fire Training was delivered on schedule and additional dates at the Academy Centre utilised, although not as fully as possible. A number of workplace training sessions for fire update and evacuation training have taken place, mostly on wards.

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10.13 Datix Reported – Pathology Incidents

13/14 Q1

13/14 Q2

13/14 Q3

13/14 Q4

14/15 Q1

14/15 Q2

14/15 Q3

14/15 Q4

15/16 Q1

15/16 Q2

15/16 Q3

15/16 Q4

0

2

4

6

8

10

12

14

16

76

76

01 1

2

14

4

23

10.13.1 The types of Pathology Incidents reported via the Datix Incident Management System include: Incorrectly labelled samples. Incorrect patient names on paperwork. Failure of laboratory equipment. Incorrect use of the POD system. Loss of ordered blood products by a failure to use.

10.13.2 The Pathology Manager hosts Health & Safety Executive inspections of the CL3 Microbiology Facility, when notified by HSE of such action. The last inspection was due on the 18 May 2016.

10.13.3 The Pathology Manager undertakes an annual walk through inspection, holds quarterly Health & Safety Meetings with members of Pathology staff and reports outcomes and issues to the Trust Health & Safety Committee as an agenda item.

10.14 Datix Reported - Abuse Incidents

13/14 Q1

13/14 Q2

13/14 Q3

13/14 Q4

14/15 Q1

14/15 Q2

14/15 Q3

14/15 Q4

15/16 Q1

15/16 Q2

15/16 Q3

15/16 Q4

0

10

20

30

40

50

60

70

80

49

70

57 60

48

5965

41

7164

3834

10.14.1 The Type of Abuse (verbal or physical) Incidents reported via the Datix Incident Management System include: Abuse of staff by patients. Abuse by staff to patient. Patient abused by relative or third party.

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Abuse of patient by patient. Abuse of staff by other staff.

10.14.2 Actions to address NHS Staff Survey concerns on Violence and Aggression (Abuse) experienced by staff continues, with a ‘Violence & Aggression Working Group’ meeting bi-monthly to coordinate the Human Resource and Divisional Management team response.

10.14.3 The Trust security Policy provides guidance and risk management strategies in order to support ward and department managers in the assessment of violence and aggression risks in their areas of responsibility.

10.15 Datix Reported – Control of Substances Hazardous to Health Incidents (CoSHH)

10.15.1 No CoSHH incidents were reported during this reporting period.

10.15.2 The Types of CoSHH Incidents reported via the Datix Incident Management System include: 1. Exposure to chemical spills (or products containing chemicals).2. Fumes from chemicals.3. Chemical contamination.4. Dermatitis caused by chemicals.5. Failure of extraction systems.

10.15.3 CoSHH covers substances that are hazardous to health and can take many forms, to include:1. Chemicals.2. Products containing chemicals.3. Fumes.4. Dusts.5. Vapours.6. Mists.7. Nanotechnology.8. Gases and Asphyxiating gases.9. Biological agents. 10. Germs that cause diseases such as leptospirosis or legionnaires disease and germs used in

laboratories.

10.15.4 If a product has packaging detailing hazard symbols, then it is classed as a hazardous substance.

10.15.5 Specific training is required to ensure managers and supervisors’ understand their responsibilities under the Trusts CoSHH Policy. A training programme will be agreed and undertaken over the year to end of March 2017.

10.16 Datix Reported - Manual Handling Incidents

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0

2

4

6

8

10

12

34

1011

3

0

5

7

4

6

10

10.16.1 The Types of Manual Handling Incidents reported via the Datix Incident Management System include: 1. Any issue caused or exacerbated in the course of an employee’s duties, leading to Work

Related Upper Limb Disorders (WRULD) Pushing Pulling lifting Carrying of loads

2. WRULD are: Aches, pains, tension and disorders involving any part of the arm from fingers to shoulder,

or the neck. Problems with the soft tissues muscles, tendons and ligaments, along with the circulatory

and nerve supply to the limb.

Table-11: Detail for Datix Reported Manual Handling Incidents - by Quarter 2015-16

Qtr Incident date

DW Number Type of incident Who Location

(exact) Description

Qtr-1

13/05/15 DW22773 Accident that may result in personal injury

Staff Community On-call Midwife called to attend BBA in the community, moving on call bag throughout callout, suffered back pain.Action: Member of staff now up to date in MH. Additional On Call Bags – each lighter

Qtr-1


Staff Emergency department

Assisting patient into bed, sharp pain to right shoulder and right hip when moving patient.Action: Member interviewed to ensure appropriate MH techniques understood, safety was considered prior to each procedure

Qtr-1


Staff Bay 1 Changing bay one bed lent over to put the sheet on the bed suffered sharp pain in back.Action: Member of staff interviewed and informed of importance of asking for assistance and bed is at the correct height.

