Part 1 Item: 10.3 29 - Kingston Hospital | Home · Kingston Hospital NHS Foundation Trust -Trust Board – Part 1 – May 2015 ... Sean Barker Fire Safety Advisor 10 12 Janette Barnes

Kingston Hospital NHS Foundation Trust -Trust Board – Part 1 – May 2015 Page 1 of 32 4

Trust Board – Part 1 Item: 10.3

29th July 2015 Enclosure: M

Purpose of the Report:

To present the Board with the annual Health and Safety report for 2014-15.

FOR: Information Assurance Discussion and input Decision/approval

Sponsor (Executive Lead):

Jo Farrar, Director of Finance

Author:

Sarah Kelly - Health & Safety Advisor

Author Contact Details:

[email protected]

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

Assurance

Legal / Regulatory / Reputation Implications:

Legal, Regulatory, Reputation

Link to Relevant Corporate Objective:

Document Previously Considered By:

Compliance and Risk Committee Executive management Board

Recommendation & Action required by the Trust Board : The Trust Board is asked to note the content of the Annual Health and Safety Report.

Kingston Hospital NHS Foundation Trust – Trust Board – Part 1 – July 2015 Page 2 of 32

Health and Safety Annual Report

01st

April 2014 to 31st

March 2015

1.0 Introduction: The Health & Safety Annual Report covers the period 01st April 2014 to 31st March 2015, 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.

2.0 Dates of Meetings: The Health and Safety Committee met on the following dates: April 1st 2014 October 7th 2014 May 6th 2014 November 4th 2014 June 3rd 2014 December 2nd 2014 July 1st 2014 January 6th 2015 August 5th 2014 February 3rd 2015 September 2nd 2014 March 10th 2015 All the above meetings met the requirements for a quorum under the Committees Terms of Reference.


3.0 Membership: During the period of this report, the committee was chaired by the Deputy Chief Executive. Members were required to attend a minimum of 75% of the planned meetings.

Members were required to attend a minimum of 75% of the planned meetings.

Name

Position

Attended

Out of Possible

Charles Bruce

Deputy Chief Executive

10

12

Deborah Lawrenson (joined

part way through the year)

Head of Corporate affairs

3

3

Hugh Gostling

Director of Estates and Facilities

10

12

Sarah Kelly

Health & Safety Advisor

12

12

Chris Sims

Estates Manager

10

12

Sean Barker

Fire Safety Advisor

10

12

Janette Barnes

Occupational Health Manager

10

12

Paul Holland

Sterile Services Manager & Decontamination Lead

10

12

Sarah Joseph

Matron

10

12

Associate Director Representative

Associate Director Representative

2

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

4.0 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 2014/2015. 5.0 Incident Reporting: As per health and safety requirements accidents, incidents and near misses events must be recorded and investigated depending on the severity, with solutions and recommendations put in place as part of the closure process for these accidents, incidents and near misses. Despite the implementation of the new reporting system in 2013 and ongoing promotion, reporting has decreased. 5.1. 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 6 incidents reportable to the Health & Safety Executive (HSE) under the Reporting of Injuries, Diseases and Dangerous Occurrence Regulations (RIDDOR) during this period, which is 1 more than the same period in 2013/2014. 5 of the 6 RIDDOR events were due to slip, trip and fall incidents, with 1 incident due to an employee falling from their chair. The 6th incident was a manual handling incident due to human error. 4 of these reportable incidents were due to absence, over 7 day period off work. The remaining reportable events were due to 2 members of staff sustaining fractures, Elbow and foot. The elbow fracture occurred due to slipping on a corridor and falling onto the elbow. The floor was not wet at the time. The flooring was checked with no reason found to be the root cause. The foot fracture (fifth metatarsal) occurred as a result of falling up a step on the stairs. The stairs were reviewed but no evidence was apparent to suggest anything further could be implemented. 5.2 Staff Incidents: The total number of recorded incidents involving staff for this period was 274. 40 manual handling Incidents have been recorded for the 2014/2015 period an increase of 15 on the previous year 2013/2014 which totalled 25. 19 incidents were due to patient moving. The manual handling injuries sustained included 10 back injuries, 2 shoulder injuries, 1 face injury, 1 foot injury and 5 injuries including hand, arm, wrist, and finger. All of these injuries were classified as minor, ranging from scratches, bruising and minor sprains, with none being reportable to the Health & Safety Executive.


Chart 1.0

A further 21 manual handling incidents were due to lifting and moving of inanimate objects. The manual handling injuries sustained were 6 back injuries, 2 shoulder injuries, 5 finger injuries, with the remaining 8 injuries to the foot, groin, knee/leg, head, hand, eye, & wrist. All injuries were classified as minor, with one of these minor injuries being a graze to the back of the hand which was a riddor reportable incident due to sickness absence. The range of inanimate objects resulting in these injuries included the lifting of files, patient notes, boxes of medication, crates, a pallet, and a trolley. Chart 2.0

Back, 6

Shoulder, 2

leg/Knee/Groin, 3Foot, 1Head, 1

Finger, 5

Eye, 1

Wrist, 1 Hand, 1

Staff Manual Handling Incidents of inanimate objects

Total 21 staff injuries

Slip trip and fall incidents have decreased significantly in comparison to last year 2013/2014 with 42 reported last year to 24 reported this year 2014/2015.


Chart 3.0:

Trip incidents totalled 4, due to 2 cable trips, 1 carpet flooring trip, 1 member of staff rushing. The IT cable trip hazards were resolved by the IT team, with the flooring issue being resolved by the estates team.

