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Health and Safety Manual Riverside Surgery November 19, 2003 0.0 - 1 Riverside Surgery Health and Safety Manual Section no: Page: Version: Date: CONTENTS 0.0 0.0 - 2 2 19/11/03 Contents 1 Why is this important? 1-1 1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 - 1 2 Using the Manual 2.1 Introducing the Sections . . . . . . . . . . . . . . . . . . 2.2 Making it Work . . . . . . . . . . . . . . . . . . . . . . . 2.2.1 Setting it in motion . . . . . . . . . . . . . . . . 2.2.2 Reviewing that it works . . . . . . . . . . . . . . 2.2.3 Using it as an everyday management tool . . . . 2.2.4 Using the Action Checklist . . . . . . . . . . . . 2.3 Making and Using Health and Safety Work Instructions 2.4 The Action Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-1 .2-1 .2-3 .2-3 .2-5 .2-5 .2-5 .2-6 .2-6 3 Policy, Organisation and Responsibilities 3.1 Manual Distribution . . . . . . . . . . . . . . . . . . 3.2 Health and Safety Policy . . . . . . . . . . . . . . . . 3.3 Organisation Chart . . . . . . . . . . . . . . . . . . . 3.4 Responsibilities of Partners . . . . . . . . . . . . . . 3.5 Responsibilities of Designated Responsible Partner . 3.6 Responsibilities of Health and Safety Administrator 3.7 Designation of Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1 - 1 . . . 3.1 - 1 . . . 3.2 - 1 . . . 3.3 - 1 . . . 3.4 - 1 . . . 3.5 - 1 . . . 3.6 - 1 . . . 3.7 - 1 4 Key Control Procedures 4.1 Accident Reporting . . . . . . . . . . 4.2 Autoclaves . . . . . . . . . . . . . . 4.3 Bomb Scares and Letter Bombs . . . 4.4 Chemicals . . . . . . . . . . . . . . . 4.5 Clinical Waste . . . . . . . . . . . . 4.6 Compressors . . . . . . . . . . . . . . 4.7 Cross-Infection, AIDS, HIV . . . . . 4.8 Display Screen Equipment (DSE) . . 4.9 Drugs and Prescription Management 4.10 Fabric and Furnishings . . . . . . . . 4.11 Fire Safety/Evacuation Policy . . . . 4.11.1 The Emergency Controller . . 4.11.2 Registers and Checklists . . . 4.11.3 Fire Training/Drills . . . . . 4.11.4 Equipment Testing . . . . . . 4.11.5 Disabled Persons . . . . . . . 4.11.6 Visitors to the Practice . . . 4.11.7 Floor Plan of Practice . . . . 4.12 First-Aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1 - 1 . . 4.1 - 1 . . 4.2 - 1 . . 4.3 - 1 . . 4.4 - 1 . . 4.5 - 1 . . 4.6 - 1 . . 4.7 - 1 . . 4.8 - 1 . . 4.9 - 1 . . 4.10 - 1 . . 4.11 - 1 . . 4.11 - 3 . . 4.11 - 4 . . 4.11 - 5 . . 4.11 - 6 . . 4.11 - 7 . . 4.11 - 7 . . 4.11 - 9 . . 4.12 - 1 Riverside Surgery Health and Safety Manual Section no: Page: Version: Date: CONTENTS 4.13 4.14 4.15 4.16 4.17 4.18 4.19 4.20 4.21 4.22 4.23 4.24 4.25 4.26 4.27 4.28 4.29 4.30 4.31 4.32 4.33 4.34 4.35 4.36 4.37 4.38 4.39 5 The 5.1 5.2 5.3 Gas Cylinders . . . . . . . . . . . . . . . . Grounds and Car Parks . . . . . . . . . . Health and Safety Committee . . . . . . . Induction into Health and Safety . . . . . Ladders and Step-ladders . . . . . . . . . Lifts . . . . . . . . . . . . . . . . . . . . . Lighting, Heating and Ventilation . . . . . Handling and Lifting . . . . . . . . . . . . Noise . . . . . . . . . . . . . . . . . . . . . Personal Protective Equipment (PPE) . . Radiological Protection . . . . . . . . . . Risk Assessments . . . . . . . . . . . . . . Safety Audits . . . . . . . . . . . . . . . . Safety Information . . . . . . . . . . . . . Safety Inspections . . . . . . . . . . . . . Safety Records . . . . . . . . . . . . . . . Selection and Control of Contractors . . . Smoking . . . . . . . . . . . . . . . . . . . Spillages: Blood, Body Fluids and Sharps Stress . . . . . . . . . . . . . . . . . . . . Substance Abuse and Misuse . . . . . . . Training in Health and Safety . . . . . . . Utilities Safety Policy . . . . . . . . . . . 4.35.1 Electrical Safety Policy . . . . . . 4.35.2 Gas Safety Policy . . . . . . . . . . 4.35.3 Water Safety Policy . . . . . . . . Vehicles . . . . . . . . . . . . . . . . . . . Violence at Work . . . . . . . . . . . . . . Welfare Policy . . . . . . . . . . . . . . . Working Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.0 0.0 - 3 2 19/11/03 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.13 - 1 . 4.14 - 1 . 4.15 - 1 . 4.16 - 1 . 4.17 - 1 . 4.18 - 1 . 4.19 - 1 . 4.20 - 1 . 4.21 - 1 . 4.22 - 1 . 4.23 - 1 . 4.24 - 1 . 4.25 - 1 . 4.26 - 1 . 4.27 - 1 . 4.28 - 1 . 4.29 - 1 . 4.30 - 1 . 4.31 - 1 . 4.32 - 1 . 4.33 - 1 . 4.34 - 1 . 4.35 - 1 . 4.35 - 1 . 4.35 - 3 . 4.35 - 5 . 4.36 - 1 . 4.37 - 1 . 4.38 - 1 . 4.39 - 1 Law and Regulations 5-1 Chemicals (Hazard Information and Packaging for Supply) Regulations 2002 . . 5 - 1 Construction (Design and Management) Regulations 1994 . . . . . . . . . . . . . 5 - 1 Controlled Waste (Registration of Carriers and Seizure of Vehicles) Regulations 1991 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 - 2 5.4 Controlled Waste Regulations 1992 (as amended) . . . . . . . . . . . . . . . . . . 5 - 2 5.5 Control of Asbestos at Work Regulations 2002 . . . . . . . . . . . . . . . . . . . 5 - 2 5.6 Control of Legionellosis HS(G) 1991 . . . . . . . . . . . . . . . . . . . . . . . . . 5 - 2 5.7 Control of Substances Hazardous to Health Regulations 2002 . . . . . . . . . . . 5 - 3 5.8 Electricity at Work Regulations 1989 . . . . . . . . . . . . . . . . . . . . . . . . . 5 - 3 5.9 Environmental Protection Act 1990 . . . . . . . . . . . . . . . . . . . . . . . . . . 5 - 3 5.10 Environmental Protection (Duty of Care) Regulations 1991 (as amended) . . . . 5 - 4 5.11 Fire Certificate (Special Premises) Regulations 1976 . . . . . . . . . . . . . . . . 5 - 4 Riverside Surgery Health and Safety Manual Section no: Page: Version: Date: CONTENTS 0.0 0.0 - 4 2 19/11/03 5.12 Fire Precautions Act 1971 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.13 Fire Precautions (Workplace) Regulations 1997 as amended by Fire Precautions (Workplace) (Amendment) Regulations 1999 . . . . . . . . . . . . . . . . . . . 5.14 Gas Safety (Installation and Use) Regulations 1998 . . . . . . . . . . . . . . . . 5.15 Health and Safety at Work Act 1974 . . . . . . . . . . . . . . . . . . . . . . . . 5.16 Health and Safety (Consultation with Employees) Regulations 1996 . . . . . . . 5.17 Health and Safety (Display Screen Equipment) Regulations 1992 (as amended) 5.18 Health and Safety (First-Aid) Regulations 1981 . . . . . . . . . . . . . . . . . . 5.19 Health and Safety (Information for Employees) Regulations 1989 . . . . . . . . 