Qtr-1


Staff Ashcombe Assisting in an emergency situation in the Pool room (Waterlilly) involved bending and leaning over a low birthing couch back became painful.Action: Midwife interviewed and informed to use correct equipment when using birthing pool. Must be back aware when leaning forward. Existing back problems must be assessed before starting care of the woman.

Qtr-2


Staff Car park Taking on-call bag from car to return to Ashcombe Birth Centre felt lower back pain on moving bag out of car.Action: Member of staff now up to date in MH. Additional On Call Bags – each lighter

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Qtr-2


Staff Admin office

Lack of blue transit boxes for medical notes, with potential to cause back and other injuries due to lifting and heavy notes.Action: there is a weight limit of 11Kg set per box which must be adhered to.

Qtr-2


Staff Rafters kitchen

Very difficult to pull apart Regen oven socket extensions, putting strain on wrists on a daily basis.Action: Member of staff advised to ask for assistance for this task as equipment is new.

Qtr-2


Staff Day case unit

Surgeon operating using new operating trolley, fraction wider that the old ones. Surgeon complained that his existing bad back had gone into spasm.Action: Staff not aware new trolley sides made the overall width of the trolley slightly wider. This surgeon will use old trolley.

Qtr-2


Staff Endoscopy Taking airway for upper GI bleed unable to sit due to the structure of the end of the ward bed and back was aching. Following day took pain relief and rested, then took a day off sick.Action: Staff to ensure they adopt a good position/posture and that the bed/trolley is at a good height to avoid bending/stooping

Qtr-2


Staff Uphill (rehab)

Nursing staff over filling linen bags making them too heavy for housekeeper to lift safely. Nursing staff asked to ensure bags are filled to a manageable weight.Action: Ensure effective communication between staff. HK to report ongoing concerns to ward sister she will address at the time of incident with staff directly involved.

Qtr-3


Staff Waterside Blue box of medical records received from Waterside - box was over filled and weighed 16.5kg, despite recommended load for these boxes being 11kgAction: Admin team to read manual handling policy and safe loads diagramDo not overfill boxes. If in doubt will weigh.Do not load notes lying down as able to overfill this way.

10.17 Datix Reported – Contamination and Sharps Incidents

13/14 Q1

13/14 Q2

13/14 Q3

13/14 Q4

14/15 Q1

14/15 Q2

14/15 Q3

14/15 Q4

15/16 Q1

15/16 Q2

15/16 Q3

15/16 Q4

0

2

4

6

8

10

12

14

16

18

34

1011

1415 15

16

11

1617 17

10.17.1 SHARPS Incidents reported via the Datix Incident Management System include; any needlestick

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injury, scalpel incidents, or incorrectly or carelessly discarded needles.

10.17.2 Sharps and Sharps InjuriesInjuries caused by needles and other sharp instruments are one of the most common and serious risks to healthcare workers. With 40,000 incidents reported each year (and at least as many unreported), this is a major cause for concern for the NHS. ‘The Health and Safety (Sharp Instruments in Healthcare) Regulations – 2013’ aims to reduce such incidents by achieving a safe working environment.

10.17.3 Sharps DefinitionsThe Health and Safety (Sharp Instruments in Healthcare) Regulations – 2013’refer to medical sharps as being:

‘An object or instrument necessary for the exercise of specific healthcare activities which is able to cut, prick or cause injury. These include equipment such as needles and scalpels. Injuries presenting

a higher risk would be those where the sharp is contaminated with blood where there is the potential of transmitting infectious agents such as hepatitis’.

10.17.4 Contamination Incident Definition‘An occupational exposure to a blood borne virus may occur when a staff member is contaminated

with the body fluids of another person. The significance of the exposure will depend upon the individual circumstances and must always be assessed’.

10.17.5 Sharps and Contamination Incidents A total of 61 Sharps and Contamination Incidents were reported from 1st April 2015 to 31st March 2016; compared with 52 in the previous financial year.

10.17.6 Needlestick / Contamination Policy An Occupational Health review and redraft of the Needlestick / Contamination Policy has been undertaken and completed, with updated detail for Hospital out of hour’s staff. The Incident reporting form / spreadsheets is being modified to enhance data capture for more comprehensive analysis; i.e. use of safety equipment

10.17.7 Contact TracingOne incident involved a source patient known to be positive to a blood borne virus. Therefore anonymous reporting to the Health Protection Agency, Communicable Diseases Surveillance Centre in London was required.

Occupational Health reports continue to be compared with data from the trust DATIX system, by liaising with the Patient Safety and Risk Administrator. Discrepancies have been addressed and appear to have reduced in the later part of the year.