Fall incidents totalled 6, 2 falls occurred from a chair and a stool. 1 fell up step on stairs, 1 fell over notes on floor, 2 members of staff fell in corridors of different areas, and the corridors were inspected and reviewed, with a request issued to ISS not to buff the floor in the areas.

Slip incidents totalled 14, with no contributing factors relating to 3 of the incidents, 1 factor was a member of staff slipping on a toy on the ground, 1 incident as a result of staff members footwear. 9 slip incidents were contributed to wet floors, due to spillages, leaks, weather and 2 of the floors being cleaned, without signage.

Chart 4.0


Contributing Factor to falls: Chart 5.0

21 1

3

1

3

1

10

1 1

0

2

4

6

8

10

12

Factors causing slip, trip & fall incidents

Wiring & Cables

Carpet

Rushing

Fall from chair & Stool

Fall up steps

No reason

Notes on Floor

Wet Floor

Toy

In order to reduce slip, trip and fall incidents, work has taken place internally with the entire main entrance and corridors being replaced with new flooring, which is still ongoing. Slip, trip and falls awareness has been emphasised in training sessions, both face to face and in the mandatory booklet. A review of theatres has taken place together with consultation with external companies who provide anti-slip flooring. This work is due to be commissioned imminently. 5.3 Staff Accidents & Injuries: 274 staff accidents, incidents and near miss events have been recorded in total for the period including, the 24 slip, trip and fall accidents. Manual handling accidents totalled 40 an increase on the previous year’s figures.

Table 1.0

Type of Event 2012/2013 2013/2014 2014/2015

1*

Abuse etc. of Staff by Patients

112

113

92

2*

Inoculation Injuries

85

98

90

3*

Slips, Trips and Falls

43

40

24

4*

Moving and Manual handling accidents

22

18

40

Totals

262

269

274


Inoculation injury rates have further reduced on the previous year, 90(cf104). Occupational health and wellbeing (OH&WB) recently conducted a study into the rates of inoculation injuries at Kingston hospital and compared these to three local trusts. Whilst it is noted that there is no standardised way of collecting this data, with each trust having its own mechanism for data collection, Kingston Hospital demonstrated an injury rate of 3 per 1000 staff in 2014, whilst the other three trusts surveyed had a 4 per 1000 staff. Whilst inoculation injuries have reduced, it should be noted that there has been an increase in the number of splash incidents to staff. Numbers have increased from 25 to 28 over the year. Many of these incidents have occurred in the maternity unit, where visors have been purchased, but this still remains a problem. Where injuries resulted from poor practice, education on prevention was given to the employee and the line manager was informed in order for appropriate measures to be taken to reduce the risk of recurrence. Presentations on inoculation injuries are incorporated into the Occupational Health &Wellbeing, Health & Safety and Infection Control induction and update sessions. A session on inoculation injury prevention is also now delivered on the new doctors’ induction programmes in particular the risk assessment and the use of Post Exposure Prophylaxis (PEP) appropriately, as a significant number of injuries involve junior doctors. 6.0 Reports from Sub- Committees: 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 Committee

Paul Holland

Bi-monthly

Fire Safety Committee

Richard Evans

Monthly

Laser Protection Committee

Andrew Pooley

Annually

Water Safety Committee

Chris Sims

Quarterly

Medical Gas Committee

Derek Cock

Bi-Monthly

Radiation Protection

Committee

Paul Reid

Annually

Security Committee

Richard Evans

Monthly

Waste & Sustainability Committee

Adedayo Adegbayibi

Monthly


6.1.1 Decontamination Committee: (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. 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.

6.1.2 Waste & Sustainability Report 2014-15: (Meet Monthly)

Introduction: The Trust has continued to work hard to improve our environmental performance and reduce our carbon emissions. We have invested in environmentally friendly building design, implemented energy efficiency measures, diverted waste from landfill through recycling and encouraged the use of sustainable transport as well as raising awareness amongst our staff as well as with patients and members of the public. The trust’s Carbon Management Plan (2010-2015) has been updated to highlight areas where improvements have been made. The carbon management plan which has a target of reducing the carbon emissions by 10% by 2015 is in its final year and will be replaced with a new 10 year plan which will run until 2025. How the Trust makes decisions about Sustainability: The Trust’s Sustainability Steering Committee has representation from various departments across the Hospital including both clinical and non-clinical staff. The committee acts as a focal point for all aspects of sustainability and energy reduction within the Trust such as staff engagement and implementation of energy efficient projects. The committee also engages with the wider Trust community to ensure that activities are varied, engaging and have a positive impact on the Hospital.


Definitions Scope 1 emissions are direct Green House Gas (GHG) emissions from sources that are owned or controlled by the entity. Scope 1 can include emissions from fossil fuels burned on site, emissions from entity-owned or entity-leased vehicles, and other direct sources. Scope 2 emissions are indirect GHG emissions resulting from the generation of electricity, imported electricity, heating and cooling. Scope 3 emissions include indirect GHG emissions from sources not owned or directly controlled by the entity but related to the entity’s activities. Scope 3 GHG emission sources currently required for GHG reporting include T&D losses associated with purchased electricity, employee travel and commuting, contracted solid waste disposal, and contracted wastewater treatment.

Summary of Performance

Area 2014/15 Performance Status

EU Emissions Trading scheme

Natural Gas & Fuel Oil

A decrease of 6% of CO2 emissions from 2013 to 2014 under the EU ETS.

Energy Scope 1 5% decrease in our Scope 1 emissions despite extra electricity imported from National Grid to cover CHP downtime and excess consumption onsite during peak periods.

