occupational health and safety self assessment audit tool · occupational health and safety self...

Towards a Safer, Healthier Workplace

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Occupational Health and Safety

Self Assessment Audit Tool

for NHS Scotland Occupational Health and Safety Services 2003/2004

DRAFT

August 2003


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CONTENTS

Self Assessment Guidance 3 – 5

Purpose

Scope

References

Definitions

Self-Assessment Audit Process

Documentation Held By The Occupational Health and Safety Organisation

Access Standards A 6 - 7

Occupational Health Practice Standards B 8 - 16

Management of Health and Safety Standards C 17 - 29


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SELF ASSESSMENT GUIDANCE

1. PURPOSE

1.1 To provide a tool to assist occupational health and safety services to assess their systems against the NHSScotland Occupational Health and Safety Standards.

2. SCOPE

2.1 For annual completion by all NHSScotland Services providing an occupational health or health and safety service to NHSScotland Staff.

3. REFERENCES

3.1 Assessment should be made against the following NHSScotland Occupational Health and Safety Standards:

• Access Standards A

• Occupational Health Practice standards B

• Management of Health and Safety Standards C


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4. DEFINITIONS

4.1 NHSScotland Occupational Health and Safety Standards – The standards set out in the document NHSScotland Occupational Health and Safety Standards.

4.2 Self-Assessment – A systematic and objective review of procedures to ensure the standards are met.

4.3 Self-Assessor – An appropriate member of occupational health or health and safety staff should be appointed to complete the self-assessment on behalf of the occupational health or health and safety service. This member of staff should be familiar with the NHSScotland Occupational Health and Safety Standards

4.4 Peer Review Team - Occupational health and safety professionals and partnership representatives from within NHSScotland have been trained and now form peer review teams. They will visit and peer review occupational health and safety services across the country.

4.5 Peer Review Visit – Peer Review Visits are intended to be helpful and not an added burden on staff. Peer Review Teams will therefore carry out peer review visits at a pre-arranged time that is convenient to the occupational health and safety services being visited. The peer review teams will inform the service being visited what information they will require prior to the visit, and this will include a copy of the occupational health and safety self-assessment audit. Each peer review visit will take one day, and prior to the review, the peer review team will inform the service being visited which of the occupational health and safety standards they intend to concentrate on. They will also provide a list of the staff members that they will need to assist with the review at identified times throughout the day. Members of staff required will include: the head of service, a member of nursing staff, and a member of health and safety staff.

5. SELF-ASSESSMENT AUDIT PROCESS

5.1 Each Occupational Health and Safety Service should annually self-assess against the NHSScotland Occupational Health and Safety Standards using the occupational health and safety self-assessment audit tool. It should be noted that other standards will be developed in due course and the audit tool will be revised to take account of this. The information gathered through the local OH minimum dataset is part of the evidence required for all of the standards. The self-assessment audit should be timetabled so that it fits in with the timetable for the Staff Governance Standard Self-Assessment Audit Tool.


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5.2 Individual Occupational Health and Safety Services should appoint a senior member of staff to co-ordinate the self assessment process. That person should maintain a list of self-assessors who contribute to the process.

5.3 The information gathered for the self assessment audit, results of self-assessments should be held by the co-ordinator and progress reviewed at least yearly with the assessor and the head of the NHS Occupational Health and Safety or Health and Safety Service. The self-assessment should be provided to the Chief Executive of the organisation and to the local partnership forum to support the information required for the Staff Governance Standard and Performance and Accountability Framework. The self-assessment should be provided to a Peer Review Team on request, and may be used during discussions at a Peer Review Visit.

5.4 The results of the self-assessment should inform the production of an action plan for improvement of occupational health and safety services.