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Table-12: Contamination SHARPS Incidents 2015-16Consultant Dr HCA HK MC

A NA Phlebotomist Podiatrist Practitioners RGN Sister Sp

NurseSt

Nurse BMS Total

Ashton Clinic 1 1

Stabbed Finger 1 1

Berrow 1 4 2 7

Stabbed Finger 1 4 2 7

Bin Room 2 2

Stabbed Finger 2 2

CDU 1 1

Stabbed Finger 1 1

Cheddar 1 1

Stabbed Finger 1 1

Day Case Unit 2 1 1 4

Cut Finger 1 1

Scratched Hand 1 1

Stabbed Finger 2 2

ED 4 1 3 8


Stabbed Wrist 1 1

HDU 1 1

Stabbed Finger 1 1

Hutton 2 2

Caught Finger 1 1

Stabbed Finger 1 1

ITU 1 1 2

Stabbed Finger 1 1

Stabbed Leg 1 1

Kewstoke 1 1

Stabbed Leg 1 1

Longfox 1 1

Stabbed Finger 1 1Consultant Dr HCA HK MC NA Phlebotomis Podiatrist Practitioners RGN Sister Sp St BMS Total

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A t Nurse Nurse

Mau 1 1

Stabbed Finger 1 1

MIU 1 1

Stabbed Finger 1 1

Outpatients 1 1 1 3


Path lab 1 1

Stabbed Finger 1 1

Podiatry 1 1

Caught Finger 1 1

Quantock 1 1

Stabbed Finger 1 1

SAU 1 1 2

Stabbed Finger 1 1 2

Steepholm 1 1

Stabbed Finger 1 1

Stroke unit 1 1

Stabbed Finger 1 1

Theatres 2 1 1 1 5

Cut Finger 1 1


Uphill 1 1 2 4

Stabbed Finger 1 2 3

Stabbed Thumb 1 1

Urology Dept 1 1

Stabbed Finger 1 1

Total 1 15 2 4 1 2 1 1 1 14 2 2 6 1 53

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Table-13: Contamination Splash Incidents:

Row Labels Blood Splash To Eye

Saliva/Blood In Face Spat At Splash Into

Mouth Splash To Mouth Total

2015 1 1 1 1 4

April 1 1

Cheddar 1 1

Nursing Assistant 1 1

July 1 1

ED 1 1

Doctor 1 1

August 1 1

Harptree 1 1

Registered Nurse 1 1

November 1 1

MAU 1 1

Registered Nurse 1 1

2016 3 1 4

January 1 1

ED 1 1

Doctor 1 1

February 3 3

ITU 1 1

Doctor 1 1

Theatres 2 2

Doctor 1 1

Operating Department Practitioner 1 1Total 4 1 1 1 1 8

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11. Key Developments during the Year

11.1 Memorandum of Understanding (MoU) - Health and Safety Executive (HSE) and Care Quality Commission (CQC).1. From 1 April 2015, CQC have new enforcement powers, which will enable it be an effective

enforcement body for patient / service user health and safety matters, including investigating incidents, in England.

2. HSE’s investigation policy will remain unchanged – but as CQC will now become the better placed regulator in most instances, HSE will defer to CQC and will not investigate such incidents. The MoU confirms this for both HSE and LAs (in respect of residential care homes registered with CQC).

3. HSE’s guidance for the health and social care sector has been revised to reflect this.

4. There are limits to CQC’s remit however, depending on the nature of the activities. There is no equivalent to HSWA Section-7, for instance. Therefore in a limited number of cases, CQC will correctly return certain incidents or concerns to HSE/Local Authorities.

5. It has been agreed that these will be returned to a single point in HSE for monitoring and checking against the MoU criteria. Some incidents may require joint or co-ordinated investigation

11.2 RIDDORs in health and social care RIDDOR will continue to apply even though CQC has the lead responsibility for patient and

service user safety from 1 April 2015.

11.3 Trust Updated Core HEALTH & SAFETY Policies Uploaded to Document Management System. Control of Substances Hazardous to Health Policy - uploaded to DMS May 2015. Slips Trips & Falls - uploaded to DMS May 2015.

11.4 Trust Health & Safety Policies Due Review by June 2016 Health & Safety Policy – review to provide clear guidance on manager’s responsibilities and a

toolkit to be used for managers HEALTH & SAFETY Assurance. Personal and Respiratory Protective Equipment Policy – Review to include updated clinical

Guidance. Latex Use Policy – Review to include updated Guidance and procedures.

11.5 Trust E&FM New Issue Policies - Ratified and on DMS 2015Five policies were ratified and uploaded to DMS in May 2015 Electrical Safety Policy. Lift Management Policy. Mechanical Systems Safety Policy. Ventilation and Air Conditioning Systems Policy. Helicopter Operational Policy.