Scope 2 In 2014/15 the Trust relocated circa 200 staff from leased of-site premises to refurbished accommodation on to the main Trust site. The Trust has reviewed its consumption data to record this additional consumption and also recognised that it had not recorded consumption in some buildings which were previously exempt. This affected the report methodology for the data which had now been rebased to reflect the omission and additional consumption.

Energy Consumption

Scope 1 & 2 In general, there was a 4.5% reduction in total energy consumption of between 2013/14 and 2014/15.

Green Champions

Staff Engagement Programme

Sustainability Steering Committee

Technical Carbon Management Projects


Emissions Scope 1 & 2 1% increase total gross emissions from Scope 1 & 2 for energy consumption fuels between 2013/14 and 2014/15.

Waste Clinical waste

The amount of clinical waste disposed decreased by 0.4% from 2013/14 to 2014/15.

General Waste

General waste disposed of decreased by 3.1% from 2013/14 to 2014/15.

Hazardous waste

Hazardous waste decreased by 82% from 2013/14 to 2014/15.

Bulky Waste Bulky waste increased by 39% from 2013/14 to 2014/15. This was due to renovations works in several wards and administrative staff moving from offsite offices to the main Trust site.

Reused/Recycled Waste

Recycled and reused waste has increased by 48.5% from 2013/14 to 2014/15

Water Water Supply & Waste Water Discharge

Water consumption and Wastewater emissions figures remained the same for both 2013/14 and 2014/15. Water consumption and Wastewater discharge figures decreased by 0.07% between 2013/14 and 2014/15. Water supply and Wastewater charges increased by 2.4% in 2014/15.

Comments

A total of 6000 carbon credits costing £30,500 purchased from carbon trader to offset carbon credits deficit with a of 21% increase CO2 emissions between 2011 and 2013.

2014/15 was significantly milder with less cold, wind and rainfall than 2013/14 when compared using degree days. This had the effect on decrease in energy consumption from steam and heating.

The Hospital wide mixed recycling scheme commenced in December 2014 to reduce waste to landfill, carbon emissions and disposal costs.

Commenced Sustainability and Energy Awareness Staff Engagement Programme in September 2014.

A number of energy efficient projects aimed at reducing carbon emissions and reduce costs were carried out in 2014/15. This includes upgrade on BMS system with smart metering, renewal of boilers and installation of LED lighting and roof insulation in Vera Brown House, introduced plate heat exchangers to replace calorifiers, major pipework and insulation of Esher Wing Plant room, window replacement for Esher Wing.

Sustainability Accounting and Reporting This section sets out the Trust’s environmental data and the financial cost associated with energy consumption, waste management and water usage across the estate. The Trust’s gas and fuel oil data is also used for reporting CO2 emissions annually in the European Union Emissions Trading Scheme (EU ETS). The Trust is an Information Declarer in the Carbon Reduction Commitment (CRC) Energy Efficiency Scheme. This report sets out the annual achievements of the Trust in sustainability, found in the following areas:

Energy, Water and Waste Management

Sustainable Travel

Sustainability and Energy Awareness Programme EU Emissions Trading Scheme (EU ETS) The EU ETS covers carbon emissions from combustion of gas and fuel oil from January to December of each year.


Year 2011 2012 2013 2014 Chart

Tonnes of CO2e

6549 7288 7925 7429

Observations:

CO2 emissions decreased by 6% between 2013 and 2014 under the EU ETS .A total of 6000 carbon credits costing about £30,500 was purchased from carbon trader to offset carbon credits deficit.-

Energy Consumption:

Non-Financial Indicators (Tonnes of CO2)

SCOPE 1: Direct Emissions

2011-12 2012-13 2013-14 2014-15

Natural Gas* 7254.9 8195.2 8574.2 8128.2

Fuel Oil 0.1 34.5 4.7 13.3

Total Net Emissions

7255.0 8229.7 8578.9 8141.5

SCOPE 2: Indirect Emissions

Purchased Electricity*

1483.1 888.5 1000.5 1534.0

CHP Generated Electricity

- - - -

Total Net Emissions

1483.1 888.5 1000.5 1534.0

Total Gross Emissions 8738.1 9118.2 9579.4 9675.5

Related Energy Consumption (MWh)

SCOPE 1: Direct Emissions

2011-12 2012-13 2013-14 2014-15

Natural Gas 39306.0 44400.0 46453.1 44037.2 Fuel Oil 0.5 4.7 17.5 49.4

SCOPE 2: Indirect Emissions

Purchased Electricity

3025.3 1812.5 2040.8 3129.2


CHP Generated Electricity

8700.3 11297.0 11078.0 9704.8

Total Energy Consumption

51032.1 57638.5 59589.4 56913.5

Heating Degree Days (18.5oC)*

2484 3087 3134 2703

Financial Indicators: Expenditure on Energy (£’000)

2011-12 2012-13 2013-14 2014-15

39306.0 44400.0 46453.1 44037.2

Chart

Observations

Scope 1 emissions are from the burning of fossil fuels that are consumed on the site. There has been a 5% decrease in our scope 1 emissions between periods 2013/14 and 2014/15.

Scope 1 emissions are from the burning of fossil fuels that are consumed on the Hospital premises. There was a 5.2% decrease in natural gas consumption between 2013/14 and 2014/15 while fuel oil had a 182% increase during the same period due to acquisition of more generators for site use.

Scope 2 emissions relate to the consumption of electricity on the premises. There has been a 53% increase in our scope 2 emissions between periods 2013/14 and 2014/15. This is due to 200 members of staff moving on site and error during data collation for purchased electricity figures from 2010 to 2014 which exempted some buildings on the Trust site which procure electricity from outside the scope of the CHP. This affected the report methodology for the data which had to be rebased to reflect these errors.