5.20 Health and Safety (Safety Signs and Signals) Regulations 1996 . . . . . . . . . 5.21 Ionising Radiations Regulations 1999 . . . . . . . . . . . . . . . . . . . . . . . . 5.22 Lifting Operations and Lifting Equipment Regulations 1998 . . . . . . . . . . . 5.23 Management of Health and Safety at Work Regulations 1999 . . . . . . . . . . 5.24 Manual Handling Operations Regulations 1992 (as amended) . . . . . . . . . . 5.25 Noise at Work Regulations 1989 . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.26 Personal Protective Equipment at Work Regulations 1992 (as amended) . . . . 5.27 Pressure Systems Safety Regulations 2000 . . . . . . . . . . . . . . . . . . . . . 5.28 Provision and Use of Work Equipment Regulations 1998 (as amended) . . . . . 5.29 Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.30 Representatives and Safety Committees Regulations 1977 . . . . . . . . . . . . 5.31 Special Waste Regulations 1996 (as amended) . . . . . . . . . . . . . . . . . . . 5.32 Working Time Regulations 1998 (and Amendment Regulation 2002) . . . . . . 5.33 Workplace (Health, Safety and Welfare) Regulations 1992 (as amended) . . . . 6 Further Information and Guidance 6.1 Accident Reporting . . . . . . . . . . . . . . . . . . . . 6.2 Clinical Waste Management . . . . . . . . . . . . . . . 6.3 Request Letter for Hazard Information from Suppliers 6.4 Display Screen Equipment - Summary . . . . . . . . . 6.5 Display Screen Equipment - Self-Assessment Forms . . 6.6 Manual Handling Operations Guidelines . . . . . . . . 6.7 Noise . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.8 Risk Assessments . . . . . . . . . . . . . . . . . . . . . 6.9 Spillages of Body Fluids, Blood and Sharps . . . . . . 6.10 Violence at Work . . . . . . . . . . . . . . . . . . . . . 7 Sample Forms 7.1 Accident Register . . . . . . . . . . . . 7.2 Accident Report Form - Internal . . . 7.3 Accident Report Form - External . . . 7.4 Drugs Management Form . . . . . . . 7.5 Electrical Applicance Checklist . . . . 7.6 Emergency Lighting - Record of Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-4 .5-5 .5-6 .5-6 .5-6 .5-7 .5-7 .5-8 .5-8 .5-8 .5-9 .5-9 . 5 - 10 . 5 - 11 . 5 - 11 . 5 - 12 . 5 - 12 . 5 - 13 . 5 - 13 . 5 - 14 . 5 - 14 . 5 - 15 . . . . . . . . . . 6.1 - 1 . . . 6.1 - 1 . . . 6.2 - 1 . . . 6.3 - 1 . . . 6.4 - 1 . . . 6.5 - 1 . . . 6.6 - 1 . . . 6.7 - 1 . . . 6.8 - 1 . . . 6.9 - 1 . . . 6.10 - 1 . . . . . . 7-1 .7-1 .7-1 .7-1 .7-1 .7-1 .7-1 . . . . . . . . . . . . Riverside Surgery Health and Safety Manual CONTENTS 7.7 7.8 7.9 7.10 7.11 7.12 7.13 7.14 7.15 7.16 7.17 7.18 7.19 7.20 7.21 7.22 7.23 7.24 7.25 7.26 Section no: Page: Version: Date: Fire Alarm System - Record of Tests . . . . . . . . . . . . . . Fire Extinguishers - Record of Tests and Inspections . . . . . Fire Instructions and Drills - Record of When Given . . . . . Gas Appliance Checklist . . . . . . . . . . . . . . . . . . . . . Health and Safety Work Instructions . . . . . . . . . . . . . . Health and Safety Work Instructions - Completed Forms . . . Housekeeping Inspection Report Form . . . . . . . . . . . . . Lifts Inspection Report Form . . . . . . . . . . . . . . . . . . Prescription Management Form . . . . . . . . . . . . . . . . . Pressure and Gas Cylinder Guidelines . . . . . . . . . . . . . Radiographic Equipment and Location . . . . . . . . . . . . . Radiographic Equipment Inspection and Maintenance Report Risk Assessment Hazard Register . . . . . . . . . . . . . . . . Risk Assessment Job Safety Analysis - Completed Example . Risk Assessment Job Safety Analysis . . . . . . . . . . . . . . Safety Audit - Safety Corrective Action Report (SCAR) Form Safety Audit - Inspection Report Form . . . . . . . . . . . . . Safety Audit - Inspection Checklist . . . . . . . . . . . . . . . Staff Personal Training Plan and Record . . . . . . . . . . . . Water Hygiene - Record of Dosing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.0 0.0 - 5 2 19/11/03 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7-1 .7-1 .7-2 .7-2 .7-2 .7-2 .7-2 .7-2 .7-2 .7-2 .7-3 .7-3 .7-3 .7-3 .7-3 .7-3 .7-3 .7-3 . 7.26 - 4 . 7.26 - 4 Riverside Surgery Health and Safety Manual Why is this important? 1 Section no: Page: Version: Date: 1.1 1-1 2 19/11/03 Why is this important? 1.1 Introduction If you employ staff answer these two questions: • Have you an up-to-date and comprehensive Health and Safety Policy document? • Have you carried out a safety risk assessment of the workplace and work tasks? If the answer to either question is ‘no’, then you require to undertake these tasks immediately and this manual will assist you to do it to the required standard. Additionally, if you employ five or more persons, these tasks should be recorded in writing, and again this manual will provide a template to assist you. What if I don’t? You are in breach of your statutory duty and risk being fined - and worse should an accident happen which could have been prevented by carrying out these duties, then there is the more serious risk of heavier penalties, even imprisonment. Your practice could also be the subject of an Improvement Notice, giving you a fixed time to undertake stipulated corrective work, or worse still, a Prohibition Notice which could bring your practice to a halt altogether and, additionally, you could again risk being the subject of a prosecution. In addition to your legal obligation to undertake proper risk assessments, your Insurance Company will expect you to have completed the risk assessments and have introduced appropriate control measures. Failure could lead to higher premiums or even withdrawal of insurance cover, which would in effect mean closure as it is illegal to operate without Employers Liability Insurance cover. While the above reasons in themselves are enough to justify compliance, there is also the far more compelling reason of being a good and caring employer. You would not wish to be responsible in any way for an accident which could result in serious injury or even death to an employee, patient or member of the public visiting your premises. The requirement to have a comprehensive Health and Safety Policy document has been around for nearly thirty years and the requirement to complete risk assessments wherever a potential risk can be identified has been with us for nearly ten years and are therefore not new. This