11.6 Trust E&FM Reviewed HEALTH & SAFETY Related Policies - Ratified and on DMS 2015. Fire Safety & Evacuation Policy – March 2015 Weston Area Health Trust and its Premises Estates & Facilities Service Policy – June 2015

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11.7 Trust Changes to Responsibilities 2015-16The following changes to Health & Safety management responsibilities took effect 1st June 2015.The ‘Director of Strategic Development’ is the designated Executive Lead for: Health & Safety Fire Safety Security

11.8 Trust Estates Department Reconfiguration During the reporting period the Estates Department initiated a programme to ensure identified changes to its Department Management System, in order to ensure it meets its Health & Safety statutory responsibilities on behalf of the trust. Significant progress has been made to date and the work is ongoing for 2016-17.

12. Summary of Health & Safety Priorities 2016-17

12.1 Estates DepartmentThe Estates Department will continue implementation of the compliance programme; to ensure the appropriate manning, policies, and safe systems of work, documentation and training required are in place, in order to fulfil its statutory duties on behalf of the trust.

To ensure that all Estates members of staff are fully conversant with new or revised department policies is as critical as the establishment of an effective Department Management System.

The Trust Health & Safety Advisor to provide support to the Estates Department Managers and Supervisors and to undertake an Inspection of the Workshop and its storage facilities.

12.2 TrainingThe Estates Department will ensure that Estates Staff undertakes all necessary compliance training.

The Trust Fire Safety Manager will continue to monitor the continued implementation of Fire Safety Training and evacuation drills with the trust Fire Safety Advisor’s, to ensure the Trust meets the 90% training attendance requirement.

The Health & Safety Advisor to develop a programme for Trust department managers and supervisors, concerning policies that require specific actions, such as risk assessments and safe systems of work to be completed (e.g. CoSHH; Manual Handling; DSE).

12.3 Health & Safety Audit ProgrammeA revised Health & Safety Assurance programme based upon a developed H&S Assurance assessment tool to be introduced from the 1 September 2016. This will provide Directorate / Department managers a tool to manage H&S Assurance from teams / department within their area of responsibility.

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13. Appendix-1: Annual Security Report 2015-16

Security Management Report 2015/16

Introduction

The challenges that currently face the NHS, Weston Area Health Trust and the wider community create unprecedented and immediate security risks. These risks require a variety of measures to safeguard the valuable assets we need to deliver an effective service which include protecting the property belonging to the Trust, protecting our staff so they can deliver the best possible healthcare, safeguarding and protecting our patients and managing the visitors to our sites.

Weston Area Health Trust provides both physical security measures in the form of access control, CCTV and security officers deployed across the site and strategic security management in the form of risk assessment, policy and procedure development, crime reduction and awareness and specialist investigation which is led by the Director of Operations and delivered by the Trust accredited security management specialists in a bid to provide the holistic safe and secure environment for all the staff, patients and visitors.

There are also Security standards that are set nationally by NHS Protect and the Trust is required to report its compliance against these standards every year and provide evidence and also report its organisational crime profile to the CCG’s each year.

Work to date

During 2015/16 the Trust and the LSMS provision was in a transitional phase from the external provider to an in house solution provided by the Estates department. Due to this transition the work plan was reduced to allow for key areas to be concentrated on whilst maintaining an effective Operational Security service. The LSMS provision was provided by nominated persons within Estates, the General Manager for Clinical Support (previous LSMS) and a private provider. The role of Security Management Director also transferred from Karen Croker to Bronwen Bishop.

Throughout 2015/16 the security contractor provided 24/7 365 days cover to provide a visible, reactive response to a variety of incidents. This presence provides reassurance, support to our staff and contribute to the wider safe and secure environment.

There has been ongoing action that supports the measures being put in place in response to the Staff attitude survey in regards to the concerns about violence and aggression in the hospital. This is being coordinated with the HR and divisional management teams. There is a ‘Violence and Aggression committee’ chaired and led by the Associate Director of Nursing (OPS) and attendance is from various staff groups, police colleagues and the Security adviser.

There has been a continued program of work to improve the security management strategies across the Trust, these have included;

Security slides included in the Trust induction Risk assessments of key high risk activities Changes and improvements to the cash collection process Investigations into loss of monies Implementing violence and aggression reduction strategies Security Awareness campaigns and continued reassurance Work towards an asset register for equipment below £5000 at department levels

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ED lockdown protocols Medicines Management Audits Medical gasses review and information for National Investigation Patients property process review

Planned work

Over 2015/16 Security Management work will continue to deliver on the improvements already commenced. There will be updating of several policies and procedures which will further enhance the safety and security of staff and patients and their visitors. These will include;

Baby and child abduction procedures Emergency lock down procedures Security risk management training for managers Patient Property Policy update Security of Medicines Audits

There will also be a concentrated effort, working alongside HR and the divisional senior management teams to develop and deliver strategies to reduce the risk of violence and aggression towards staff from patients and visitors.