This was due to extra electricity imported from National Grid to cover CHP downtime and staff moves to Vera Brown House. There was a 12% decrease in electricity generated by the CHP Plant.

The decrease in consumption of fossil fuels (natural gas) was due mainly to the weather in 2014/15 being significantly milder, less cold and with less rainfall than 2013/14. The heating degree day value was also lower than previous year thus leading to less consumption of energy.

There was a 4.5% reduction in total energy consumption of between 2013/14 and 2014/15.

There was a 2% reduction from 2013/14 to 2014/15 in Energy costs

There is a need to undertake further energy/CO2 emissions projects as detailed in the Trust Carbon management Plan. The Trust has completed a plant room insulation project for pipework, valves and flanges for heat conservation, embarked on the second Phase of a staff energy awareness campaign, as well as renewed the boilers and installed LED lighting in Vera Brown House. A full list of projects can be found in the Trust’s Carbon Management Plan.

Future Plans

Continue to implement and update the Trust’s Carbon Management Plan and undertake further energy/CO2 emissions projects as detailed in the plan. This includes installing LED external lighting for car park, maintain moment and embed Staff Energy Awareness programme. A full list of projects can be found on the Trust Carbon Management Plan.

Reduce the amount of imported electricity purchased through awareness programmes to reduce energy consumption.

Install variable speed drives on HVAC system fans, pumps and other motors to enable speed to vary in response to system demand.

Install solar panels to reduce imported electricity from National Grid.

Develop bids for funding of energy and CO2 emissions projects throughout the Trust.

Continue to monitor and report on energy consumption. Waste Management

Non-Financial Indicators (tCO2e)

SCOPE 3: Un-quantified Emissions

2011-12 2012-13 2013-14 2014-15 Chart

Clinical Waste 108.3 104.4 107.6 107.1

General Waste 236.6 233.1 267.2 258.6

Reused/Recycled - - - -

Bulky Waste 20.9 24.4 24.3 33.7

Hazardous Waste 1.5 0.8 0.9 0.1

Total Gross Emissions

367.3 362.7 400.0 399.5

Waste SCOPE 3: 2011-12 2012-13 2013-14 2014-15 Chart


Tonnages (Tonnes)

Un-quantified Emissions

Clinical Waste 475.0 458.0 472.0 470.0

General Waste 431.7 425.4 487.7 472.0

Reused/Recycled 68.0 122.2 101.7 150.0

Bulky Waste 38.2 44.6 44.4 61.0

Hazardous Waste 6.8 3.9 3.9 0.7

Total Tonnage 1019.7 1054.1 1109.7 1153.7

Financial Indicators: Expenditure on Waste Disposal (£’000)

2011-12 2012-13 2013-14 2014-15

260 281 300 357

Chart

Observations

There was a 0.1% decrease in total waste emissions from periods 2013/14 to 2014/15.

Waste disposal charges have increased by 19% between 2013/14 and 2014/15.

The amount of clinical waste disposed decreased by 0.4% from 2013/14 to 2014/15.

General waste disposed of decreased by 3.1% from 2013/14 to 2014/15.

Recycled and reused waste has increased by 48.5% from 2013/14 to 2014/15 and forms 13% of the total waste tonnage for 2014/15. There was also a 4% increase in recycled and reused waste against total waste produced in the 2013/14 and 2014/15.

Bulky waste increased by 39% from 2013/14 to 2014/15. This was due to waste arising from renovations works and general clutter in several wards and administrative offices during ward and office relocations on the Trust site

Hazardous waste decreased by 82% from 2013/14 to 2014/15. Future Plans

Implementation of food waste recycling scheme across the Hospital site to commence in 2015/16.


Introduction of wood recycling scheme.

Recycling of single use instruments.

Green waste composting. Waste Supply & Waste Water Discharge

Non-Financial Indicators (tCO2e)

SCOPE 3: Unquantified Emissions

2011-12 2012-13 2013-14 2014-15 Chart

Water Supply 14.9 12.2 14.9 14.9

Waste Water 30.6 25.0 30.7 30.7


45.5 37.2 45.6 45.6

Financial Indicators: Expenditure on Water Supply & wastewater Discharge (£’000)

2011-12 2012-13 2013-14 2014-15

74 79 83 85

Chart

Water Supply & Wastewater Discharge (m3)

SCOPE 3: Unquantified Emissions

2011-12

2012-13

2013-14

2014-15

Chart

Water Supply

43766.0 35311.0 43363.0 43330.0

Waste Water 43766.0 35311.0 43363.0 43330.0


87532.0 70622.0 86726.0 86660.0


Observations

Water consumption and waste water discharge emissions remained the same for both 2013/14 and 2014/15 financial period.

Water supply and waste water charges increased by 2.4% at the end of 2014/15 financial period.

Water consumption and waste water discharge decreased by 0.07% respectively between 2013/14 and 2014/15.

Future Plans

To continue to monitor water consumptions across the Trust.

Introduce energy efficient saving taps and showers systems. Sustainable Travel

Carbon Emissions from Patient Transport The Trust is in the process of tendering for a new contract which will enable more accurate monitoring from September 2015 onwards.

Carbon Emissions from Courier Transport The majority of the Trust’s courier runs remain largely unchanged from the previous year. The recent changes to the Pathology services within the South West London (SWLP) cluster will result in significant changes to these runs, it was hoped that this would be completed in 2014/5 financial year but this will now not take effect until July 2015. The consolidation of courier runs by SWLP will allow for the runs to be redesigned and likely reduced in number. The contract also contains assurances from the provider to move towards a greener fleet (such as hybrid vehicles) and the consideration of electric vehicles where possible. A number of collections will also be carried out by motorbike instead of vans which will further reduce the carbon emissions.


