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Enclosure Q

Kingston Hospital NHS Foundation Trust -Trust Board – Part 1 – July 2014 of 26 4

Health & Safety Annual Report

Trust Board Meeting:

Part 1

Item: 10.3

30th July 2014 Enclosure: Q

Purpose of the Report:

FOR: Information Assurance Discussion and input Decision/approval

Sponsor (Executive Lead):

Sarah Tedford, Deputy CEO

Author:

Sarah Kelly - Health & Safety Advisor

Author Contact Details:

Risk & Safety Department Regent Wing

Risk Implications – Link to Assurance Framework or Corporate Risk Register:

Assurance

Link to Relevant Corporate Objective:

Document Previously Considered By:

Compliance and Risk Committee Executive management Board

Recommendation & Action required by the Trust Board :

The Board is asked to note the attached Health and Safety Annual Report.

Health and Safety Annual report April 2014 S. Kelly of 26

Health and Safety Annual Report

01st

April 2013 to 31st

March 2014

Introduction: The Health & Safety Annual Report covers the period 01st April 2013 to 31st March 2014, the standard financial year. The annual report aims to give board members an overview of how the trust is performing against health & safety requirements. The Health & Safety committee has been established to plan, organise and monitor organisational compliance with its statutory health & safety obligations and duties. The role of the health & safety committee is to ensure compliance with external body requirements such as the health and safety executive, NHSLA, department of health, CQC etc. The health & safety committee identifies and addresses matters which require joint consultation and negotiation and reports into the Compliance and Risk Committee. The overall aim and purpose of the health and safety committee is: 1. To ensure continued and effective health & safety management arrangements 2. To ensure the trust can demonstrate compliance with health & safety legislation and

other statutory and mandatory estates related standards 3. To ensure the provision of a safe environment for staff, patients, visitors and others. 4. To ensure the trust has effective occupational health & safety processes and

systems 5. To develop procedures necessary to carry out the committees functions, taking into

account the requirements of the health and safety at work act 1974 6. Review health & safety functions within the division every 6 months. 7. Receive reports of investigations of accidents, non-clinical incidents, near miss and

dangerous occurrences and occupational ill-health episodes, monitor trends and action plan compliance and make recommendations to reduce and prevent such events from re-occurrence and put in place measures for reduction and prevention.

1. Dates of Meetings: The Health and Safety Committee met on the following dates: April 2nd 2014 October 1st 2014 May 7th 2014 November 5th 2014 June 4th 2014 December 3rd 2014 July 2nd 2014 January 7th 2015 August 6th 2014 February 4th 2015 September 3rd 2014 March 4th 2015


All the above meetings met the requirements for a quorum under the Committees Terms of Reference.

2. Membership: The committee is chaired by Sarah Tedford, Deputy Chief Executive. Members were required to attend a minimum of 75% of the planned meetings.

Name

Position

Attended

Out of Possible

Sarah Tedford

Deputy Chief Executive

10

12

Hugh Gostling (Commenced in August 2013)

Director of Estates and Facilities

7

12

Sarah Kelly (Commenced Mid May)

Health & Safety Advisor

10

12

Chris Sims

Estates Manager

9

12

Sean Barker (Commenced November)

Fire Safety Advisor

5

12

Janette Barnes

Occupational Health Manager

10

12

Paul Holland

Sterile Services Manager & Decontamination Lead

8

12

Sarah Joseph

Matron

8

12

Associate Director Representative (Alan Thorn)

Associate Director Representative

6

12

Richard Evans

Operations Manager

11

12

Adedayo Adegbayibi

Waste Manager

10

12

Gary Mills Mike Jackaman

PRIME

7 5

12

Caroline Fiore

Emergency Planning

11

12


3. Compliance with Terms of Reference:

The health & safety committee is responsible for ensuring the trust demonstrates compliance with health & safety legislation, approved codes of practice, safety guidance notes, statutory and mandatory standards, including hospital technical memorandums, (HTM’s). The main duties outlined in the terms of reference for the health & safety committee is to include Incident reporting, statutory compliance to legislation including specific risk areas, health and safety policy and procedural development. This report summarises the main health & safety issues for the period 2013/2014. 3.1 Incident Reporting: During February 2013, the incident reporting tool was changed from Datix to Ulysses. A lot of work took place to improve and promote incident reporting throughout the trust. Ulysses is a type of database which enables staff to report accidents, incidents and near misses. From this system, reports are created to enable the trust to trend and analyse the data. As per health and safety requirements accidents incidents and near misses events must be recorded and investigated depending on the severity, with solution and recommendations put in place as part of the closure process for the various accidents, incidents and near misses. 3.1.1 RIDDOR: Under the RIDDOR Regulations all work places must record specific accidents, incidents and nears miss events. Depending on the severity and nature of injury and indeed party affected, the trust has a legal duty to report this data to the health and safety executive. There were 5 incidents reportable to the Health & Safety Executive (HSE) under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) during this period, which is 1 more than the same period in 2012/2013. 4 of the 5 RIDDOR events were due to slip, trip and falls, with 1 incident due to an employee falling from their chair. 2 of these reportable incidents were due to absence, over 7 days period off work, one member of staff totalled 32 days absence with the other member of staff totalling 13 weeks absence. The remaining reportable events were due to three members of staff sustaining fractures. Ankle, shoulder and wrist. The ankle fracture occurred due to slipping on wet leaves and mud on a footpath externally. Immediate action taken was to sweep up the area. On a permanent basis the area was re-surfaced with tarmac. The shoulder fracture occurred as a result of falling down approximately 2 steps of an internal staircase. The stairs were reviewed but no evidence was apparent to suggest anything further could be implemented. The wrist fracture occurred as a result of falling off a chair, whilst sitting and moving. The chair was inspected, but was not deemed to be damaged, or indeed to require replacement.