Alongside the planned work for 15/16 there will also be a program of pro-active work in the following areas as identified by NHS Protect standards with a view to improve and maintain our rating from ‘Amber’ to ‘Green’.

Strategic Governance Continue to develop the organisation’s security strategy assessing and addressing identified risk.

Complete the ratification of the organisation’s security strategy in line with NHS Protect’s strategy and standards

Inform and Involve Continue to develop and undertake risk assessments. Preparation of a single sheet tri -fold leaflet to promote the pro

security culture work Create robust and appropriate alert system for national and local

security risk warningsPrevent and deter Introduce evaluation measures to demonstrate the effectiveness of

the equipment, processes and procedures in relation to security. Support the review of The Medicines Policy Review the Patients Property Policy to ensure that the current

arrangements are effective and consistent. Supporting the development and testing of the Major Incident and

emergency lockdown procedures Review and update baby & child abduction procedures

Hold to account Consider adapting the policies that currently exist making them generic and applicable to both fraud and security cases.

Summary

2016/17 will continue to see further developments to help improve the working lives of our staff through enhanced security and risk assessments. This will be carried out by the newly nominated LSMS, Josh Randall, who has recently undertaken the NHS LSMS training program.

The Trust will continue to identify its high risk areas and provide the appropriate mitigation to reduce the risks. These measures will include improved training, awareness and provide skills and confidence so our staff are

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better prepared to respond. The security management team, LSMS and Operational Security, will continue to work with colleagues to support them in their clinical and corporate roles as they deliver their services to our patients, the staff and the visitors to our sites.

The board is asked to note the comments in this report and support the ongoing security management strategy.

Prepared by

Mo Swinscoe Certified Security Management Specialist

Executive sponsorBronwen Bishop SMDDirector of Strategy

Karen Croker Director of Operations

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14. Appendix-2: Annual Occupational Health Service Report April 2015 to March 2016

Avon PartnershipOccupational Health Service

Annual Occupational Health Report April 2015 to March 2016 for Weston Area Health NHS Trust, ‘Infection Prevention and Control Committee’ and the ‘Health and Safety Committee’

Contamination IncidentsA total of 61 incidents occurred from April 2015 to March 2016 compared with 52 in the previous financial year. Detailed information about the incidents is recorded below and trends shown in the charts on pages 38 – 44 below.

One incident involved a source patient known to be positive to a blood borne virus. Anonymous reporting to the Health Protection Agency, Communicable diseases surveillance centre in London was required.

Occupational Health reports continue to be compared with data from the trust DATIX system, by liaising with Donna Millard, Patient Safety and Risk Administrator. Any discrepancies have been addressed as appropriate but appear to have reduced in the later part of the year.

Contamination Incidents: Reported to Occupational Health - April 2015 to March 2016

Key: Timing of incidents D=during: A= after: O=other or unknown

Year Month Job TitleWhere incident

occurred Equipment involved

Timing of

incidentDetails of incident

2015 April Doctor MAU Needle D Stabbed finger2015 April Doctor Cheddar Needle A Stabbed finger2015 April Doctor HDU Needle A Stabbed finger2015 May RGN Uphill Needle A Stabbed thumb2015 May RGN Longfox Needle A Stabbed finger2015 May Consultant Outpatients Needle A Stabbed finger2015 May RGN ED Butterfly A Stabbed wrist2015 May RGN Day case unit scalpel D cut finger2015 May Doctor Day case unit Suture needle D Stabbed finger2015 June St. Nurse Uphill Needle A stabbed finger2015 July RGN Berrow Needle A Stabbed finger2015 July HCA Day case unit dental drill A scratched hand2015 July sp Nurse Outpatients ? O Stabbed finger2015 August RGN Hutton Needle A Stabbed finger2015 August sp. Nurse Urology dept Needle A Stabbed finger2015 August Doctor Day case unit Needle D stabbed finger2015 August Phlebotomist Berrow Needle A Stabbed finger

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2015 August RGN Theatres scalpel blade A cut finger2015 August podiatrist Podiatry scalpel D caught finger2015 August Doctor CDU Butterfly D Stabbed finger2015 September Sister SAU clinical waste bin A ?2015 September HCA ED Butterfly A Stabbed finger2015 September RGN Hutton Needle A Caught finger2015 September Doctor ? Needle A stabbed finger2015 October Doctor ED Butterfly A Stabbed finger2015 October ST. Nurse Uphill Needle A stabbed finger2015 October RGN Berrow Needle A stabbed finger2015 October Housekeeper Kewstoke needle in black bag O Stabbed leg2015 October Doctor SAU Needle A Stabbed finger2015 October Housekeeper Bin Room Needle O Stabbed finger2015 October RGN Berrow Needle A Stabbed finger2015 October RGN MAU Needle A stabbed finger2015 October NA Quantock Needle O stabbed finger2015 November St. Nurse Steepholm Needle A Stabbed finger2015 November Housekeeper Bin room needle in bag O stabbed finger2015 November RGN ED Butterfly A Stabbed finger2015 November sister Theatres Needle D stabbed finger2015 November MCA Ashton clinic Needle A Stabbed finger