Green Transport Initiatives The Trust continues to develop its Healthy Transport Plan in conjunction with the local council. This is designed to encourage the use of alternate methods of transport and reduce the carbon footprint of staff.

All car parking application forms also offer information on cycling and loans for travel cards and improvements are being made to the public transport infrastructure in the immediate vicinity of the Trust including the bus stop at the front of the site.

The Trust continues to work towards improving the bus frequency and promoting additional services to areas poorly, or indirectly, served through feedback to Transport for London (TFL) and the Council.

The Trust continues to host a number of initiatives to improve awareness of green transport including Walk to Work Week, Cycle Week and bike maintenance workshops. There are also additional bike sheds planned for installation in the coming year to further encourage staff and visitors to use bicycles. The Trust’s Cycle Scheme (which allows staff to purchase bicycles at preferential rates and spread payments over a year) continues to be popular, especially during the spring.

Sustainability and Energy Awareness Programme In September 2014, the Trust in partnership with Carbon Credentials launched a sustainability and energy awareness staff engagement programme. The aims of the programme were to:

Raise levels of awareness about the Trust’s environmental impact

Change attitudes and behaviours

Embed the responsible use of energy and other resources

Contribute to the Trust’s carbon reduction target

Achieve cost savings

Support patient care by creating comfortable environments

A three phase plan was set up to achieve the aims of the sustainability programme:

Establish and plan the right programme to fit into the Trust values

Empower staff and management and deliver appropriate tools

Embed change so staff can take ownership The effect of this will be reported in 2015/16.


5.1.3 Security Committee: (Meet Monthly) The Security Group has prioritised two areas this year; ensuring incidents are reported (as

in previous years) and working to identify and resolve missing patient incidents. The group

has noted with pleasure that the training levels for Conflict Resolution Training have

remained high with sessions being made available to existing staff (as refresher training)

and for new starters . The Trust continues to build local partnerships with Trust staff

attending local neighbourhood ward meetings to keep the public involved with the Trust

and allow their concerns to be raised. The Safer Neighbourhood Police Teams have

increased their presence on site and have expressed their pleasure with improvements in

some Trust processes and the Trust is no longer listed as 'hotspot' for crime.

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. Unfortunately the clarifications from the Department of Health

have not made the issues clearer with the additional information provided leaving Trusts

without definitive guidance, our Local Security Management Specialist continues to liaise

with other Trusts and work towards ensuring the Trust is able to address this issue

correctly.

There have been 839 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, 635 in 2012/13 and 784 in 2013/14 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. It has been noted a number of these

requests have required Security Officers to maintain watch on patients for times in excess

of 12 or even 24 hours. These reports have raised concerns as the officers should not be

used in place of specials and it is very difficult for our small team to maintain an effective

watch on multiple patients at once and for such extended timeframes.


Chart: 6.0

67

91

38

47

111

40

445

Incident Reports 2014/15

Assaults**

Aggression

Abusive Behaviour

Evictions

Missing Persons

Thefts

Others

** Please note some incidents of reported assaults resulted in multiple people being assaulted in a single incident

The reported incidents of violence (resulting in an assault) continue to rise from last year,

reaching 71 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. A number of medical wards in particular have shown

good reporting habits. Their reporting of assaults (normally from patients suffering from

dementia) has allowed them to identify risks and put in local management plans for these

patients. Investigations still suggest 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 mean the support that should be available to them is

often lacking and that there are poor warnings for other staff involved in the patient's care,

leading to subsequent assaults on staff.

The Trust has continued to push for prosecution of patients assaulting staff who do not

have medical factors involved in their actions however this continues to be challenging

with either staff declining the opportunity to make statements or the Crown Prosecution

Service deciding it is not in the public interest to pursue further steps. The Trust continues

to follow its own processes with a number of warning letters issued and local

arrangements made with troublesome patients/visitors limiting their access to the Trust.

The growing number of patients suffering dementia has led to awareness about the

dangers such patients can present to staff, feedback from the Conflict Resolution Training

has suggested staff are keen for physical skills to be taught, and a decision on this will

need to be made following the completion of the restraint policy.

2012/13 2013/14 2014/15

Assaults Reported 35 67 71


Chart: 7.0

Of these assaults 48 were ‘medically factored’ (where it was deemed the patient’s medical

situation played a significant part in the assault), 23 were deemed ‘non-medical factored’

for which there was no medical reason for the individual to act in this way.

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 including FFT

terminals. The overall reported thefts through the Trust systems were 40 for the year with

petty thefts (particularly after the Christmas period) driving the numbers up, the police also

received reports directly of thefts or suspected thefts not included in these numbers. The

most pertinent of these are discussed at the Security Group. A Local neighbourhood

police continue to run theft awareness days and undercover operations. The group was

pleased to note that the Trust again has avoided the theft of nitrous oxide this year with

the previous target-hardening carried out remaining effective.

There has been a significant number of missing patient reports this year (111 reported)

which 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. The Security Group has overseen the introduction of a new patient minding

form to assist the ISS officers in managing these situations and ensuring the handover is

completed in a timely and efficient manner. However this year has seen a number of

patients absconding from the ward prior to security being contacted which has led to a

number of incidents that could easily have become very serious and present a threat to

the well-being of patients. This has led to queries about the level of training issued to one -

to-one staff and the positions they are placed in, perhaps without the support network that

they need. The group has been considering information from other Trusts and the


methods they use to cope with these types of patients. A report due imminently will allow

the Trust to make decisions about how they wish to address this and any additional

training needs that are felt to be required. To assist with management of patients in the

Emergency Department a partial turn on of the access control has been planned and

remedial works are being carried out to repair damage to the system prior to this going

live. The Group will then be looking at options for management of absconding patients

from the ward as well as considering the impact of the smoking ban on site and if this will

lead to additional cases of patients leaving site to smoke.