4.1.2 Staff Incidents: The total number of recorded incidents involving staff for this period was 607. The main cause for concern is slip, trip and fall incidents. A total of 42 falls occurred throughout the hospital premises for this period. 40 staff falls were recorded Including the 5 RIDDOR reportable events. 1 contractor slipped on a wet floor in a Royal Eye Unit (REU) bathroom. On investigation, the sink was found to have a leak, which was addressed immediately. 1 member of the public fell due to a pothole in the car park, after a survey of the trust car parks, resurfacing of the car parks has been completed throughout the period. 34 slip, trip and fall incidents occurred inside the hospital premises with the remaining 8 incidents occurring externally such as the car parks, footpaths etc. Breaking these down further Slips totalled 3. Trips totalled 9, Trips included, Staff tripping over Patient’s rollator, extension lead, shoe, Zimmer frame, chair. Falls totalled 30. Chart 1.0:

0 5 10 15 20 25 30

Slips

Trips

Falls

3

9

30

Ratio of Slips Trips Falls

Slips

Trips

Falls

The locations of the various falls include: Wards totalled 12 staff slip, trip & fall incidents with Hardy having the most (6 in total) due to the water fountain causing splashes thus wetting the floor. A review of the area has taken place, with staff and the ISS team being alerted to empty the over-fill units. Estates have been tasked with sourcing anti-slip flooring, mats, and/or resurface the area. Main Theatres totalled 4 staff slip, trip & fall incidents Maternity totalled 3 staff slip, trip & fall incidents Stairs totalled 7 staff slip, trip & fall incidents Offices in general totalled 8


Percentage of areas of staff falls: Chart 2.0

Reason for fall: Chart 3.0

In order to reduce slip, trip and fall incidents, work has been taking place such as re-surfacing of external areas, car parks etc. Slip, trip and falls awareness has been emphasised in training sessions, both face to face and on-line. A review of the re-occurring areas involving infection control, estates and health & safety is ongoing, with areas identified as high risk, being targeted as a priority. This includes a review of the


actual flooring, anti-slip surfaces laid in specific areas such as the bridge leading to Princess Alexander Wing. Specific areas such as the water fountain, and sinks in theatres, these trends identify the root cause is human factor/ human behaviour. 4.1.3 Staff Accidents & Injuries: 356 staff accidents, incidents and near miss events have been recorded in total for the period including, the 40 slip, trip and fall accidents. Adverse events such as other minor accidents such as sprains, cuts grazes, bruising etc. totalled 87, again an increase on the previous period figures. Manual handling accidents totalled 18 a decrease on the previous year’s figures. Physical abuse, assault incidents of staff totalled 53 and verbal abuse of staff totalled 60, this will be detailed further under security.

Table 1.0

Type of Event 2011/2012 2012/2013 2013/2014

1*

Abuse etc. of Staff by Patients

101

112

113

2*

Adverse events that affect staffing levels

96

84

87

3*

Sharps incidents

94

85

98

4*

Slips, Trips and Falls

72

43

40

5*

Moving and Manual handling accidents

40

22

18

Totals

403

346

356

Inoculation injuries and Splash events have increased since the last period 2012/2013 from 85 to 98. Inoculation injuries recorded were 84 and 14 splash events. This has remained a focus point, particularly, as the trust invested a lot of time and effort with suppliers and implementing pilot studies to procure safety devices during 2012/2013 in order to comply with the EU Directive, “Management of sharps”, which went live in April 2013, along with the introduction of the “smart bin” during the same period. As part of a direct response to the increasing numbers of reported splash events and inoculation injuries and after discussion at the Health & Safety Committee an action plan has been devised to address the increasing trend. This will include audits of all clinical departments areas incorporating the following information :- Staff knowledge of

inoculation injuries


incident reporting

available equipment (safety needles, sharps bins)

Staff knowledge of PPE (Personal protective Equipment)

Purpose

Location

Availability

.Staff knowledge of

Safe Practice Environment

Location of equipment

Availability of equipment Training

Continued training and awareness via mandatory training sessions 4.2 Reports from Sub- Groups: Updates from the sub-groups of the health & safety Committee have been received. These areas were identified as being integral elements of the trust’s health & safety management system (HSMS). Table 2.0

Group

Chair

Frequency of Meetings

Decontamination Group

Paul Holland

Bi-monthly

Fire Safety group

Richard Evans

Monthly

Laser Protection Group

Andrew Pooley

Annually

Water Safety Group

Chris Sims

Quarterly

Medical Gas Group

Derek Cock Chris Sims

Monthly

Radiation Protection Group

Mike Reid

Annually

Security Group

Richard Evans

Monthly

Waste Group

Adedayo Adegbayibi

Monthly

4.2.1 Decontamination Group: (Meet Bi-monthly) The Decontamination Group continues to meet bi-monthly to discuss matters related to safe decontamination of equipment used in patient care and the development of related policies and procedures as appropriate. The aim of the group is to prevent and control the


spread of infectious agents through the provision of sound decontamination principles, consistent with current best practice and linking together existing inter-related decontamination documents for the safety of staff, patients, visitors and contractors.

The objective is to ensure that Trust decontamination policies and procedures are consistent with corporate governance.

Meet corporate, legal, professional and clinical standards.

Minimise risk.

Engender safe systems of work.