negates any possible defence that you have not had sufficient time to comply. The Government through its “Revitalising Health and Safety” document published in June 2000, in addition to setting new targets for a reduction in accidents, makes many proposals the more pragmatic of which are: Riverside Surgery Health and Safety Manual Why is this important? Section no: Page: Version: Date: 1.1 1-2 2 19/11/03 • changes to the law with a new charge of corporate killing • the ability to bring private prosecutions • a duty on companies to nominate a Director to be responsible for Health and Safety • heavier fines and the use of imprisonment • publication of company accident statistics • companies being convicted of health and safety offences to be named and shamed on the HSE Website • involvement of the insurance industry in the promotion of higher standards Currently HSE have indicated that employers should focus on the risk from trips and slips, musculo-skeletal injuries, internal transport systems and falls from height. These are the areas which have been shown to have the worst record for accidents and injuries. It is vital for general practices to recognise that, in the eyes of the law, they are a business like any other and that partners are employers whether they like it or not. Therefore Health and Safety law must be complied with within general practices. This manual will assist you to comply with your statutory obligations in terms of health and safety. Riverside Surgery Health and Safety Manual Using the Manual 2 Section no: Page: Version: Date: 2.1 2-1 2 19/11/03 Using the Manual 2.1 Introducing the Sections Health and Safety at Work is complex. There are significant laws of the land which must be complied with, numerous regulations - more recently with a European origin - that give substance to the laws, approved codes of practice which we ignore at our peril, guidance notes to help make sense of it all, etc. In addition, professional bodies and trade unions have long had a concern for the health and safety of staff and have themselves added considerably to the literature. It can be even more complex, although it doesn’t have to be, when one considers the various bodies that regulate health and safety. Everyone has heard of the Health and Safety Executive, the advisory and inspection body normally associated with health and safety. However, in practice they share that function with Local Authorities, so that some premises, depending on the nature of the business, will be regulated by the Health and Safety Executive and others by the relevant Local Authority. It is sufficient for the purpose of this manual to be aware that General Practices are regulated by the Health and Safety Executive. In addition, the local Fire Authority is responsible for ensuring that fire regulations are properly observed. Practices will already be aware whether their premises require a Fire Certificate or whether they are exempt. In the unlikely event that this is not known, a call to the local Fire Authority will quickly clarify the matter. The purpose of this Health and Safety Control Manual is to simplify the process without in any way compromising the intricacies of legal demand or the integrity of moral imperative. It is presented in such a way that anyone familiar with the various processes of the business can work through it to ‘customise’ it, i.e. make it personal to that particular business, i.e. general practice. in its specific setting. At the most, this will mean discarding some parts, editing others and, rarely, adding another. The manual has been put together to help you achieve: 1. security within the law; 2. optimum staff safety from work-related injury or disease; and 3. significant potential financial savings. Section 3: Policy, Organisation and Responsibilities The law lays important obligations on employers that are unshirkable and cannot be delegated. There are duties towards their own employees, the employees of others working on Riverside Surgery Health and Safety Manual Using the Manual Section no: Page: Version: Date: 2.2 2-2 2 19/11/03 the premises, and also the general public when on the premises. A few may have conditions, e.g. the employer must ensure that a written health and safety policy is formulated, that it is made clear to staff and that it is in operation, but only if he employs 5 or more staff. Section 3 contains a model policy and highlights the areas where responsibility lies for all employers, e.g. the Partners as employers carry full responsibility for the health and safety of staff and others on the premises, but the Practice Manager may have a delegated responsibility to administer the system and oversee the various procedures. It is strongly recommended that a nominated Partner, representing all the Partners, be responsible for ensuring legal compliance. Section 4: Key Control Procedures An employer has certain legal obligations to meet in terms of health and safety. When an employer has premises, whether purchased or leased, there are further obligations to be met. Also, when an employer has five or more staff, whether full or part-time, there are further legal requirements imposed, as detailed above. This is all apart from the health and safety obligations that relate to the particular business of that employer. Section 4 presents model control procedures relating to the business of being a ‘General Practice’ where the safety obligations are placed on the Partners as employers. Some may not apply to an individual practice, e.g. there may not be a car park or a lift. The model procedures are presented alphabetically for convenience; it would be quite wrong to consider that they are presented in any sort of priority. Section 5: Health and Safety Legislation and References This section presents brief details of the relevant legislation, arranged in alphabetical order. Anyone requiring more detailed description will find a valuable source in the Health and Safety Executive publications. Section 6: Further Information and Guidance Reference is sometimes made in the model procedures to more detailed information and guidance to support the model procedures, e.g. detail about handling and lifting, clinical waste management, risk assessment, etc.; this is provided here. Section 7: Sample Forms Reference is made in the model procedures and elsewhere to recording forms