The Trust continues to work with ISS to improve the utilisation of the Security Officers and

help to address the issues facing them, such as increased demand for their services

leading to reduced time to patrol and provide a visible deterrent around the site. The new

patient minding form will allow for greater analysis of their usage and both parties remain

committed to freeing up additional time

The Trust’s access control network continues to be extended with Main Theatres and

Worcester ward being added into the system, it remains a focus of the group to unite the

disparate systems and negotiations with Prime over the system in the Kingston Surgical

Centre have begun. The group has also noted the increasing age of the CCTV systems on

site and the potential need for investment in this area. The Trust continues to look at

redeploying the most effective units to key areas however this is a short term solution.

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. The devices are currently used by a number of community teams (PONT

and Maternity) as well as isolated staff on site working unsocial shifts and those at outlying

clinics such as Raynes Park. The devices have also been used on wards where staff felt

trepidation due to the presence of violent patients (or visitors) to add an additional layer of

protection.

The attendance of clinical staff at the Security group has increased dramatically towards

the end of the year and this had led to increased liaison with the wards and the ability to

address their concerns and issues more effectively. The Group is very keen to stress the

importance of this and to ensure that the nursing staff are an essential part of the

development of the security procedures on site.

5.1.4 Radiation Protection Committee: (Meet Annually) The annual Radiation Protection Committee 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. The overall management of radiation protection was found to be excellent, as per all previous audits. The audit demonstrated that the diagnostic radiology and the subspecialties operate with a high degree of compliance with IRR99, IR(ME)R2000 and all other relevant radiation protection guidance and legislation. All recommendations the


previous year’s audit have been satisfactorily addressed and many points of good practice were noted. The Department had an environment agency inspection during May 2014 and was found

to be non‐compliant to the permit condition on one issue. This was “the Iodine sharps waste which had been stored for longer than 6 months”. This was immediately rectified. The EA inspector also made some further recommendations, which were addressed by the department. A patient who had been injected with a radioactive isotope returned to the ward accompanied by a porter. An incident occurred whereby a pregnant nurse on the ward came into contact with the patient and was unaware. This resulted in the radiology department procuring red wrist bands for patients identifying them after receiving the radioactive isotope, so all clinical staff on the wards are aware, thus reducing unnecessary risk of exposure. 5.1.5 Laser Protection Committee: (Meet Annually) The Laser Protection Group meet annually to review the current working practices, equipment and changes in legislation. This is 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 August 2014. The overall outcome, from the inspection was that the Royal Eye Unit is compliant with only a few minor actions to be implemented. These have now been actioned and completed. 5.1.6 Fire Safety Committee: (Meet Monthly)

The Fire Safety Group is responsible for the review of all fire safety matters. The Groups purpose is 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 2014 to the 31st March 2015, the Trust had no fire incidents. (i.e. no sustained combustion.) The last fire incident at the Kingston hospital site was 21/08/2013. Fire Alarm Activations: The Kingston Hospital site ‘Fire Detection and Alarm System’ is managed and tested by the Trusts 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’. Since October 2014, this data is also entered into the Ulysses Incident Reporting system. During the period from the 1st of April 2014 to the 31st March 2015, the Trust had 67 Fire Alarm Activations; these have all been ‘Unwanted Fire Signals’ (false alarms). This is well within the parameters given in guidance document, B.S. 5839-1:2013 ‘Fire detection and fire alarm systems for buildings – Part 1: Code of practice for design, installation, commissioning and maintenance of systems in non-domestic premises’, where a system


the size of Kingston Hospitals (4737 automatic fire detectors) would typically generate approx. 90 ‘Unwanted Fire Signals’ per annum. To reduce and manage the Trusts 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 meet. This system has the full support of the London Fire Brigade. With the ‘Fire Response Team’ system in place, during the period from the 1st of April 2014 to the 31st March 2015, the London Fire Brigade attended false alarms at the Kingston Hospital site just 3 times. London Fire Brigade: During the period from the 1st of April 2014 to the 31st March 2015, the Trust had 2 official visits from the London Fire Brigade.

Following an attendance to an Unwanted Fire Signal in Kingston Surgical Centre (AAU level) on the 18th of May 2014, the Trust was visited by Fire Safety Inspecting Officer, John Draysey, on 5th June 2014, to conduct a building audit. The 999 call made to the brigade, on the 18th May 2014, was deemed appropriate with no remedial actions or recommendations as a result of this audit.

On Monday 26th of January 2015, Green Watch, from Kingston Fire Station, conducted a site inspection and familiarisation visit. The inspection was predominantly external with internal inspection to parts of Esher Wing, Kingston Surgical Centre, Outpatients and A&E. There were no remedial actions or recommendations as a result of this visit.

Fire Risk Assessments: Department Fire Risk Assessments (FRA) are conducted on a rolling roster by the Trusts Fire Safety Advisers. An amended Health Technical Memorandum 05-01: Managing healthcare fire safety, was published April 2013 (HTM 05-01), with recommendations that whilst the Fire Safety Adviser 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. Fire Doors: During the period from the 1st of April 2014 to the 31st March 2015, identified during the FRA process, were 2 significant issues in relation to the effectiveness/ compliance of Fire Doors.