6. DOCUMENTATION HELD BY THE OCCUPATIONAL HEALTH AND SAFETY ORGANISATION

i) Self Assessment Audit Dates ii) Named co-ordinator and list of Self Assessors iii) Self-Assessment Checklist (currently comprising A1, B1-B6 and C1-C9). iv) Self Assessment Report v) Action Plan

ACCESS STANDARDS A

A1 Access to Occupational Health & Safety Services


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All NHS Scotland staff will have access to comprehensive, competent and confidential OHSS services of the standard recommended by Towards a Safer Healthier Workplace.

CRITERIA & EVIDENCE RESULTS

A1(a) Provide access to a comprehensive OHS service. As a minimum this must be the standard of service provision in Towards a Safer Healthier Workplace.

Evidence – What services are provided. Do they meet the required minimum. What is not provided and why.

A2(b) Ability of staff through the partnership process to influence OHSS policy and practice.

Evidence – Is there an OHS group which fully involves staff.

A3(c) Provision of a competent and confidential service to staff.

Evidence – Policy and procedure for provision of a confidential service. Are the facilities conducive to providing a confidential service. Is there a confidential reception and waiting area.

A4(d) Services provision must be made by appropriate and competent staff with access to best practice, training opportunities and continuous professional development.

Evidence – Competence of staff and evidence of CPD. Number of staff and staff category providing the service.


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A4(e) OHS should provide advice to the organisation and staff on rehabilitation issues.

Evidence – Policy and procedure on rehabilitation. Evidence of number of cases dealt with and outcome.

A4(f) OHS should provide staff with equity of access to services as far as is practical, taking account of location, shift patterns and availability of trained staff.

Evidence – Do all staff have equity of access. Hours of opening and policy and procedure for out of hours contact.


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OCCUPATIONAL HEALTH PRACTICE STANDARDS B

B1 HEALTH SURVEILLANCE - SENSITISING AGENTS NHS Boards are required to provide health surveillance for staff who are exposed to significant risk of respiratory and skin sensitises and irritants if a COSHH risk assessment identifies a health risk despite control measures and where there is a suitable screening method.


B1(a) The OHS will have a written protocol/process/procedure describing their system for dealing with health surveillance.

Evidence - Documentation as indicated above.

B1(b) All NHS Boards must be able to identify those workers who require health surveillance.

Evidence - H&S Strategy

B1(c) A procedure must exist during recruitment to identify posts where health surveillance is required. This information must be provided to the NHS OHS, which will assess applicants for such posts as a fitness in relation to the hazard as well as any other post specific factors.

Evidence - Communication between HR and OH; Managers revisit assessment for vacancy; Evidence of DEHS within OHS; Criteria for onward referral

B1(d) NHS Boards must advise the OHS of current workers requiring health surveillance. Current workers must be offered health surveillance at regular intervals while they perform work with the specific hazardous substance.

Evidence - of existing health surveillance protocols

B1(e) The purpose of the health assessment (to determine fitness to work with the substance) and possible outcomes of assessment must be clearly indicated to staff when they are


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CRITERIA & EVIDENCE RESULTS offered assessments.

Evidence - Copies of document; Questionnaires

B1(f) Any internal staff movement or a change in current duties that will result in work with a hazardous substance that is risk assessed and requires health surveillance must be notified to the OHS. The OHS will offer health surveillance in such circumstances.

Evidence of any such notifications.

B1(g) A group report of the results of health surveillance will be provided by the OHS to the manager of the high-risk area.

Evidence - Group Reports

B1(h) Certificate indicating the fitness to work with the hazardous substance will also be provided by the OHS to the manager.

Evidence - Certification Slips

B2 HEALTH SURVEILLENCE - NIGHT WORKERS

All NHS Boards must identify those workers who are classified as night workers under Working Time Regulations


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All night workers employed by NHS Boards must be offered a free assessment under the Working Time Regulations


B2(a) A procedure must exist during recruitment to identify posts involving night work. The information must be provided to the NHS OHS who will assess applicants for such posts.

Evidence - Communications between HR AND OHS; Vacancy risk assessments

B2(b) NHS Board must advise the OHS of current night workers. Current Workers must be offered a free health assessment at regular intervals.