and protocols. Samples are reproduced in this section, which can be used by a Practice as they stand or as models for more personalised forms. Riverside Surgery Health and Safety Manual Using the Manual 2.2 2.2.1 Section no: Page: Version: Date: 2.2 2-3 2 19/11/03 Making it Work Setting it in motion It must be stressed at the outset that implementing any health and safety system - even as helpfully presented as this - cannot be done overnight. Given the everyday work pressure experienced by most staff in general practices, it is recommended that a steady progressive approach is taken to customising, introducing and implementing all the procedures that apply. If it takes six months or even a year to implement ‘good practice’ procedures, this must be preferable to doing nothing at all or simply putting this manual on the shelf and forgetting it. Perhaps a plan of action might start with health and safety policy and responsibilities, and move steadily on through fire policy, first-aid, accidents, utilities safety, manual handling, chemicals, clinical waste management, spillages, etc. Looking through the contents of Sections 3 and 4 will indicate clearly what is in place and what is not. Where procedures do exist, an assessment will highlight the extent to which staff work according to them. Success will only be guaranteed if the model policy and procedures are made ‘personal’ to the specific Practice; experience shows that staff will work according to policy and procedures when: • they are relevant to the everyday tasks of staff • staff feel they have influenced their final shape • the employer’s commitment is obvious throughout • implementing them does not add greatly to workload This should all be borne in mind when customising Sections 3 and 4. Section 3 Using this Section, a Health and Safety Policy Statement can be established, together with a clarity about areas of responsibility throughout the Practice. However, this manual cannot do some things. It cannot ensure that the policy’s words about commitment to staff safety and the intention of establishing safe working practices expressed by the Partners are really genuine - the staff will make their judgements based on experience and will embrace the policy enthusiastically or cynically. It is obvious that the Partners must be fully behind this policy for the staff to take it seriously and even begin the process of feeling that it is their policy also. Riverside Surgery Health and Safety Manual Using the Manual Section no: Page: Version: Date: 2.2 2-4 2 19/11/03 It is pointless having a policy that remains in a filing cabinet. It must be accessible, available, discussed, regularly updated and on display. Only then will it really encourage and inform the development of safe working practices throughout the Practice. The policy and the accompanying ‘responsibility’ documents in Section 3 should be signed and dated appropriately. Who knows when an employer may face a statutory demand to produce it, whether during an investigation by the Health and Safety Executive following an accident or as part of a formal workplace inspection? This is the beginning of ‘getting the paperwork right’ - as well as significantly demonstrating ownership. Section 4 Firstly, there is the need to check out what applies to you, e.g. do you require a Fire Certificate or Exemption, do you have a gas supply, is a lift installed? Then, with those model procedures that do apply to the Practice, make them personal to the Practice, ensuring that any changes you make do not dilute the total safety impact. Many of these obligations are of an ‘absolute’ nature - you either do them or you don’t - you cannot ‘half-do’ them. For example, you either satisfy the fire regulations or you don’t - and you have to! Therefore there is a request at the end of each control procedure for the Health and Safety Administrator (probably the Practice Manager, but it must be clearly established in Section 3 who it is) to state categorically whether the procedure is in place, known to relevant staff and in operation. If the answer is ‘No’, then it must be reported to those responsible, i.e. the Partners; it is for them to determine how the Practice will satisfy the legal requirements. This process is only complete when the answer to every question is ‘Yes’. Even then, regular monitoring and review are necessary (See Section 2.2.2). Reference is made to the legal basis for each procedure. Section 5 contains the relevant detail of each of the legal references, presented in alphabetical order. References are also made to further information and guidance in Section 6 and to sample reporting forms in Section 7. These forms may be copied or modified and arrangements made for appropriate completion, filing and safe-keeping. It cannot be stressed enough how important it is that these procedures relating to general practice are customised to each Practice. However, care should be taken that any changes or modifications do not weaken the safety impact of the procedure. Remember that only those which apply need be included. If a new procedure needs to be added because of a special feature of the Practice, with the example of 40 model control procedures in the manual, this should not be beyond the competence of an interested person within the Practice, even if not a health and safety specialist. Riverside Surgery Health and Safety Manual Using the Manual 2.2.2 Section no: Page: Version: Date: 2.2 2-5 2 19/11/03 Reviewing that it works Regular reviews or audits should be carried out according to the procedure in Section 4.25. This should lead to reassessment of whether the procedures are being operated by staff or, indeed, whether they are still applicable to changing conditions, and also whether they are achieving their aim. If not, the Partners must be made aware of the deficiencies. Also, a review must be made of all accidents recorded in the accident book. This may suggest that procedures need to be modified, new procedures introduced, training offered to staff, etc. It is important to be aware of new procedures, equipment or any other circumstance that increase the risk faced by staff, visiting members of the public, etc. The risk must be assessed and, if necessary, appropriate control procedures worked out, written down and added to the manual over time. The manual must become a ‘living’ document in the life of the Practice. 