During June and July of 2014, extensive remedial works were undertaken to

address an issue with the fire rating of glazing and effectiveness of intumescent/

cold smoke seals to Fire Doors within the Kingston Surgical Centre. This issue has

now been fully resolved with most of the key doors replaced rather than

overhauled.


During January and February 2015, to attain the degree of compartmentation

required for the trust’s Fire Emergency Evacuation protocol i.e. Progressive

Horizontal Evacuation, a number of full fire compartment doors (60 minute),

throughout Esher Wing underwent remedial works to bring them up to an

acceptable standard.

The Estates Department will continue to carry out assessments on Fire Doors and any issues identified will be addressed. Fire Doors identified during FRA’s, by the Trusts Fire safety Advisers, as needing remedial works will also be addressed by the Estates Department. All Fire Safety Training at the Trust, induction and mandatory updates, covers the importance of reporting any Fire Door issues to the Estates Helpdesk. Fire Safety Information Manuals: Another recommendation within HTM 05-01, to help with effective communication of Fire safety issues, is the provision of a local Fire Safety Information Manual. Each ward, department and/or area should be provided with a bespoke Fire Safety Information Manual that should be maintained by the local manager. The information contained within this manual should be freely available to be reviewed by any member of staff, patient or patient’s representative. With an organic approach to the rollout of this recommendation, the need for some form of bespoke Fire Safety Information Manual is being highlighted as part of the FRA process and within the Fire Warder/ Fire Warden Refresher training. Training: The Workforce Development department/ Education Centre situated on the 5th floor of the Kingston Surgical Centre, coordinates and manage the Trusts Fire Safety training requirements. In addition to the programmed mandatory Fire Safety training sessions, departments can arrange with the Trusts Fire Safety Adviser, a local Fire Safety briefing or drill/ evacuation exercise. These local sessions have proved more popular since the introduction of the new Mandatory Update Training Booklet in March 2014, requiring the ‘Fire Safety’ briefing to still be delivered face to face within a classroom environment.

The Fire Safety Committee is responsible for the review of all fire safety matters. The Committee’s 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. 5.1.7 Water Safety Committee: (Meet Bi-Monthly) This has been a good year in terms of the Trust water management systems, with very few incidences of water borne pathogens across the hospital site. The group continues to monitor and manage all aspects of water safety. The terms of reference have been reviewed and will be acknowledged at the next group meeting.


We employed external resource to help with the execution of remedial works exposed by our regular checks of the systems and can report we are up to date with all work identified. The Trust Responsible Person (RP) for water Safety and the Deputy RP have both undertaken comprehensive refresher training in the last year. Pseudomonas Aeruginosa As per the national guidance we sample for Pseudomonas Aeruginosa bi annually. In all our checks we have only once had a positive sample which was cleared with a local disinfection. The cleaning routine was reviewed and all subsequent re- samples have been clear. A contributory factor in this good record is the daily flushing regimen, recorded using L8Guard is well adhered to (see flushing). All the water outlets in ITU and the Neo Natal nursery are flushed daily and recorded on L8 Guard. The completion rate is consistently over 95%. One reason for their noteworthy record is the number of people they have nominated to be allowed to submit a report. Areas which only have one primary and an escalation contact should take note. The last Pseudomonas testing was carried out on 22nd April `15, next due in October. Legionella Pneumophila We continue to use temperature control as our primary method of controlling legionella. Maintaining hot water temperatures has been improved by installing plate heat exchangers in place of large calorifiers in Esher and MOPD. This also increases energy efficiency. The replacement of the corroded steel pipework in Esher with copper tube has almost been completed. In three wards work was suspended due to winter bed pressure. Due to much higher than expected admissions the Trust cannot currently decant these wards and give access to the contractor to finalise work in these areas. All the remaining work, including the main distribution pipework will be completed, up and including new to isolation valves controlling the areas in delay. This will allow work in them to be undertaken, as individual packages, when in-patient numbers allow. MOPD is scheduled to have the steel pipework replaced next. In the meanwhile all occupants have agreed to flush outlets daily. Electrical over sink water heaters are being fitted in treatment and consulting rooms where, due to the condition of the pipework there is little or no hot water. The Health & Safety Executive (HSE) guidance (version 4) of the Approved Code of Practice (ACOP) “Legionnaires’ disease: The control of Legionella bacteria in water systems (L8)” along with supporting Technical Guidance (HSG274parts 1 to 3), which was updated in 2014 the first significant update for over 10 years has been fully incorporated into our water quality management systems. Significant changes are:

All thermostatic mixer valves to be inspected, cleaned, descaled and disinfected annually

Water softeners to be serviced and disinfected annually

Hot water subordinate loops to be tested for temperature quarterly on a monthly rolling rota

On a quarterly basis we test for legionella in areas identified as high risk by the infection control department. At this time we add areas where a change in working practice or some other disruption to the normal working of an area (IE building works) could have an


impact on the water use. In future we will add those areas which consistently under perform on the reporting risk assessments of low use water outlets. (See flushing). We also check areas reported as having poor temperature control in our routine system checks. Of the 65 areas sampled in November 2014 6 were positive. In February 2 positives were found in 50 samples. The most recent checks in May identified one positive from over 60 samples. We occasionally get an enduring outbreak, usually in OPD due to the condition of the pipes. Twice in the past year we have treated the whole system to a complete disinfection to cure a persistent problem (in different areas). Risk Assessing and Flushing of Low Use Water Outlets (Flushing) We continue to use the electronic reporting system called L8guard to demonstrate our compliance with Department of Health guidelines which state; 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. See graphs below detailing site flushing compliance;