Evidence - Communications between HR OHS and Employee

B2(c) The purpose of the Health Assessment (to determine fitness for night work) and possible outcomes of the assessment must be clearly indicated to staff when they are offered the assessments

Evidence - Questionnaire

B2(d) Any internal staff movements of a change in current duties, which will result in night work, must be notified to the OHS. The OHS will offer a health assessment in such circumstances.

Evidence of notification of change

B2(e) The OHS will have written protocol/process/procedure describing their system for dealing with health surveillance.

Evidence - written internal documentation including regular reviews


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B3 Health Surveillance - Audiometery

Employees occupationally exposed to noise at or above the First Action Level (Noise at Work Regulations 1989) will be identified and advised of the need for regular health surveillance which will be undertaken by the NHS OHS.


B3(a) NHS Boards must assess risks to health from noise levels, which will include noise surveys undertaken by competent staff/contractors.

Evidence - H&S Strategy; Noise Surveys; Training Records for competent staff undertaking noise surveys.

B3(c) The OHS will have a written protocol/process/procedure describing their system for dealing with audiometery.

Evidence - Written documentation supporting compliance with relevant criteria above.

B3(d) Audiometery is undertaken by staff able to demonstrate competence in audiometeric screening for nose-induced hearing loss.

Evidence - Training Records; Numbers Trained


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B4 IMMUNISATIONS

All NHS Employers must provide a clinical immunisation service to NHS staff via the NHS OHS.

All NHS Employers must ensure that a system exists to assess applicants being considered for a post for their TB immunity status. CRITERIA & EVIDENCE RESULTS

B4(a) The NHS OHS must use expert evidence to maintain an immunisation service

Evidence – Policy and references/MELs/HDLs

B4 (b) The OHS will maintain guidelines on staff immunisation that are regularly reviewed to ensure that they take account of developments in vaccine licensing and provision within Scotland.

Evidence – Policy and references/MELs/HDLs

B4 (c) The OHS will provide immunisation programmes, which meet these guidelines.

Evidence – Risk assessments, Programme & Policy

B4(d) The OHS will ensure that immunisations are administered in a safe manner within suitable facilities.

Evidence – Evidence of anaphylaxis training/review of facilities

B4(e) All clinical and laboratory NHS workers must be offered pre-employment assessment of TB immunity status and (with consent) be offered with BCG vaccination, if clinically indicated.

Evidence – Programme & review notes x 3/disclaimers


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B5 CLINICAL GOVERNANCE

All NHS Scotland OHS must have an annual clinical governance programme that complies with NHS Scotland requirements.


B5(a) Annual programmes must be submitted to the Clinical Governance Committee and reports on progress submitted quarterly.

Evidence – Annual Programme & reports

B5(b) Each programme will identify the methods used to involve clients and their representatives.

Evidence – Documentation of meeting / consultation / partnership

B5(c) There will be evidence of consultation with clients of service developments.

Evidence – Documentation of meeting / consultation / partnership

B5(d) There will be evidence of actions to demonstrate compliance with the programme.

Evidence – Documentation relating to agreed actions

B5(e) Notification to the OHS will result in appropriate follow up of the workers appropriate to the risk from the source, the workers TB immunity status and any symptoms that exist or develop.

Evidence - Documentation from HR to OHS

B5(f) The OHS will have a written protocol/process/procedure describing their system for dealing with serious communicable disease exposures.

Evidence - Documentation relating to agreed actions


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B6 Exposure to Serious Communicable Diseases

All NHS Employers must have arrangements in place to ensure a service for staff who have needlestick and other injuries that could result in transmission of BBV's. NHS Employers must ensure that a system of notification of staff contacts of TB to the OHS must exist and that the OHS provides suitable follow-up of staff.

CRITERIA & EVIDENCE RESULT

B6(a) Arrangements will include the NHS OHS for initial assessment of all cases during the normal working hours of the OHS. An out of hours arrangement must be in place and staff made aware of all the arrangements for their care.