Are monitored and reviewed systematically. This past year has been challenging in that a new Pre Purchase Questionnaire (PPQ) was developed and introduced to assist purchasers make informed decisions on equipment procurement which met clinical requirements and could be safely decontaminated with existing equipment and chemistries. As this was a more challenging document for suppliers, the Decontamination Group became more involved in the procurement process than anticipated; and unexpectedly brought us into greater dialogue with the MHRA concerning potential suppliers, whose “Instructions for Use” (IFU) did not meet European and international standards. This resulted in a number of MHRA investigations and the Trust, in a few instances, not proceeding with procuring devices. Decontamination practices are continually audited within the organisation on a rolling basis and the results reported through the Health and Safety Committee in Decontamination Group Minutes. The Health and Safety Committee will continue to monitor and will support any recommendations and actions to ensure that the Trust meets current standards for Decontamination. 4.2.2 Waste Group: (Meet Monthly) Introduction The waste group monitors environmental issues and to ensure legislative compliance which included the roll out of a new waste management system across the Trust. There continues to be a need for introductory and refresher waste awareness training, and waste audits are carried out every month the benefit of these two functions is an improved attitude and awareness of staff towards all waste streams. Highlights The highlight of last year was the implementation of secure metals recycling system which eradicated the issue of metal theft and also attracted a rebate for the Trust has 9.5 tonnes of metal waste at £100 per tonne has been sold since September 20013 approved to external contractor. The mixed recycling system also had the business case approved and a tender for supply for mixed recycling bins for site wide distribution is to be sent out to interested contractors in May 2015 with the mixed recycling scheme itself starting in June 2015. Since the mixed recycling pilot scheme has been in place the Trust has recycled 21.5 tonnes of recyclable waste. The waste group also organised a “dump the junk day” on two occasions in 2013/14 to assist in dispose of general clutter which have built up in departments /wards and also organised a sustainability day of action to raise more awareness amongst staff on reducing waste and energy in their departments. Waste Policy and targets


The Trust adopted a Carbon Management Plan (CMP) in 2010 and yearly reviews its Sustainable Waste Action Plan (SWAP) as well as a waste management Policy. These documents, detail a requirement to reduce carbon emissions, make efficient use of resources and minimise waste production. In order to implement some of the requirements of these documents it is necessary to highlight specific areas of work and set relevant waste targets. The CMP has a target of reducing Trust carbon emissions by 10% from 2010 -2015 using 2006/07 as baseline year, while the current SWAP which runs from 2013 -2015 has the following targets:

Reduce domestic waste volume by 2% each year

Reduce clinical waste by 10% (from 2006 levels) between 2010 – 2015

Increase the recycling rate from 8.8% to 20% by 2015 The Trust waste management Policy covers issues such as correct waste segregation for all waste streams along with a colour coding system for easy identification, good housekeeping, legislative requirements to mention a few. An analysis of waste arising’s across the Trust site for effective continuous monitoring and assessment to reduce waste can be found in Table 1.0 below. Table 3.0

Waste Streams 2011/12 2012/13 2013/14 Charts

Clinical Waste

425.6

407.9

394.5

General Waste

431.7

425.4

487.7

Reused/Recycled

68.0

122.2

101.7

Bulky Waste

38.2

44.6

44.4

Hazardous Waste

6.8

3.9

3.9

Total Tonnage 970.3 1004 1032.2

Clinical Waste There has been a steady decrease in clinical waste produced, with the periodic target of a 2% decrease been achieved. From periods 2011/12 to 2013/14, there has been a 7.3% decrease in clinical waste produced from 425.6 tonnes to 394.5 tonnes which equates to 31.1 tonnes of Clinical waste. This success can be attributed to correct waste segregation practices and waste audits which have been able to identify problematic areas which are then quickly resolved. General Waste General waste disposal decreased by 1.45% between 2011/12 and 2012/13 resulting in a reduction of 6.3 tonnes, this reduction was aided by the introduction of a pilot mixed recycling scheme. Unfortunately, general waste produced by the Trust increased by 15% between the periods 2012/13 and 2013/14 resulting in an increase of 62.3 tonnes . This increase in general waste has been attributed to waste arising from renovation works and


general clutter in several wards and administrative offices during ward and office relocations on the Trust site. Reused/Recycled Waste This consists of waste types such as dry mixed recyclables, confidential waste paper, cardboard, metals recycling, toner cartridges etc. There has been a sharp rise in reused/recycled waste with a 49.5 % rise between 2011/12 and 2013/14. This is expected to increase in recycling rates, once the site wide mixed recycling scheme has been implemented. Bulky Waste There was a 16.7% increase in bulky waste generated during the periods 2011/12 to 2012/13, but this has decreased by 0.5% from 2012/13 to 2013/14 which is partly due to the introduction of metals recycling which commenced in September 2013. Hazardous Waste This waste type covers special wastes such as batteries, waste lamps and fluorescent tubes, chemicals, waste oils; general and IT waste electrical items. Waste lamps, batteries, and oily rags are collected on an ad hoc basis; this is estimated to be once every three to four months. Computers are bulked up and collected once the storage container has reached capacity, or are collected by the contractor straight from the department if the amount of computers is of a large enough quantity. Waste Disposal Costs Table 4.0

Period 2011/12 2012/13 2013/14

Expenditure on Clinical waste & Hazardous Waste (£’000)

196 199 197

Expenditure on General waste & Other Waste (£’000)