2015 DecemberBiomed scientist Path lab slide D Jabbed finger

2015 December Doctor Theatres Needle D stabbed finger2016 January RGN Berrow Needle A Stabbed finger2016 January NA Uphill Needle A Stabbed finger2016 January ST. Nurse Needle A Stabbed finger2016 February St. Nurse Berrow Needle A Stabbed finger2016 February Domestic ITU Needle in bag O Stabbed leg2016 February St. Nurse Stroke unit needle A stabbed finger2016 February Doctor Theatres Wire A stabbed finger2016 February Doctor ED Needle D Stabbed finger2016 February Doctor ED Needle D stabbed finger2016 February Practitioners Theatres Needle D Stabbed finger2016 March Doctor ED Needle D stabbed finger2016 March RGN ED Needle A stabbed finger2016 March Doctor ITU Needle D stabbed finger

Splash Incidents: Reported to Occupational Health – April 2015 to March 2016

2015 April NA Cheddar cannula DBlood Splash into eye

2015 July Doctor ED None O Spat at2015 August RGN Harptree splash to mouth

2015 November RGN MAU Dsplash into mouth

2016 January Doctor ED Cannula D Saliva/blood in

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face

2016 February ODP Theatres Ablood flicked into eye

2016 February Doctor ITU DBlood splash to eye

2016 February Doctor Theatres Dblood splash to eye

A review and redraft of the Needlestick / Contamination Policy within Occupational Health has taken place and a training package revised for Hospital out of hour’s staff.

Incident reporting form / spreadsheets is currently being modified to enhance data capture for more comprehensive analysis; i.e. use of safety equipment

Action: Training dates to be arranged

Contact TracingNo events recorded during the year

Seasonal Flu Vaccination CampaignFor a fourth year Trust vaccinators were utilised to administer this year’s campaign. The overall percentage was down on last year as per our neighbouring Trusts.

This should not deter from the overall effort by the Trust vaccinators and Angela Lovell, Infection Prevention control Nurse for co-ordinating the program. Congratulations all!

By the end of February a total of 778 doses (previous year 963 doses) had been given. This equates to 55% Trust staff, who were defined as eligible for the flu vaccine as recommended by the Department of Health, who received the vaccine this year compared with 67.6% last year.

2014-2015 2015-2016Number of healthcare workers eligible for the flu vaccine as recommended by the Department of Health

1425 1412

Number of flu vaccines given 963 778% of employees vaccinated 67.6% 55.1%

Figures and graphs supplied by Infection ControlDetailed charts on page 7 (vaccinations per ward/department available)Vaccine Compliance

477 health @work forms cleared 268 attended a vaccine update / review appointment, which equates to 56% In light of vaccine compliance now being on the at risk register, Occupational Health formulated

a project plan to ascertain compliance within the current staff group. A costing / resource document was produced to ascertain if funding was available to expedite

the process but declined. Action – plan to continue trawling OH records commencing with priority groups. Lookback on new starters since August 2015 (date initial staff list given) and send appointments

for OH. Each month list of new starters to OH to book vaccine review appointment or potential plan to

see new starters on induction days (to be discussed further) of 52

Pathology completed in preparation for UKAS visit in June.

Management Referrals The total number of referrals remains fairly constant from previous year, 298 in 2014 and 305

in 2015. There is a slight reduction in the total number of referrals for musculoskeletal, mental health

and skin from 58% in 2014 to 49% in 2015, however Mental health decreased from 71 (41%) in 2014 to 42 (28%) in 2015 Musculoskeletal increased from 89 (52%) in 2014 to 104 (70%) in 2015 N.B More aggravated by work but NOT caused by work Skin decreased from 12 (7%) in 2014 to 5 (3%) in 2015

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Weston MSK, Mental Health & Skin Summary2014 2015

ytdOct to

DecJan to Mar

Year 2014 2015 2015 2015

Total number of referrals: 298 305 80 64Total of MSK ** & Mental Health * & Skin Referrals 172 149 42 28

APOHS does not record 'stress', as it isn't a clinical condition - we record the effects of stressNumber of cases in Mental Health* Referrals 71 42 11 7Aggravated 21 7 2 1Blank 2 0 0 0Caused 4 4 1 1Factor in causation 16 13 6 3Unrelated 28 18 2 2