2.2.3 Using it as an everyday management tool An accessible Health and Safety Control Manual such as this can be of daily use to the staff. For example, a patient may drop a specimen bottle on the waiting room floor, splattering its contents; simply by reference to the contents, immediate access to the relevant procedure is possible - Section 4.31, which in turn will direct the enquirer to further information in Section 6.9 - and the appropriate remedial action can be safely taken without fuss. Obviously this will only work if: 1. staff who are likely to need access to the manual or parts of it have that access; and 2. staff have been informed how to use it. In this way the Health and Safety Control Manual can become a living document within the Practice, rather than something that is lodged in the Practice Manager’s office from one review to the next. 2.2.4 Using the Action Checklist An Action Checklist is presented in the following pages of this Section to support the Health and Safety Administrator (probably the Practice Manager, or the Senior Receptionist in a smaller Practice) to manage the process over time. Completing the Action Checklist must not be used as an alternative to reporting a non-conformance to the Partners but should be used in conjunction with that formal reporting to Partners. It is simply a tool to help maintain Riverside Surgery Health and Safety Manual Using the Manual Section no: Page: Version: Date: 2.4 2-6 2 19/11/03 clarity about where the Practice is in achieving safety. Using the checklist will help the Health and Safety Administrator remain clear about what has been done and what remains to be done, what control measures are required and when it is intended to be in place. 2.3 Making and Using Health and Safety Work Instructions In controlling some hazards in the workplace, specific procedures may call for special precautions, e.g. wearing personal protective equipment, working in pairs, etc. Also, some procedures may not be performed often and staff could easily forget the recommended action, e.g. dealing with a spillage involving body fluids and broken glass. It is recommended that specific health and safety work instruction cards are created as a constant reminder and support to staff. Introducing these cards is a simple mechanism to record the hazard, the risk and the control mechanism, i.e. what could go wrong and how to avoid it. A cards would not normally be prepared for routine professional procedures, e.g. giving an injection. A blank health and safety work instructions card is shown in Section 7.11, with completed examples in Section 7.12. Cards should be filed or located in an appropriate site so that all staff have easy access to them and their contents. 2.4 The Action Checklist The Action Checklist is presented below as an additional tool to support the implementation and auditing processes. A blank form is appended in order that additional procedures needed by a Practice can be added to the list. Download Form: Action Checklist Forms Riverside Surgery Health and Safety Manual Policy, Organisation and Responsibilities 3 Section no: Page: Version: Date: 3.1 3.1 - 1 2 19/11/03 Policy, Organisation and Responsibilities 3.1 Manual Distribution Note Copy Number with the Signature of the Recipient: Recipient - Partner/Title Copy No: Dr P M Tracy Dr J C Barnes Dr I P Coombs Dr K P Hunt - Designated Responsible Partner Julie Larsen - Health and Safety Administrator Julie Larsen - Practice Manager Other Practices may have differing titles which should be inserted opposite the holder’s name. Riverside Surgery Health and Safety Manual Policy, Organisation and Responsibilities 3.2 Section no: Page: Version: Date: 3.2 3.2 - 1 2 19/11/03 Health and Safety Policy Health and Safety at Work Act 1974 Policy Statement for Riverside Surgery The Partners of Riverside Surgery are responsible for the conduct of the business of the Practice. The Health and Safety at Work Act imposes statutory duties on employers and employees. To enable these statutory duties to be carried out, it is the policy of the Riverside Surgery, so far as is reasonably practicable, to ensure that responsibilities for safety and health are assigned, accepted and fulfilled at all levels of the Practice; that all practicable steps are taken to manage the health, safety and welfare of all employees; to assess risks in advance of any significant exposure to them, and to have in place measures to reduce risks to tolerable levels; to conduct the business in such a way that the health and safety of patients and other visitors, such as employees of other companies, while on any premises under our control is not put at risk. 1. It is the intention of the Practice, so far as is reasonably practicable, to ensure that: 1. the working environment of all employees is safe and without risks to health and that adequate provisions are made with regard to the facilities and arrangements for their welfare at work; 2. the provision and maintenance of machines, equipment and systems of work are safe and without risks to the health of employees, patients and other visitors, contractors and any other person who may be affected with regard to any premises or operations under our control; 3. arrangements for use, handling, storage and transport of articles and substances for use at work are safe and without risk to health; 4. adequate information is available with respect to machines and substances used at work detailing the conditions and precautions necessary to ensure that when properly used they will be safe and without risk to health; 5. employees are provided with such instruction, training and supervision as is necessary to secure their health and safety; 6. the Health and Safety Policy will be reviewed and updated as and when it is necessary. Communication of any such changes will be made to all employees. 2. It shall be the duty of all employees at work to ensure: 1. that reasonable steps are taken to safeguard the health and safety of themselves and of other person who may be affected by their acts or omissions at work; 2. co-operation with the Partners so far as is necessary to ensure compliance with any duty or requirement imposed on the employer, or any other person, under any relevant statutory duties. Riverside Surgery Health and Safety Manual Section no: Page: Version: Date: Policy, Organisation and Responsibilities 3.2 3.2 - 2 2 19/11/03 3. The Partners appoint one of their number, Dr K P Hunt, as the Designated Responsible Partner, i.e. the person responsible for health and safety within the Practice, whose particular responsibilities are detailed below. 