62 82 103

Charts

The cost of disposal of clinical waste increases yearly but this has not had a major effect on the disposal costs due to success achieved in reducing clinical waste and also hazardous waste. Due to this factor, there has only been a 0.5% increase in disposal costs by the Trust for clinical and hazardous waste from 2011/12 and 2013/14. However, this is not the same for disposal cost for general waste and other types waste. In fact the


15% increase in general waste produced in 2013/14 has been a major contributory factor to the 66% rise in disposal costs between 2011/12 and 2013/14. However, it is expected that there would be a decrease in disposal costs for general waste and other waste types once a full site wide recycling scheme is introduced around mid-2014. Future plans Service Level Agreements between the Trust and waste management contractors are to be continually tightened and monitored, whilst purchasing agreements and tenders should continually be incorporated with the requirements of waste legislation. Contracts need to be reviewed to ensure we are receiving best value for money and that collections are being undertaken in the most efficient way. The implications of new contracts may see significant changes in cost. In order to achieve the targets highlighted within the waste policy the Trust needs to make a significant change in its current operational and procurement practices. The principles of the waste hierarchy need to be embedded into the Trust culture both on an individual and managerial level. Once waste is produced we have missed our opportunity. Measures to reduce and reuse waste need to be implemented, for example:

Sustainable procurement

Reusing items across departments

Waste minimisation campaigns

Donating items to charitable organisations

Green waste composting

Awareness raising through academic and managerial staff

Finalise introduction of site wide recycling scheme across the Trust site mid-2014.

Work on implementation of food waste Recycling after completion of site-wide dry mixed recycling by 2015

Implement a Wood recycling scheme by 2015 Whilst implementing the above will manage waste, it does not address cultural and behavioural change which will ultimately dictate whether any initiative works and whether targets are met.

4.2.3 Security Group: (Meet Monthly) The Security Group has continued to prioritise two areas this year; ensuring incidents are reported and investigated and improving the number of staff receiving Conflict Resolution Training. A considerable amount of work has also gone into improving links between the Trust and local partners (particularly local police services) to ensure that all groups are co-ordinating to ensure patient and incidents are managed properly. The Trust’s Conflict Resolution Training continues to be delivered by in-house trainers and the last 18 months of intensive sessions has resulted in the number of staff trained rising to above 75%. Rising to this level allows us to adopt a more low key approach in the coming year with an online ‘refresher’ course is now being developed and some classroom sessions retained for new starters and those who prefer to receive training face to face. The Department of Health guidance regarding restraint and the Deprivation of Liberty Safeguards has been studied, particularly in light of recent legal action over the usage (or lack thereof) of restraint. The group is currently considering these changes and their implementation across the Trust as well as the ramifications for Trust staff and police officers handing over patients in the Emergency Dept. These discussions will allow the group to deliver guidance and recommendations over the summer.


There have been 784 reported security incidents this year (in the event a single incident has been reported multiple times different multiple persons/groups this has been counted as a single incident). This year has seen as increase in the number of reports made by Trust staff rising from 611 in 2011/12 and 635 in 2012/13 to the current levels. The pattern of incidents remains similar year on year. The largest number of security incidents relate to requests for patient minding and supervision of patients known to be potentially violent or at risk of self-harm/absconding. The vast majority of these were successfully managed and did not escalate further.

Chart: 4.0

The reported incidents of violence and aggression continue to rise, reaching 67 reports this year; however the group is satisfied that this represents an increase in the awareness of the reporting systems as opposed to a rise in the actual numbers of assaults taking place. However investigations have suggested that a significant number of ‘minor’ assaults still go unreported, particularly where the victim feels there was little or no malice shown by the perpetrator. This does however present significant difficulties in managing the assaults, ensuring staff receives the appropriate support and putting in place plans to warn staff of the dangers associate with these patients. The Trust has moved to exclude a number of violence patients as well as providing statements to support criminal prosecution. An increased awareness of ‘medical factored assaults’ has highlighted the importance of identifying these patients and making arrangements to ensure staff managing the patient are sufficiently trained and warned of their behaviour and ensuring they are, where possible, nursed in areas that minimise their impact on other patients. About 15% of assaults on staff are deemed to be non-medical factored.

2011/12 2012/13 2013/14

Assaults Reported 28 35 67


Chart: 5.0

There has been a disappointing rise in the number of thefts targeting hospital property, a risk associated with the increased usage of ‘desirable’ electronic items. The overall reported thefts reached 36 for the year with bicycles remaining the most targeted items and remain fairly constant when compared to previous years. Local neighbourhood police continue to run theft awareness days and undercover operations. There has been a significant number of missing patient reports this year (134) that has been a cause for concern as these have included a number of patients identified as ‘high-risk’. The development of protocols between the police, Trust staff and ISS security officers is seen as key in reducing these and minimising the impact of those that do occur, ongoing discussions between the parties will result in agreed protocols being formalised later in the year. A number of options for improvement in infrastructure on the wards are being considered and will be presented to the Health & Safety Committee in July. Improvements in the access control arrangements in the Emergency Dept. are also being implemented to allow for greater control of the entrances/exits, particularly the ambulance entrance. The Trust has also overseen the development of the role of security officers, with alterations proposed to the service level specification of the officers. These changes, developed with Prime and ISS, will allow for greater clarity in their roles and Trust expectations of their actions. To continue the theme of clarity there has been greater co-operation between the police, mental health agencies and the Trust surrounding the protocols in place for sectioned patients. This work will continue into this year. The Trust’s access control network continues to be extended with the Gynae wards being added onto the system and Theatres joining them in the next month, almost 90 doors are now access controlled including drug rooms and entry/exits into vulnerable areas. Consolidation of the disparate systems across the site remains a priority for the group as well as managing growing concerns over the CCTV systems operated by the Trust, many of which are moving towards the end of their operational life span. There are currently