Graph 1.0:

Graph 2.0:


As can be seen in the graph and the table below, we seem to have plateaued at the mid 80% compliancy. We continually try to improve on these figures and regularly contact areas identified in the monthly report on water safety as poor performers. However when there are staff changes or someone is away for a time the performance degenerates. For this reason we encourage all areas to nominate as many primary recipients of the E mail alert as possible (One area reporting on Pseudomonas has sixteen). There can only be one escalation nomination, a senior manager who should take responsibility for reporting if the primary has failed too. From the graph we see May 2015 was a record for escalations. If the system was properly managed locally no escalations should be necessary. We can take some consolation from reports that our compliance record is above average. Month Commencing:

Expected Submitted Compliancy Ratio

01-06-2015 304 263 87% 01-05-2015 Expected Submitted Compliancy

Ratio

812 699 86% 01-04-2015 Expected Submitted Compliancy

Ratio


Ratio


Ratio


Ratio


Ratio


Ratio


Ratio


Ratio



Ratio


Ratio


Ratio

880 720 82% Summary of Water Quality and Safety: The Trust has recognised that for too long insufficient investment had been made in the infrastructure of the estate and its condition was becoming critical. They have now instigated a capital programme to refurbish and upgrade its assets to be fit for purpose in the 21st century. This has many benefits including reducing spend on energy as the new systems are more efficient, reducing our carbon footprint which is a mandatory requirement of the Department of the Environment. The increase in comfort of the patients is a benefit which should result in better outcomes and shorter stays as in patients. All of these mean the reputation of the Hospital, in the local community and nationally is enhanced. Water safety At Kingston hospital is taken seriously. Our proactive organisation of water safety management has seen an overall reduction in the incidence of all types of bacteria proliferating in our water systems as especially during the summer months it is most probably imported, in a benign state, through the mains. We have a dynamic system to monitor and manage our water quality and by attention to the details of the work and proactive supervision the risk represented by all water borne pathogens is kept as low as possible 5.1.8 Medical Gases Committee: (bi-annually) 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. Storage of CD cylinders on the wards has been reviewed with much discussion and negotiation. Funding needs to be agreed to purchase and install wards based brackets and racks. The medical gas policy has been revised, submitted and agreed and will be presented at the compliance and risk committee for ratification.


Operational difficulties were experienced by nursing staff as piped medical gases were not available to all beds, when the ward moved up to the 7th floor. Cylinders of gas were used when required by patients or patients were moved to areas where piped medical gas was available. All efforts should be made in the future to ensure that piped medical gas be available to all patients during temporary ward moves. The external appointed engineer has recently carried out an audit of piped medical gas systems. The report will be presented to the medical gas committee members at the next meeting in August. 6.0 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 6.1 Policy and Procedural documents: Revised policies: Review Date Bomb Threat May 2017 Fire Safety May 2017 Laser Protection Terms of Reference November 2015 Medical Gases Terms of Reference June 2016 Radiation Terms of Reference November 2015 Fire Terms of Reference August 2015 Water Safety Terms of Reference August 2015 Slips, Trips & Falls Policy July 2015 Security Terms of Reference September 2015 Healthcare Clearance Healthcare Workers Policy September 2017 Confined Spaces Policy October 2017 Remote Working Policy December 2017 Asbestos Policy January 2018 Staff Working Remotely & Occasional Homeworking Policy January 2018 Environmental Cleaning Policy January 2018 Pest Control Policy February 2018 Water Safety Policy February 2018 H&S Policy Statement March 2016 Organisational Roles & Responsibilities Policy March 2018 7.0 Training: The main platform for Health and Safety training sessions is currently the mandatory training booklet. The booklet was introduced to enable staff the opportunity to read at their leisure in a suitable time frame. Much work has been carried out in training, however as new staff are employed and existing staff leave, it is continuously being refreshed.


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

Review of 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. 7.0 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:

Storage of CD cylinders on the wards has been reviewed, as there is a risk associated with improper storage and control of stock with this type of cylinder. Action Taken:

Brackets have been agreed to be installed on the wards

Funding needs to be agreed to purchase and install wards based brackets and racks.

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:

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. This has led to a robust process being put in place.


7.5 Security: In light of incident reporting figures being low in the last numbers of years, it was agreed to raise awareness and the importance of reporting amongst staff including ISS staff. Action taken:

In order to enable true and accurate figures in the reporting systems it has been agreed for ISS managers to be given access to the Ulysses reporting system Ulysses.

Identify and resolve missing patient incidents thus improve and reduce the frequency by putting in place more controlled robust process.

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 Staff Incidents & RIDDOR:

Continue to promote incident reporting and management.

Focus on high levels of incidents recorded such as manual handling incidents, Slip, trip and fall incidents, 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. Improve management of incident reports and resolve closure of incident reports across the trust, implementing recommendations and monitor.

3. Increase awareness of staff accident, incident reporting. 4. Implementation of the health and safety action plan. 5. Review increase in Manual Handling incidents in line with trends and benchmark

with other trusts of similar size. 6. Support Implementation of the trust becoming a “no smoking Hospital” 7. Review number of patients absconding and missing from particular areas of trust

under security committee, identify gaps and trends and put in place measures of prevention and control.

8. Review medical gas cylinder control, working with contractors to ensure robust systems are in place adhered to and implemented.

Documents

Part 1 Item: 10.3 29 - Kingston Hospital | Home · Kingston Hospital NHS Foundation Trust -Trust Board – Part 1 – May 2015 ... Sean Barker Fire Safety Advisor 10 12 Janette Barnes