4. The Partners appoint, Julie Larsen, as the Health and Safety Administrator, with responsibilities detailed below. Adopted by the Partners: Signed Date Dr P M Tracy Dr J C Barnes Dr I P Coombs The Designated Responsible Partner, as in para 3 above: Dr K P Hunt Riverside Surgery Health and Safety Manual Policy, Organisation and Responsibilities 3.3 Section no: Page: Version: Date: 3.3 3.3 - 1 2 19/11/03 Organisation Chart Draw your organisation chart showing line management responsibilities and health and safety responsibilities. Ensure it covers everyone: Partners, Practice Manager, Senior Administrator, Senior Practice Nurse, Receptionists, Secretaries, Practice Nurses, Cleaners, Caretaker, etc. Job titles may vary from Practice to Practice. Please insert more appropriate title if necessary or delete where not applicable. Riverside Surgery Health and Safety Manual Policy, Organisation and Responsibilities 3.4 Section no: Page: Version: Date: 3.4 3.4 - 1 2 19/11/03 Responsibilities of Partners The Partners are responsible for approving the Health and Safety Policy and ensuring the policy is regularly reviewed, with updating as necessary. The Partners will ensure that one of their number is appointed the Designated Responsible Partner for Health and Safety, and will ensure that he or she has access to whatever information, training and resources as may be required to achieve and maintain the Practice’s compliance to health and safety legislation. The Partners will make appropriate arrangements to ensure that the Health and Safety Policy and allied procedures are complied with throughout the Practice. The Partners will ensure that any serious breach of the Health and Safety Policy is investigated. The breach, together with details of its investigation and any subsequent actions, will be reported to the Partners. It will be the responsibility of the Partners to ensure training and information is given to those delegated with responsibility for Health and Safety matters. The Partners will ensure that Health and Safety matters are considered at every Partners’ business meeting. Riverside Surgery Health and Safety Manual Policy, Organisation and Responsibilities 3.5 Section no: Page: Version: Date: 3.5 3.5 - 1 2 19/11/03 Responsibilities of Designated Responsible Partner The Designated Responsible Partner is a nominated Partner and is responsible for: General Ensuring that the objectives of the Health and Safety Policy are fully understood and observed by all levels of management and employees and that the agreed Health and Safety Policy is correctly implemented. Communication Ensuring that adequate communication channels are maintained so that information concerning health and safety matters is communicated. Also, that any health or safety matter of concern to any employee is directed to the responsible manager or to the Partners so that any necessary action can be taken. Responsibilities and Training Delegating responsibilities for health and safety activities to the appropriate staff as identified in the Health and Safety Policies and Procedures. Ensuring that adequate training and instruction is given to enable responsibilities to be met. Consultation with Partners and others Undertaking routine consultation to seek the views of Partners and other persons who will be affected by the Health and Safety Policy and arrangements. Taking those views into account when any significant decision is made influencing the health and safety arrangements of the Practice. Riverside Surgery Health and Safety Manual Policy, Organisation and Responsibilities 3.6 Section no: Page: Version: Date: 3.6 3.6 - 1 2 19/11/03 Responsibilities of Health and Safety Administrator The Health and Safety Administrator is the focal point for the implementation of the Policy and the Procedures and these responsibilities will normally be delegated to the Practice Manager (or to the Senior Receptionist in a smaller Practice). The Health and Safety Administrator is responsible for: General Carrying out those tasks allocated by the Partners or through the Designated Responsible Partner which ensure the proper application of the Health and Safety Policy Implementing the Health and Safety Policies and Procedures within and throughout the Practice Regularly monitoring the Practice’s operations to ensure that the procedures outlined in this document are implemented Ensuring that support is given to the Partners and employees so that the objectives of the Health and Safety Policies and Procedures are met Liaising with the Enforcing Authorities Safety Equipment Ensuring that all safety equipment, personal protective equipment (PPE), fire fighting equipment and first-aid facilities are suitable (fit for the purpose), used, maintained and subject to regular inspection as directed by the policies and procedures Systems of Work Ensuring safe systems of work only are employed in achieving the objectives set for the personnel within the Practice. Correct tools, equipment, means of access and wearing of PPE all contribute to safe systems of work, as does using the correct procedures to carry out the work Communication Ensuring all employees in the Practice receive up-to-date information concerning health and safety matters and any concerns they may raise are addressed, investigated and corrected if possible Accidents Keeping detailed records of all accidents, enabling the identification of any problem area Riverside Surgery Health and Safety Manual Policy, Organisation and Responsibilities Section no: Page: Version: Date: 3.6 3.6 - 2 2 19/11/03 Notifying accidents under RIDDOR where appropriate Monitoring Procedures Ensuring regular statutory inspections of equipment within the Practice are carried out as required Regular monitoring of all accidents to see if procedures require amendment Training Ensuring that all members of the Practice have had sufficient instruction and training to allow them to work in a safe manner irrespective of the task which has to be carried out Safety Meetings Assisting in the organisation of and attending safety meetings Writing