just over 100 cameras deployed across the Trust with approximately 10% in the last year of their projected life. The Trust CCTV system has provided assistance to police on over a dozen occasions in the last year in relation to crimes and has also begun to be used more extensively to assist during missing person episodes. The roll out of the new lone worker devices has been very successful and has both raised the profile to staff groups and led to improved engagement from clinical areas with the security group. There are currently over 20 devices utilised by the community maternity groups with others deployed to ENT, Health Records and available for staff working in remote areas; fortunately there has not been a single activation. Other areas of the Trust have been invited to utilise this system to provide additional protection to staff. The group remains concerned about the lack of engagement from nursing areas but has seen significant improvement from Maternity and the Emergency Department which has allowed a number of concerns in these areas to be addressed and resolved. 36 Theft Reports (this only includes reports where the victim was prepared to make a statement/give details) 359 Other Reports (Almost all of these are ‘patient minding’ requests) 4.2.4 Radiation Protection Group: (Meet Annually) The annual Radiation Protection Group meeting took place in November, at which the Annual Radiological Protection Report was submitted. The report covered all aspects of Radiological protection including; equipment performance; new equipment; audits; incidents and legislation. From the findings an action plan has been devised, identifying the 17 actions with only 6 outstanding actions which are either work in progress or still to be completed. There were three incidents / near misses investigated by the RPS’s/ RPA’s (1) An 87 year old lady underwent a CT scan; this was intended for a different person.

This was reported to the CQC (2) Two patients were imaged, however the patient was not identified correctly,

however the other patient also needed a chest x-ray. This was not reported as an incident as the patients both needed chest x-rays. It was investigated internally as a near miss.

(3) A child underwent a CT head and was imaged twice as the incorrect protocol was

used this was reported to the CQC. As a result of these incidents, all staff using ionizing radiation attended (97%) a mandatory “Radiation Protection Lecture” and the RPS is maintaining lectures this spring for the new starters. The RPA confirmed that the protocols, policies and procedures of the Trusts Radiological Service are in good order. The report issued by the Radiation protection Agency (RPA) only raised minor issues and praised the Trusts performance. As reported last year we are expecting a proactive inspection and will be looking at a number of key themes that include Ionising Radiation Medical Exposure Regulations (IRMER) procedures, incident notification, referral criteria and pregnancy enquiry procedures, in all of these points and others the Trust is performing well.


The Trust is complying with new Department of health (DoH), IRMER reporting threshold standards, HPA and BIR guidelines. 4.2.5 Laser Protection group: (Meet Annually) The Laser Protection Group meet annually to review the current working practices, equipment and changes in legislation. This is normally initiated by the trust’s appointed laser protection advisor, who carries out the annual safety inspection. There are 2 areas inspected annually. Royal eye unit, the annual inspection took place in November 2013 and is due next November 2014. The overall outcome, from the inspection was that the Royal Eye Unit is nearly fully compliant with only a few minor improvements necessary. The annual inspection of the day surgery unit took place in June 2013, with the next inspection due in June 2014. The overall outcome from the inspection was the day surgery unit is nearly fully compliant with only a few minor improvements required. 4.2.6 Fire Safety Group: (Meet Monthly)

The Fire Safety Group is responsible for the review of all fire safety matters. The Groups objectives are to promote co-operation between management and staff in instigating, developing and carrying out measures, to ensure the fire safety of employees and others affected by the activities of the Trust. Fire Incidents During the period from the 1st of April 2013 to the 31st March 2014, the Trust had 2 fire incidents: specifics of these incidents are described in more detail further on in this report. Fire Alarm Activations The Kingston site Fire Detection and Alarm system is managed and tested by the Trust’s Estates department. Data for Fire Alarm Activations is currently collated by the Trusts Fire Safety Adviser from two sources, the ‘Fire Call Report’, which are filled in by security, and the ‘Fire Response Team Leader return’. Work is in progress to integrate the reporting procedure into the ‘Ulysses’ reporting system. During the period from the 1st of April 2013 to the 31st March 2014, the Trust had 88 Fire Alarm Activations, 2 being Fire incidents and 86 being unwanted fire signals.

28th May 2013. 09:25.hrs. A&E. Roof plant area. Plant motor burnt out. Area checked and made safe by estates engineers. London Fire Brigade called and attended. No casualties/ injuries. Damage to burnt out motor only.

21st August 2013. 15:11.hrs. Bernard Mead Wing. Pathology Department. UPS unit overheated and caught on fire. Extinguished by Fire Response Team member using fire extinguisher. Area checked and made safe by estates engineers. London Fire Brigade called and attended. No casualties/ injuries. Damage to UPS unit only. To reduce and manage the Trust’s calls to the London Fire Brigade, due to unwanted fire signals, a 10 minute delay protocol was introduced as of 1st July 2013; this was done following extensive training with the Trust’s Fire Response Team, including exercises to test procedures. The protocol has appropriate safeguards in place, that would override the 10 minute delay and the Fire Brigade would be called immediately if one of the safeguard criteria is met.


