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Supporting Guidance Standard 2.1

Health and Care Standards

Supporting Guidance
Standard 2.1: Managing Risk and Promoting Health and Safety

 

What is the Standard about?

This standard is about keeping people safe and to protect them from harm

Ensuring risk management and health and safety is embedded within all healthcare settings and is monitored to ensure continuous improvement.

There is compliance with the requirements of the Civil Contingencies Act 2004 and supporting guidance. This will include undertaking risk assessments, having current and tested emergency plans and business continuity arrangements developed through collaboration with partner agencies. This will ensure delivery of a robust response and ensure continuity of essential health services in the event of a major incident or emergency situation.

 

Who is it for?

All health services in all health care settings.  All employers and employees in health and social care settings have health and safety responsibilities.

In relation to the standard criteria (in bold) the following key questions need to be considered:

Best practice is applied in assessing, managing and mitigating risk which draws on people’s experiences of the service.

  • Does your risk management policy and strategy comply with legislation and support best practice?
  • Have you developed a risk assurance framework?
  • How do you keep it up-to-date and use it?
  • How do you train and support staff to be competent in their roles and responsibilities?
  • How do you contribute to and learn from key reports e.g. HSE and Patient Safety Wales reports and alerts?
  • How does the learning identified from your concerns link to your risk management processes?

Risk management and health and safety are embedded within all healthcare settings and are monitored to ensure continuous improvement.

  • How do you protect the health, safety and wellbeing of patients, service users, carers, staff and the public?
  • How do you review and improve these arrangements?
  • How are you learning and sharing from risk, health and safety issues?

Access to up to date and relevant information is readily available to identify, prioritise and manage real risks that may cause serious harm.

Measures are in place to prevent serious harm or death where the required controls are well known.

  • How is the board assured that the controls are in place and effective?
  • How is the learning from Serious Incident and Never Event investigations informing this process?

Safety notices, alerts and any such communication are acted upon.

  • How do you disseminate these to the right people in a timely way?
  • How do you ensure action has been taken?
  • How do you monitor action taken?
  • How do you gain assurance that the actions are being maintained?

Issues relating to the environment such as security, safe and sustainable design, clear signage, planning, privacy, fire safety, age related general health and safety, and disability accessibility are considered.

  • Are your premises accessible to all patients, service users, carers and staff?
  • Is specialist advice on accessibility needed?
  • Have you done an equality impact assessment of changes to an environment or of a new development?
  • Are you premises accessible by public transport? Do you have adequate parking and drop-off facilities?
  • How do you know your sign posting meets basic accessibility criteria?
  • What provision have you made for assistance in accessing premises, e.g. physical adaptations or people to give advice?
  • What provisions have you made for safe access to outdoor space?
  • Are your premises safely accessible for people with a disability or sensory loss?
  • How do you respond to fire risk assessments and audit findings and evidence of changes in practice?
  • Have you considered how the environment can be made more accessible for people with sight loss, including:
    • Use of colour contrast in interior design (eg doorways, stairways) and in furniture and other equipment
    • Ensuring signage and way-finding is clear, bold and has large print lettering
    • Ensuring adequate lighting
    • Audio enabling lifts
    • Clearing obstacles to make the environment safer?
  • For patients who are deaf, how do you ensure staff know how to book communication support e.g. British Sign Language interpreters or how to source assistive equipment such as Sonido Listeners?

There is compliance with legislation and guidance to provide safe environments that are:

  • accessible
  • well maintained
  • fit for purpose
  • safe and secure
  • protect privacy
  • sustainable
  • How do you ensure the legal requirements of the Health and Safety at Work Act etc.1974 are met?
  • How do you ensure compliance with equality legislation?
  • How do you ensure compliance with All Wales Standards for Accessible Communication and Information for People with Sensory Loss?
  • How do Independent contractors in primary care under the minimum standards for practice premises set out in The National Health Services (General Medical Services – Premises Costs) (Wales) Directions 2015, familiarising themselves with all current relevant statutory requirements and ensure its compliance with the same? The General Minimum Standards set out in Schedule 1 list, a range of requirements, including adequate procedures for the continuing safety of the practice premises and suitability including risk assessments.  A GP contractor will need to ensure they have arrangements in place to deal with the type of urgent problem they may encounter. EG heating system failure in winter, or roof leak leading to water damage in the surgery / consulting room.  