Evidence - Flow chart to indicate process for needlestick or sharps

injuries.

Instructions to staff on action to be taken in the event of a

communicable disease.

B6(b) Alternative arrangements will be in place where the NHS OHS is not present to assess cases (rural and remote areas) or where the assessment is undertaken by another clinical service.

Evidence - Instructions to staff on actions to be taken in the event of an exposure to communicable disease.


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CRITERIA & EVIDENCE

RESULTS

B6(c) Support from GUM/ID for the follow-up of staff commenced on HIV PEP is necessary.

Evidence - Serious Communicable Disease Policy

B6(d) Arrangements must ensure that PEP can be provided immediately if required at the time of initial assessment.

Evidence - Instructions to staff. Agreement with GUM or A/E Staff

B6(e) The arrangements must include consideration of rural practice and out-of-hours assessments.

Evidence - Instructions to staff, Agreement with GUM or A/E Staff

B6(f) Notification to the OHS will result in appropriate follow-up of the workers appropriate to the risk from the source, the workers TB immunity status and any symptoms that exist or develop.

Evidence - OH Procedure

B6(g) The OHS will have a written protocol/process/procedure describing their system for dealing with serious communicable disease exposures.

Evidence - Guidance or Written Protocol


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MANAGEMENT OF HEALTH AND SAFETY STANDARDS C

C1 RISK MANAGEMENT - INTEGRATION OF OCCUPATIONAL HEALTH AND SAFETY SERVICES The Organisation must be able to demonstrate a common risk management strategy, which integrates all aspects of risk, and risk advisory services, and utilises a consistent framework for the identification, evaluation and control of risks.


C1(a) The risk management strategy must clarify linkages between all aspects of risk and specialist advisors.

Evidence - CNORIS Level 1; H&S Strategy; H&S Policy

C1(b) The strategy must detail organisational arrangements for all aspects of risk.

Evidence – Organisational Arrangements Chart

C1(c) The organisation must have systems in place to ensure a consistent role of specialist advisers.

Evidence - Job Specification; Professional Review

C1(d) All risk related policies and procedures must demonstrate a consistent approach with regard to risk control and line management responsibilities.

Evidence - Internal OHSS Risk Management Strategy


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C2 AUDITING OF HEALTH AND SAFETY MANAGEMENT SYSTEMS

The organisation must be able to demonstrate a regular audit process of the overall management system. The audit must identify the effectiveness of the system and deficiencies either in the structure of the system or its application. An action plan for corrective action must be available which has partnership representation.


C2(a) Evidence must be available of Senior Management commitment to the Audit process.

Evidence - H&S Strategy; H&S Policy

C2(b)Evidence must be available to all staff involved in the audit, and informed of the purpose and outcome of the process.

Evidence - H&S Action Plan; A6 Progress Reports; A6 H&S Minutes

C2(c) The resulting action plan includes details of relevant policies, systems, procedures and training programmes where improvements are required.

Evidence - Performance Management System; H&S Minutes;

Training Plans; Numbers Trained

C2(d)The audit should involve an attempt to measure the level of involvement of managers and staff in application of the management system.

Evidence - Performance Management System; H&S Action Plan; OHS Minimum Dataset ;Staffing Levels; A time-scale for a repeat audit must be indicated. H&S Action Plan


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C3 Hazard Identification, Risk Assessment and Control The organisation will require to demonstrate that it has an effective system of systematic identification of all hazards and risks. This system must include a robust risk assessment procedure, which will evaluate and prioritise risks and ensure the implementation of controls to minimise risks and promote best practice.


C3(a) The process for hazard identification must be robust and evidence available of its suitable use in practice.

Evidence - Rick assessment procedures (written) including forms e.g.: Risk assessment inventory.

C3(b) The risk assessment procedure must be 'suitable and sufficient' and identify control measures to reduce the risk. These include risk avoidance and minimisation procedures. The procedures must be agreed by the 'competent person' and have a risk rating process and recommendations/action section. This procedure may be directly linked to the risk register required through CNORIS.