Number of cases in MSK ** Referrals 89 104 31 20Aggravated 27 45 12 12Blank 4 1 0 0Caused 7 8 3 1Factor in causation 6 6 2 2Unrelated 45 44 14 5

Number of cases in Skin Referrals 12 5 2 1Aggravated 8 2 1 1Blank 0 0 0 0Caused 0 1 0 0Factor in causation 2 0 0 0Unrelated 2 2 1 0

Number of cases in Skin category (Advice Line) 4 4 1 1Aggravated 3 1 1 0Blank 0 0 0 0Caused 1 1 0 0Factor in causation 0 0 0 0Unrelated 0 0 0 1

* Includes Anxiety, Bereavement, Distress and Depression, but not adjustment disorder, eating disorder, other, psychosis.** includes back, lower limb, neck, other, shoulder, upper limb disorder

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Comparison of last two Quarters

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1

2

3

4

5

0 1 2 3 4 5 6 7

2

0

1

6

2

1

0

1

3

2

Jan to Mar Oct to Dec

Aggravated

Blank

Caused

Factor in causation

Unrelated

0 2 4 6 8 10 12 14 16

1

2

3

4

5

12

0

3

2

14

12

0

1

2

5


Aggravated

Blank

Caused

Factor in causation

Unrelated

0 0.2 0.4 0.6 0.8 1 1.2

1

2

3

4

5

1

0

0

0

1

1

0

0

0

0


Referral Mental Health

Referral MSK

Referral Skin

Aggravated

Blank

Caused

Factor in causation

Unrelated

0 0.2 0.4 0.6 0.8 1 1.2

1

0

0

0

0

0

0

0

0

1


Advice Line Skin

SEASONAL FLU VACCINATIONS - Comparisons

Flu vaccines given to frontline Healthcare workers by staff group as reported on ImmformNumbers eligible for vaccine2014-2015

Numbers eligible for vaccine2015-2016

Number of vaccines given2014-2015

Number of vaccines given2015-2016

% of group vaccinated2014-2015

% of group vaccinated2015-2016

Doctors 185 214 140 87 75.7 41Qualified Nurses

478 507 316 413 66.1 81

Midwives 36 17 47Other professionally qualified clinical staff

152 158 85 68 55.9 43

Support to clinical staff

610 432 422 113 69.2 26

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CONTAMINATION INCIDENTS -

Timing of IncidentsDuring Procedure (D) After procedure(A) Other(O)

2014/2015 32 18 22015/2016 19 34 8

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Charts – Details of Contamination Incidents

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2008 2009/2010 2010/2011 2011/2012 2012/2013 2013/2014 2014/20150

102030405060708090

100

64

91

57 55 5853 52

Total number of contamination incidents in last 7-years

AprilMay June

July

August

Septem

ber

October

November

December

January

February

March

0123456789

4 4

2

4

2

6

4 4

6

8

3

5

Total number of contamination incidents by month across Trust

During procedure (D) After procedure (A) Other(O)/Unknown(U)0

5

10

15

20

25

30

35 32

18

2

Timing of incident - current year Following graph shows comparison with previous years

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2009/2010 2010/2011 2011/2012 2012/2013 2013/2014 2014/201505

101520253035404550

During procedure (D)After procedure (A)Other(O)/Unknown(U)

Agency

NA/Rep

Biomedica

l Scien

tist

Dentists

& Docto

rs

Housekeep

ers

Lab Assi

stant

Medica

l Studen

ts

Midwifes &

Nurses

Nursing A

ssista

nts/HCA

OPD

Radiogra

pher Assi

stant/S

tudent

Studen

t Nurse

05

10152025

03

14

03 1

22

3 2 03

Staff groups involved in an incident (note -1 report staff group not recorded)

Butterfly N

eedle

Cannula N

eedle

Cannula (

Safet

y) Ne...

Capilla

ry tube

Finge

r nails

/bite

Glass

Insulin nee

dlesK-w

ire

Needles

Patella

clamp

Scalpel

blade

Suture

needle

Splas

h/bloody vomit

05

1015202530

2 1 0 0 2 04

1

25

0 2 39

Equipment type

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Ashcombe

Berrow ED

Elton

Harptre

e

HuttonHDU ITU

Kewsto

keMAU

Outpatien

ts

Pathology

Lab

SAU

Seash

ore cen

tre

Steep

holm

Stroke

Unit

Theat

res

Watersi

de Unit

Not record

ed

0

2

4

6

8

10

23

4

1 1

3

1

4

2

6

1

5

3

12

1

9

12

Departments/Wards

Report prepared by Nicky Harvey; Occupational Health Nurse Specialist; April 2016

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15. Appendix-3: Annual Health and Safety Work Plan 2016-2017

The Health & Safety Committee will review the work plan at its quarterly meetings:Actions Time Scale Person Responsible

1. Trust H&S Committee to focus on re-invigoration of the committee, its membership and its analytic capability

Summary of role of H&S to be circulated Trust wide by end July 2016

Dec 2016

Director responsible

Trust Health and Safety Advisor and TU reps

2. Trust H&S Advisor continue to assess the requirement for new or redrafted Health & Safety polices in light of new or revised legislation or guidance from the HSE

Rolling programme throughout the 2016-17 reporting period.