The 10 minute delay was in line with London Fire Brigade recommendations, which have a close working relationship with the trust. Indeed, the London fire brigade have praised the support and on-going co-operation of the trust members. As of the 1st of January 2014, the London Fire Brigade introduced a charging scheme to recover costs from buildings with a poor false alarm record. It is hope this charging scheme will encourage those responsible to improve the maintenance and management of their Fire Detection and Alarm systems. The cost of a callout to a false alarm, ten times or more in a 12 month period, will be £290 +VAT per appliance. The pre-determined attendance to a hospital is 3 appliances. Since the trusts 10 minute delay was introduced, the London Fire Brigade have attended 6 unwanted fire signals. Since 1st of January 2014, the London Fire Brigade have attended 1 unwanted fire signal, without any financial charge. Fire Risk Assessments Department Fire Risk Assessments (FRA) are conducted on a rolling roster by the Trusts Fire Safety Advisor. An amended Health Technical Memorandum 05-01: Managing healthcare fire safety was published April 2013, with recommendations that whilst the Fire Safety Advisor should undertake the FRA, the ownership of the FRA and its findings should be vested in the person in control of the area that has been assessed. The local ownership of fire safety issues ensures that the person with control over individual departments or areas of the premises, can manage, monitor and control fire hazards more effectively at a local level. Local management are now fully involved in the FRA process, with copies sent to all relevant parties and a digital copy on the site wide’ W’ drive. Training: The Workforce Development department/Education Centre coordinates and manages the Trusts Fire Safety Training requirements. In addition to these programmed mandatory fire training sessions, departments can arrange with the Trusts Fire Safety Adviser, a local fire drill/ evacuation exercise. These local sessions build on the classroom theory with a practical application of Progressive Horizontal Evacuation within the trainee’s workplace. Whilst uptake of these local training sessions has been better than in previous years, the aim for the coming year is to improve on this by driving the importance of regular training sessions and highlighting the need for such training. London Fire Brigade: Following on from the fire which occurred in the Bernard Meade Wing, Pathology Department, 21st August 2013, the Fire Safety Inspecting Officer, Duncan Hodge, from the London Fire brigade revisited the location, carrying out a fire safety inspection. Due to a number of Fire Safety issues, this inspection resulted in the Trust being issued with a ‘Notification of Fire Safety Deficiencies’. After remedial works by the Estates Department and procedural changes made by the Pathology Department, this area was re-Inspected on 18th March 2014. The London Fire Brigade were happy with the work that has been carried out in respect of the ‘Notification of Fire Safety Deficiencies’ and no further action will be taken in respect of this incident. A scheduled Inspection of the Staff Day Nursery also took place on 18th March 2014. This went well with positive comments throughout. The only recommendation was for the provision of ‘Fire Blankets’ appropriately located in both kitchen areas.


London Fire Brigade Exercises A joint exercise, between the Trusts Fire Response Team and London Fire Brigade, took place on Tuesday 3rd September 2013, within the Old Nurses Home. The main objectives of this exercise were to test fire-ground communications between the Fire Response Team and responding fire brigade crews, confirm that the time delay which has been implemented within the trust is suitable and sufficient and ensure all Fire Response Team members are aware of and can carry out the respective roles. The exercise was conducted without incident and with no adverse comments from the London Fire Brigade as to the Trusts Fire Response Team procedures. A London Fire Brigade only exercise was conducted on Monday the 13th January 2014, again utilising the vacant Old Nurses Home. The exercise was conducted without incident. 4.2.7 Water Quality Group: (Meet Bi-Monthly)

The remit of this group is to cover all aspects of water safety, i.e. pseudomonas. The terms of reference, (ToR) of the group were revised and it was re-named the Water Safety Group. It was also decided to change the frequency of the meeting to bi-monthly from quarterly. The Group continues to warrant the Trust is meeting its compliance requirements as defined in Healthcare Technical Memorandum (HTM) and Approved Code of Practice (ACoP) L8 and the Control of Substances Hazardous to Health (COSHH) requirements. Pseudomonas Aeruginosa Following a pseudomonas outbreak in Belfast, Northern Ireland the HSE revised their advice to duty holders. The recommendation for bi annual checks in high risk areas was instigated. In the case of findings here at the trust, one positive was found in the nursery which was treated and the cleaning procedure was revised. We have also added daily flushing, recorded on the L8 guard system to ensure monitoring and compliance. The second check was all clear. Legionella pneumophila As recommended in Healthcare Technical Memorandum (HTM) 04 areas identified as high risk by the infection control department (i.e. intensive care ward, Neo-Natal nursery) have water samples analysed quarterly, routinely. Other areas are tested ad-hoc, usually following an inspection as part of the planned performance monitoring of the water systems. In 2013 water samples from an average of thirty locations were analysed on twenty four occasions. This amounts to over seven hundred samples. We have a trend of less than 8% of outlets showing bacterial growth. Temperature control and regular use or flushing is generally successful in clearing legionella. Engineering solutions are tried to prevent re-occurrence. Occasionally local disinfection is used, but this does not always get to the root of the problem. All outlets tested positive, must be re tested until clear. In 2014, on three occasions we found Legionella pneumophila, sero-group one (the more dangerous strain). In February, it was identified in the ITU ward. It was cleared with extended flushing. In March in the SSD staff room, redundant and underused pipework is being removed as the sink infected has good usage. Also in March, following previously reported Legionella detections in MOPD resamples were taken & serogroup 1was detected from water samples taken from outpatients areas, from the hot and cold water


systems. Flushing did not reduce the colony counts, it was decided that a chemical disinfection should be carried out on both the cold and hot water systems supplied by the outpatient’s water services. We used Sanosil 25 to disinfect the water systems. There was no need to isolate areas, as with chlorine based disinfections, the concentrations used to disinfect is safe, & ensured minimal patient disruption. Resamples have been taken from all affected areas. We await the results. Throughout the year water samples were regularly taken from all areas deemed high risk by the infection control team (Neo Natal, ICT etc.) and outlets identified as having low (hot) or high (cold) water temperatures and outlets selected at random. As a trend less than 8% of outlets showed bacterial growth. A specialist water quality organisation, Advance Environmental Ltd (AEL) undertook the bi annual review of the legionella risk assessment in October 2013 of the Hospital’s water systems and produced an action plan with recommendations for improvements & it identified some remedial works which are in hand. At time of writing, all high & medium risk tasks have been completed. This includes cleaning and chlorination of storage cisterns. AEL reviewed the ‘written scheme’ as a guide for the trust to follow, in order to manage its water systems safely.