There is compliance with the requirements of the Civil Contingencies Act 2004 and supporting guidance. This will include undertaking risk assessments, having current and tested emergency plans and business continuity arrangements developed through collaboration with partner agencies. This will ensure delivery of a robust response and ensure continuity of essential health services in the event of a major incident or emergency situation.

  • Do you have an officer on the Executive Board who is accountable for the organisation’s civil contingency arrangements who is supported by staff with civil contingency responsibilities and at least one trained and competent person with full-time responsibility for maintaining the organisation’s civil contingency arrangements in a state of readiness?
  • How are you prepared to meet the health needs and impact on services arising from any major incident or emergency? This will involve working in co-operation with other NHS organisations and partner agencies.
  • Do you have in place current documented response plans that are resilient against assessed risks and co-ordinated with the response plans of partners, including arrangements for mutual aid and warning and informing the public, where appropriate?
  • Do you have in place current business continuity management arrangements that are aligned with ISO22301 and the Publicly Available Specification (PAS) 2015 in order to demonstrate that adequate business resilience arrangements are in place?
  • How do you ensure staff are appropriately trained and have fully functioning equipment for their role within emergency response and business continuity arrangements and that a programme is in place to exercise and test response plans?
  • Do you have a robust Board mechanism for internal validation and assurance on levels of civil contingency preparedness to ensure arrangements are fit for purpose and compliant with guidance that includes reporting into the senior management team/executive board and the discharging of the Accountable Officer responsibilities?

 

Legislation and Guidance

All organisations in Health and Social Care settings are required to meet their legal duties as set out in Health and Safety at Work etc Act 1974.

Health and Safety at Work Act etc. 1974

Health and Safety Executive

The Health and Safety Executive provides information about managing risks in health and social care settings that can affect employees and service users:

http://www.hse.gov.uk/healthservices/index.htm

The All Wales NHS Health and Safety Managers Forum has developed the ‘NHS Wales Health and Safety Management System’. The document sets out minimum standard guidance on how NHS Wales will manage health and safety in Health Boards and Trusts and it describes the management system through 11 principles. The document was developed in 2014-15 and will be revised following a 12 month implementation period from xxx 2015

The National Health Service (General Medical Services – Premises Costs) (Wales) Directions 2015

Civil Contingencies Act 2004

Civil Contingencies Act 2004 - Emergency Preparedness

Civil Contingencies Act 2004 - Emergency Response & Recovery

UK Influenza Preparedness Strategy 2011

UK Pandemic framework

NHS Wales Shared Services Partnership - Specialist Estates Services - Publications

For Dental Teams – GDC Standards for the Dental Team

Serious Incident Reporting– Section 9 Putting Things Right Guidance (version 2)

Never Events List 2015/16

 

Toolkits

All Wales Clinical Governance Practice Self Assessment Tool

The on-line maturity matrix style CGPSAT was made available to all Welsh General Practices in 2010 and was designed to be completed via self assessment and review.  The tool encourages practices to reflect and assess the governance systems they have in place in order to facilitate safe and effective clinical practice and is mapped to the Standards for Health Services in Wales.

The CGPSAT may act as an assurance to bodies such as Health Boards, the General Medical Council and Community Health Councils that governance systems are in place and effective or, if not, that the practice is planning to introduce or improve such systems

Primary Care Quality (PCQ) has teamed up with Workboost Wales to bring together the work undertaken across Wales by both the PCQ and Workboost Wales, part of Public Health Wales.

Risk Assessment and Risk Management is an essential component for any practice, Workboost Plus now offers an expert guidance and support to general practices looking to identify business and clinical risks to the estate, assets – human and utilities, and functionality of their business.

An audit of WHTM 01-05 – Decontamination in primary dental care and the community dental service

http://www.walesdeanery.org/index.php/en/practice-quality-improvement-programme/national-audit-projects.html

 

Good Practice Guides

RNIB –Top Tips for Healthcare Professionals. Accessing Care and the Physical Environment. 

RNIB Expert Series Blog – Slight Loss, Dementia and the Built Environment