Trust Health and Safety Advisor

3. Trust H&S Advisor to continue the provision of Health and Safety Support to the pathology department; in its formal response to the HSE Containment Level-3 inspection that took place on the 18th May 2016.

Action Plan by 1st July 2016 Training Needs analysis by 1st

July 2016 Initial response to HSE

inspector by 19-08-16.1. CL-3 specific CoSHH risk assessments to detail required by Inspector2. Training Needs Analysis for Pathology Manager CL-3 qualifications3. Identification and costings of appropriate Porton Down CL-3 course.

By the 31st December 2015; follow up submissions as required by the HSE Inspector for Non CL-3 Pathology CoSHH assessments to same standard.

Remedial actions surrounding the laboratory infrastructure

Training and awareness for lab staff – General CoSHH in a Lab setting and CL-3 specific

Trust Health and Safety Advisor

Pathology Manager – Elisa Moores

Biomedical Scientist – Mark Woodward

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4. Trust H&S Advisor to develop a revised Trust H&S Assurance programme, using a prepared H&S Self Assessment Assurance Assessment tool:

To ensure Team Leaders and Managers are able to assure themselves and Directorate / Department Managers (including matrons) of their H&S Compliance position.

To highlight gaps in Trust requirements for Health & Safety To ensure Directorate and department risk registers reflect H&S Risk.To ensure that Directorate and Department Managers (including matrons) are able to assure the H&S Committee that H&S Risks are being managed.

Initial issue of Tool to Managers by 01/09/2016.

Initial H&S assurance rating from self assessments made by 01/11/16.

Completion of Assurance by 31st

march 2016

Health and Safety Advisor

5. Trust H&S advisor and Executive Lead to develop revised H&S Reporting Metrics and dashboard, as [art of an overall relaunch of the H&S Committee reporting, attendees, Safety Representatives and development of an intranet page.

Initial by 8th August 2016 Ongoing workstream

throughout 2016 to 31 march 2017

Health and Safety Advisor Director of Strategic

Development

6. Review H&S training requirements arising from the Trust H&S Self Assessment Audit programme, make recommendations to the H&S Committee and Training Manager, for any additional requirements noted.

Initial TNA by 1st November 2016


7. Develop a programme of in house Training for staff in supervisory / management roles, commensurate with the role held. Duties under the law, trust policies and procedures, H&S requirements of their roles

30th September 2016 Health and Safety Advisor

8. Continue the daily Quality Improvement Team SitRep and the assessment of H&S risk where this is a factor in a Datix reported incidents.

Daily throughout 2016-17 reporting period.


9. Monitor the continued implementation of Fire Safety training and evacuation drills, within the Trust.

Rolling programme throughout the 2016-17 reporting period.

Fire Safety Manager and Fire Safety Advisors / Training Department

10. Training Department to continue to review Training uptake and where appropriate implement action for members of staff who persistently fail to attend essential training.

Reporting to H&S Committee Quarterly in the 2016-17 reporting period.

Training Manager

11. Liaise with E&FM on the implementation of measures to ensure statutory responsibilities are met:

Correct and appropriate assurance documentation is in place Training is undertaken as required Competencies are maintained. Workshop meets all statutory requirements and risk assessments’ are in place and that

the H&S Inspection actions are prioritised for completion. Tool box talks are undertaken Control of Contractors is reviewed and updated to include all departments who bring

contractors on site independent of Estates and put in place control measures

E&FM weekly meetings in 2016-17 reporting period.

Head of Estates

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12. Implementation of safer sharps mechanisms (Sharps Regs) and the HSE report on NHS Organisations compliance June 2016:

Relaunch Working Group to continue with requirement to:o Questionnaire to managers / supervisors using sharps.o Review Trustwide Sharps use.o Complete Risk assessments.o Undertake Information instruction and training of staffo Recommend safer sharps where appropriateo Identify costs (savings or pressures)o Review the Trust Sharps policy to ensure it accurately reflects above and reporting

of Sharps injuries measures in place

Initial By 1st December 2016 Ongoing workstream till 31

March 2017.

Health and Safety Lead Lead Infection Control

Nurse Procurement Sister Procurement Team Department Matrons,

Sisters, Managers

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