Table: 5.0

AEL reported that these actions were being undertaken. They essentially include temperature control; water treatment; flushing low use outlets & monitoring. In accordance with Department of Health guidelines a risk assessment must be done to establish if a water outlet is deemed low use. If it is established it is it must be flushed for three minutes. This must be recorded at least twice a week even if no flushing is required. Due to the inconsistency of the flushing and the risks associated the Trust has embarked upon an electronic reporting system called L8guard. When a Risk Assessment is due, the system will automatically email a reminder to the nominated person for the departments. As soon as a risk assessment is issued, the ‘clock’ starts ticking. The recipient is given 24 hours to complete the risk assessment. If they do not achieve this, the risk assessment is automatically escalated to a more senior person for that department. Should an escalation occur, it is noted for audit purposes within L8guard, and the nominated person for escalations is automatically sent an email. The regular monitoring of water temperatures has found deficiencies in MOPD. This is caused by the aged condition of the pipework & adaptation’s over time which have impaired the efficiency of the original design. Local managers have agreed to carry out daily flushing of all water outlets to maintain quality until an engineering solution can be instigated.


See graphs below detailing site flushing compliance; Chart: 5.0

Chart:6.0


Summary of water quality and safety:

Kingston hospital has a typical stock of buildings varying in age and condition. Many are overdue major refurbishment and the problems this creates are reflected in the water management plan. Temperature control is our major defence against legionella bacteria. As part of the upgrade work now taking place, old calorifiers are being replaced with plate heat exchangers, increasing operational efficiency, whilst reducing energy use. Work is in hand to upgrade the lagging of pipework across the site, which will maintain water Temperature beyond conditions for bacterial growth. Following the business critical estates condition review, which identified corroded pipework and its effect on water quality as an acute problem, requiring immediate action. Esher block, as a major clinical area was prioritised. A capital project is underway to replace all the domestic water distribution pipework, back to the supply. This is a two year project, complicated by it being fully occupied for the duration, close working with the clinical staff is essential. The work will finish early in 2015 after the break for winter bed pressure. It is planned to continue this work into MOPD which has severe problems caused by the defective plumbing. Legionella bacteria are inevitable we have no guarantee that it doesn’t come in with the mains supply. When the average age and condition of the building stock, it is considered some bacterial growth is unavoidable. So water management has to be taken seriously. At Kingston we have developed robust systems to monitor and manage water quality. By constant vigilance and focused action the risk represented by all water borne pathogens is kept as low as possible. 4.2.8 Medical Gases Group: (Meet Quarterly) The purpose of the medical gas committee is to ensure risks associated with medical gases are recognised, documented and action taken to minimise them. The objective of the group is to provide guidance to ensure that all appropriate steps are taken to comply with the Duty to Manage Medical Gases within Kingston Hospital NHS Foundation Trust and to comply with medical gases related legislation, approved codes of practice, guidance and relevant standards and Medical gases Health Technical Memorandum 02-01: Medical gas pipeline systems. The medical gas committee will continue to receive reports from pharmacy and estates. The health and safety committee will continue to support and monitor any actions arising. Throughout the period, it was established, the existing medical gas oxygen, air flow meters, low & high suction appliances had become non- standard and therefore obsolete, resulting in no support to the trust by the supplier. As part of the capital plan, bought out of revenue from 2012-2013, the medical gas group decided to invest in upgrading and installing new Medical Gas appliances for Oxygen, Air flow meters, Low and High Suction appliances trust wide. The Health Technical Memorandum 02-01 Medical Gas Pipeline Systems guidelines require all theatre hoses are changed every 5 years. Once, this was raised by the Medical Gas Group, it was decided by the Director of Estates to incorporate this infrastructure work into capital projects globally. Areas to be upgraded are Day Surgery Unit, Theatres, Maternity and Eye Theatres. Currently, Esher wing is completed and part Surgical (70% completed). The supplier chosen allows for an updated platform of what is currently in use but allows for complete standardisation and subsequent support.


This work required the change of approximately:

600 Air, 600 O2 flow meters, 600 High Suction and 50 Low Suction units and should have no impact on patient care safety or the trust with the changes made.

During this installation process, it was found staff using these appliances (whilst training had been given) appeared, not to be fully aware of the correct procedure and process, and displayed confusion as to which colour code represented the specific appliances. This was raised at the Medical Device group and an action plan put in place to ensure adequate training provided where required. As part of the ventilation process in ITU, A&E and other departments, E-Cylinders were used throughout the Trust but were changed to the HX integrated cylinder. After time in using these integrated cylinders, it has been found the cylinder becomes jammed in the socket and in order to release the jam, it is necessary to rotate the yoke. Unfortunately, the action of rotating the yoke predominantly in an anticlockwise cycle causes the yoke to undo, thus causing a risk of exposure of gas. There are still on-going issues with the E cylinders whereby on certain ventilators the gas coupling gets jammed in the HX cylinders, when staff rotate the coupling which can lead to total yoke coupling failure, with ITU, A.E and other departments using the Drager Oxylog 3000 series portable ventilators. Storage of cd cylinders on the wards has been reviewed with much discussion and negotiation. This shall be finalised in the coming weeks with a more controlled system being implemented. 5.0 Policy and Procedure Development: The Health and Safety Management system is based upon HSG65, Successful Health & Safety Management, a framework developed by the Health and Safety Executive (HSE) and widely received and adopted across all employment sectors. The components of HSG 65 are:

Policy

Organisation

Planning and Implementation

Measuring performance

Audit and review 5.1 Policy and Procedural documents: Revised policies: Review Date Cleaning and disinfection procedure April 2017 Clostridium difficile guideline November 2016 Lone worker policy and procedure June 2016 Dress code and uniform policy February 2016 Carbon management plan January 2017 CCTV Policy March 2016 Bomb Threat Policy September 2016 Fire Safety Policy May 2017


6.0 Training Health and Safety training is well established into Mandatory training sessions including HCA, Consultant and Maternity Focus days, including face to face and on-line training sessions available. Along with, the inclusion of other training programmes including: Risk Assessments, Medical gases and Display Screen Equipment (DSE) training, moving and manual handling training (clinical & non-clinical), root cause analysis, COSHH, incident including serious incident management training, Ulysses incident reporting and managers reports. However, the statistics show we are still below par, for example, moving and manual handling training of staff recorded at 67%, against the NHSLA compliance target of 95% outlined in 2012. 7.0 Current Risks and Actions Taken: 7.1 Water Safety including legionella Control & Management:

Water safety will always remain a risk but will continuously be managed using approved systems. Action taken:

Promote awareness of all staff, clinical and non-clinical on the importance

of flushing system

Regular flushing of system

Continuous monitoring and sampling

L8 Guard system for notification installed throughout

Replacement of pipework in Esher wing has commenced under capital projects

7.2 Medical Gas:

The Health Technical Memorandum 02-01 Medical Gas Pipeline Systems guidelines require all theatre hoses are changed every 5 years. Once, this was raised by the Medical Gas Group, it was decided by the Director of Estates to incorporate this infrastructure work into capital projects globally. Action Taken:

As part of the capital plan, upgrading and installation of new Medical Gas appliances for Oxygen, Air flow meters, Low and High Suction appliances trust wide commenced. Areas upgraded are Day Surgery Unit, Theatres, Maternity and Eye Theatres. Currently, Esher wing is completed and part Surgical (70% completed). The supplier chosen allows for an updated platform of what is currently in use but allows for complete standardisation and subsequent support. Guarantee assurance at handover.

As part of the capital plan, bought out of revenue from 2012-2013, the medical gas group decided to invest in upgrading and installing new Medical Gas appliances for Oxygen, Air flow meters, Low and High Suction appliances trust wide. 600 Air, 600 O2 flow meters, 600 High Suction and 50 Low Suction units is the estimated number.


7.3 Fire Safety: Fire safety will always remain a risk within the trust but it is with continuous management and monitoring, the risks can be reduced thus providing the board, assurance Action Taken:

Implementation of 10 minute fire delay in calling the fire brigade, along with the trust’s fire response team, who investigate all trust alarm activations.

Risk assessments carried out on a rolling roster by fire advisor.

Emphasis on local ownership of fire safety issues to ensure the person(s) with control over individual departments or areas of the premises, can manage, monitor and control fire hazards more effectively at a local level.

7.4 Decontamination:

It was necessary to introduce a pre-purchase questionnaire, (PPQ) to enable purchasers make informed decisions when purchasing equipment. This brought many challenges. Action taken: The decontamination group became heavily involved from liaison with both suppliers and the MHRA, in particular, where “Instructions for Use” (IFU) did not meet European and international standards. This resulted in a number of MHRA investigations and the Trust, in a few instances, not proceeding with procuring devices.

7.5 Security: In light of incident reporting figures being low in the last numbers of years, it was greed to raise awareness and the importance of reporting amongst staff. Action taken: Awareness was raised amongst staff with the result; there was an increase, in reporting of security incidents. The fact these incidents were reported, it enabled trending of known patients and staff that along with the implementation of the red card/yellow card system, along with investigations, has enabled a number of prosecutions to go forward. Increased work relations with police, whereby specific patients and/or families have been issued with ASBO’s. Continuous monitoring.

7.6 Policies and Procedures: Continuous review of policies and procedures incorporating any changes in legislation and process. Review current process along with health & safety Executive, NHS and CQC standards.

7.7 Training:

Much work has been carried out in training, however as new staff are employed and existing staff leave, it is always having to be refreshed.

Work is being carried out to review the mandatory training programme along with the UK core skills training framework.

Review training statistics for trust staff both clinical and non-clinical.


Identify programmes which may require more focus along with training department.

Identify groups not fully compliant in training and address. 7.8 Staff Incidents & RIDDOR:

A lot of work on training has been the focus over the year particularly with the introduction of the Ulysses reporting system. A lot of work has taken place to remap the system along with the new service line managers to ensure access is available for staff, in line with management ownership of incidents.

Continue to promote incident reporting and management.

Focus on high levels of incidents recorded such as Slip, trip and falls, inoculation incidents and splash events and continue to measure against action plans, with recommendations and actions completed.

Benchmark against Health & Safety Executive standards and other trusts of similar size.

8.0 Objectives / Forward Plans

1. Review of Health & Safety policies and procedures, along with review of legislation and update accordingly.

2. Implement new health and safety hospital action plan. 3. Improve management of incident reports and resolve closure of incident reports

across the trust, implementing any recommendations.

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