Evidence - Qualitative and quantitative tools linked the CNORIS and also demonstrated job description

C3(c) A system must be in place to identify relevant legislation when undertaking hazard identification and risk assessment procedures.

Evidence - Competency and continual learning process. (Clinical Governance) (Personal Development Plan)


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C3(d) The organisation must be able to demonstrate that managers have had suitable and sufficient training in the system to enable them to undertake the process competently and know when to ask for specialist assistance where necessary.

Evidence - Risk Assessment training record. Structure for provision of competent advice. How it is communicated to staff.

C3(e) A written system must be in place to demonstrate how identified risks are flagged up to the relevant level of management for action or prioritisation for resource allocation.

Evidence - Mechanism for management accountability, Health & Safety Plan, Policy and procedure.


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C4 Management Review

A documented procedure must be in place for an annual review of the health and safety management system, which is supported by an Executive Director and employee representation from the Health & Safety Committee.

CRITERIA & EVIDENCE RESULTS C4(a) An annual report presented to the Board on the operation and effectiveness of the Occupational Health and Safety management system agreed at Partnership Forum.

Evidence - Board Report/Staff Governance Committee

C4(b) Annual Reviews should be conducted by a responsible Executive Director and include employee representation.

Evidence - Board Minutes

C4(c) All Reviews are communicated extensively through the organisation. Evidence - Board Bulletins and Publications of new data set in annual report.

C4(d) All Reviews should include partnership involvement. Evidence - Partnership arrangements

C4(e) Resource requirements for the forthcoming financial year should include the OH&S Review.

Evidence - Business planning and budget allocation.


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C5 Policy & Procedures for Health and Safety.

The organisation must have effective health & safety procedures, which meet statutory requirements and the needs of the work environment and work activities. The organisation must be able to demonstrate a management system for identifying what is required and devising and implementing effective health and safety policies and procedures across the organisation.

CRITERIA & EVIDENCE RESULTS C5(a) A process must be in place to evaluate what organisational policies are required.

Evidence - Statement of intent within Policy - Organisation and Arrangements

C5(b) All policies must be devised and compiled through a mechanism, which includes experts/specialists in the field and representation from areas/locations affected and partnership.

Evidence - Competent Advisers named.

C5(c) Robust systems must be in place for the consultation, development and dissemination of policies and the implementation at departmental level.

Evidence - Process for policy development & review.

C5(d) System must be in place for managers to demonstrate how they have implemented relevant policies.

Evidence - Organisational flow-chart. Accessibility of policy for staff. Performance Management system. Minutes of Management team meetings. Action plan - Health & Safety.

C5(e) Where appropriate, written procedures and guidelines should be devised in order to fully implement health and safety policies. Evidence must be available for this process.

Evidence - Evidence of standard operating procedures - Performance management system.


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CRITERIA & EVIDENCE

C5(f) Policies and procedures are to be subject to monitoring and review.

Evidence - Health & Safety action plan.

RESULTS


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C6 STRUCTURE, PLANNING AND IMPLEMENTATION OF HEALTH AND SAFETY.

Then organisation will require to demonstrate that it has appropriate written arrangements for the management of health and safety across the organisation and for securing adequate occupational health and safety of its' staff, visitors and patients.


C6(a) The Health and Safety Policy of the organisation must be current, and have a clear statement of the intent to manage occupational health and safety.

Evidence - Health & Safety Policy - statement of intent.

C6(b) The Policy or associated documents must define, the detailed means by which risk is managed and by which all occupational health and safety risks are systematically controlled

Evidence - Statement of intent, which clearly identifies roles & responsibilities at all levels.

C6(c) The organisation must be able to demonstrate and produce a current Health and Safety Action Plan which details priorities for the organisation to minimise risk.

Evidence - Corporate Health & Safety Plan - included, evidence of consultation and progress reports.