the minutes of the previous meeting Reporting on accident statistics covering the interval between safety meetings Riverside Surgery Health and Safety Manual Section no: Page: Version: Date: Policy, Organisation and Responsibilities 3.7 3.7 3.7 - 1 2 19/11/03 Designation of Responsibilities The Partners of Riverside Surgery recognise their obligation as employers under the Health and Safety at Work Act 1974, as summarised in 3.4 above. The Partners designate one of their number, Dr K P Hunt, as the Designated Responsible Partner, with responsibilities as summarised in 3.5 above. The Partners appoint Julie Larsen as the Health and Safety Administrator, with responsibilities as summarised in 3.6 above. Signed Date Dr P M Tracy Dr J C Barnes Dr I P Coombs Signed Dr K P Hunt - Designated Responsible Partner Julie Larsen - Health and Safety Administrator Date Riverside Surgery Health and Safety Manual Key Control Procedures 4 Section no: Page: Version: Date: 4.1 4.1 - 1 2 19/11/03 Key Control Procedures 4.1 Accident Reporting Purpose 1. To ensure that the Partners comply with the duty placed on them by legislation to inform the appropriate authorities of any persons injured at work performed for or on their behalf. 2. To ensure an accurate record of all accidents is kept by the First-Aider in the Accident Register. (See Section 7.1) References 1. Health and Safety at Work Act 1974 (See Section 5.15) 2. Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995 (See Section 5.29) Procedure Important: Refer to Section 6.1 for definitions of injuries, etc., and for reporting procedure under RIDDOR. 1. All accidents involving staff in the course of their work, whether incurred on the premises or outside, must be recorded in the Accident Register, however major or minor in character as indicated above. All dangerous occurrences must also be recorded. (See Section 7.1) A similar recording protocol will apply to members of the public whether on Practice premises or at home, if treatment is being carried out by the Practice. The Health and Safety Administrator shall ensure that such recording is made. 2. This recording should be in a new format accident book complying with the terms of the Data Protection Act 1998. Only authorised persons can have access to the personal and accident details recorded there. 3. All major injuries are reported immediately to the Designated Responsible Partner and the Health and Safety Administrator. Riverside Surgery Health and Safety Manual Section no: Page: Version: Date: Key Control Procedures 4.1 4.1 - 2 2 19/11/03 4. All accidents will be investigated by the Health and Safety Administrator. The written report will include full details of the accident, its cause, its effects, and any recommended changes to work procedures (See Section 7.2). This report will be presented to the Partners. Note:The internal accident report will contain more information and fuller details of the accident than is recorded in the Accident Register; it will also contain the results of any accident investigation with both findings and recommendations. 5. The Health and Safety Administrator, after consultation with the Designated Responsible Partner, will report under RIDDOR those accidents which fall into the criteria specified in the RIDDOR regulations to the Health and Safety Executive, using any of the methods described in Section 6.1. (See Section 7.3) 6. Using the details recorded in the Accident Register, the Health and Safety Administrator will compile a monthly summary collecting and collating these statistics. 7. The treatment of minor illnesses, i.e. the administration of medicine or tablets, must not be carried out by the First-Aider unless specifically trained to do so. 8. The First-Aider can diagnose a transfer to hospital being necessary if this is not immediately obvious. The transfer will be carried out by private car, taxi or ambulance, whichever is thought more expedient at the time, and the injured person should always be accompanied. Check: • Are you satisfied that this procedure is known to relevant staff? Yes/No • Are you satisfied that this procedure operates as above? Yes/No If the answer to any question is ‘NO’, report it immediately to the Partners. Signed Date Riverside Surgery Health and Safety Manual Key Control Procedures 4.2 Section no: Page: Version: Date: 4.2 4.2 - 1 2 19/11/03 Autoclaves Purpose 1. To ensure that daily testing of the equipment is carried out. 2. To ensure that the appropriate examinations, servicing and performance testing are carried out at the required intervals. References 1. Health and Safety at Work Act 1974 (See Section 5.15) 2. Pressure Systems Safety Regulations 2000 (See Section 5.27) 3. Management of Health and Safety at Work Regulations 1999 (See Section 5.23) Procedures 1. The Health and Safety Administrator shall ensure that daily tests are carried out using either an Autoclave Test Strip or similar test material to ensure the working efficiency of the equipment. 2. The Health and Safety Administrator shall ensure that the equipment conforms to BS 3970 Part 4 which requires features such as a double interlock mechanism to prevent the autoclave door from suddenly opening or the lid coming off. 3. The Health and Safety Administrator shall ensure that the equipment is covered by a regular written scheme of examination prepared by a competent person (engineer) for each autoclave. This scheme should also include details of the nature and frequency of the examination required. 4. The competent person shall provide the Health and Safety Administrator with a report on Forms F55 and F55a. Records of all inspections should always be kept. (See Section 7.16) 5. The Health and Safety Administrator shall ensure that the requisite Insurance Certificate is filed and available for inspection. Note:It is important to recognise that inspection for safety reasons is not equivalent to servicing and performance testing. These should be carried out according to the manufacturer’s instructions. Check: Riverside Surgery Health and Safety Manual Section no: Page: Version: Date: Key Control Procedures 4.2 4.2 - 2 2 19/11/03 • Are you satisfied that this procedure is known to relevant staff? Yes/No • Are you satisfied that this procedure operates as above? Yes/No If the answer to any question is ‘NO’, report it immediately to the Partners. Signed Date Riverside Surgery Health and Safety Manual Key Control Procedures 4.3 Section no: Page: Version: Date: 4.3 4.3 - 1 2 19/11/03 Bomb Scares and Letter Bombs Purpose 1. To reduce the possibility of accident at work through wholly external agencies. References 1. Health and Safety at Work Act 1974 (See Section 5.15) 2. Management of Health and Safety at Work Regulations 1999 (See Section 5.23) Procedures 1. Should a warning be received that a bomb is on the premises or should there be a good reason for suspecting that a letter or parcel contains a bomb, then the Practice Manager or a Partner will initiate immediate evacuation procedures - exactly as for a fire (See Section 4.11). 