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CRITERIA & EVIDENCE

C6(d) The Policy or associated documents must indicate the Health and Safety committee structure of the organisation, which must reflect the management arrangements within the organisation.

Evidence - Organisational/arrangements Health & Safety Policy

RESULTS

C6(e) Evidence must be available of Partnership representation on all such committees.

Evidence - Partnership arrangements for Health & Safety Committees at all levels.

C6(f) Evidence must be available of how any health and safety management system has been implemented across the organisation.

Evidence - Minutes of Meetings at Senior level including progress reports.


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C7 Measuring and Monitoring Performance for Health and Safety

The organisation must be able to demonstrate a system for pre-actively and reactively measuring performance against the health and safety management system and applicable health and safety legislation.


C7(a) The measurement of performance should be undertaken in accordance with principles of 'quality management' whereby results of such measurements form part of a continuous improvement plan.

Evidence - Performance Management System. Reporting process and mechanism.

C7(b) Performance indicators must be identified and agreed by the organisation.

Evidence - Corporate Health & Safety objectives and associated action plans + progress reports + minutes.

C7(c) Evidence must be available to show that performance indicators are measured and the results used to improve health and safety performance.

Evidence - Progress reports + action plans + statistical analysis of minimum data set.

C7(d) The organisation must be able to demonstrate a system for performance measurement by reactive means. A detailed system and procedure must be in place for reporting, recording, analysis and investigation of all health and safety related incidents.

Evidence - Performance Management system - minimum data set.


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CRITERIA & EVIDENCE

C7(e) The organisation must have a robust system for the recording, recording and analysis of incidents.

Evidence - Incident/accident policy & procedures + forms.

RESULTS

C7(f) A searchable database must be available for incidents, to provide such data as is required to provide the 'Minimum Data Set'.

Evidence - Quarterly progress reports + resulting minutes.

C7(h) Evidence must be available of actions resulting from analysis reports at the highest level.

Evidence - Board minutes and Action Plan.

C7(i) A system must be agreed for the detailed investigation and report of certain types of incidents such as those reported to the Enforcing Authorities. Management actions based on these investigations must be documented.

Evidence - RIDDOR Procedures


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C8 Training and Competent Advice for Health and Safety

The organisation must have in place systems for the identification of training needs and delivery.

CRITERIA & EVIDENCE RESULTS C8(a) A system for staff training needs analysis must be in place. Evidence - Training needs analysis report, which is clearly linked to the risk assessment process.

C8(b) An organisation wide system for the evaluation and funding of training needs must be evident. Evidence - Training action plan and programme

C8(c) Training needs for the organisation must be prioritised on the basis of statutory, mandatory and best practice training.

Evidence - Linked to above.

C8(d) Evidence must be available that OHSS/risk management staffing numbers have been agreed on the basis of organisational needs and statutory compliance. Evidence - Organisational arrangement within Health & safety policy. CPD. Prep etc. Job description.


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C9 Communication and Consultation for Health and Safety.

The organisation must be able to demonstrate how it communicates and consults on all matter affecting the occupational health and safety of employees.

CRITERIA & EVIDENCE RESULTS C9(a) Evidence must be available of Partnership working on discussions affecting health and safety. Evidence - Partnership forum minutes.

C9(b) A documented policy or procedure must be in place across the organisation with respect to Partnership.

Evidence - Partnership Policy & Procedure

C9(c) Systems must be in place to involve staff with the health and safety management system and to ensure that the results of risk assessments, inspections, etc are disseminated to staff.

Evidence - Communication Strategy + Health & Safety input or Health & Safety communications procedure.

C9(d) Procedures must be in place to ensure staff is aware of incident analysis trends for the organisation and their department. Evidence - Minimum data set Minutes Action plan Reporting process

C9(e) Systems must be in place to ensure minutes of relevant meetings are circulated to staff and that staff has the opportunity to highlight health and safety issues at departmental level. Evidence - Local Health & Safety minutes.

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