2. Using a telephone system outside the premises, contact the Police and Fire Service. 3. Re-enter the premises only when told to do so by the Emergency Services. Some warning signs that a letter or package may contain an explosive device are: • grease marks on the envelope or wrapping • an unusual odour such as marzipan or machine oil • visible wiring or tin foil, especially if the envelope or package is damaged • the envelope or package may feel very heavy for its size • the weight distribution may be uneven: the contents may be rigid in a flexible envelope • it may have been delivered by hand from an unknown source or posted from an unusual place • if a package, it may have excessive wrapping • there may be poor handwriting, spelling or typing Riverside Surgery Health and Safety Manual Section no: Page: Version: Date: Key Control Procedures 4.3 4.3 - 2 2 19/11/03 • it may be wrongly addressed, or come from an unexpected source • there may be too many stamps for the weight of the package Check: • Are you satisfied that this procedure is known to relevant staff? Yes/No • Are you satisfied that this procedure operates as above? Yes/No If the answer to any question is ‘No’, report it immediately to the Partners. Signed Date Riverside Surgery Health and Safety Manual Key Control Procedures 4.4 Section no: Page: Version: Date: 4.4 4.4 - 1 2 19/11/03 Chemicals Purpose 1. To ensure that the Practice complies with the obligations placed on it by the COSHH regulations. 2. To ensure that control measures minimise risk of exposure of employees to identified hazardous substances. Reference 1. Health and Safety at Work Act 1974 (See Section 5.15) 2. Control of Substances Hazardous to Health Regulations 2002 (See Section 5.7) 3. Chemicals (Hazard Information and Packaging for Supply) Regulations 2002 (See Section 5.1) (Chip Regulations) Procedures 1. A survey of all the chemicals used within the Practice will be undertaken. 2. This survey will be done irrespective of the quantities of chemicals used or stored so that those which are hazardous can be identified. 3. A risk assessment of the use of any hazardous substances will be carried out taking acount of the hazard information sheets supplied by the manufacturer in terms of the Chip regulations. 4. Measures will be taken to control or prevent exposure to identified hazardous substances. 5. The Health and Safety Administrator will monitor the use of control measures as part of inspection and review. 6. The COSHH assessment will be reviewed on a regular basis and particularly when hazard sheets from the manufacturer are changed, as will any control measures that have been put in place or personal protective equipment provided. 7. Employees will be required to assist COSHH procedures: 1. by using control measures when and as required Riverside Surgery Health and Safety Manual Key Control Procedures Section no: Page: Version: Date: 4.4 4.4 - 2 2 19/11/03 2. by reading information on hazards before using chemical substances, remembering that the information on a container label may not be sufficient, when reference should be made to the manufacturer’s data sheet 3. by using tools fit for the purpose 4. by co-operating with the Practice on health and safety programmes 5. by using safe working procedures when doing any job. 8. Employees are encouraged to report anything which they find unusual in the normal course of their job. For example, a burst or leaking container must never be assumed to have been already noticed and reported. 9. The COSHH assessment will be reviewed regularly by the Health and Safety Administrator to ensure it is up to date. This is especially the case if procedures, hazard information sheet or equipment are changed or a new chemical is introduced (see Procedures for Suppliers below). 10. The Health and Safety Administrator will inspect and examine on a regular basis any safety equipment put in place by the Practice in a manner and at intervals recommended by the equipment suppliers or by legislation. Procedures for Suppliers 1. As part of the CHIP regulations, suppliers must provide safety or hazard data sheets on all of their products. These sheets will be requested, if not supplied, for ALL the chemical products used by the Practice (See Section 6.3). 2. The Practice will follow recommended handling procedures, control measures and personal protective equipment (PPE) requirements, as stipulated by the manufacturer/supplier. 3. The hazard data sheets sent by the suppliers will be filed by the Health and Safety Administrator and made available for perusal by all employees and also for use in any emergency situation when the details of the makeup hazards of a particular substance are required. Employees will be informed of any known hazardous chemicals in use in the Practice. 4. A request form for seeking hazard information from suppliers has been prepared for use on occasions when the information has not been forthcoming (Section 6.3). Training 1. All chemicals must be handled with caution, initially assuming there is a potential for harm. Riverside Surgery Health and Safety Manual Section no: Page: Version: Date: Key Control Procedures 4.4 4.4 - 3 2 19/11/03 2. Where special training may be required, the issue and use of chemical substances will be limited to those who have had such training. Check: • Are you satisfied that this procedure is known to relevant staff? Yes/No • Are you satisfied that this procedure operates as above? Yes/No If the answer to any question is ‘NO’, report it immediately to the Partners. Signed Date Riverside Surgery Health and Safety Manual Key Control Procedures 4.5 Section no: Page: Version: Date: 4.5 4.5 - 1 2 19/11/03 Clinical Waste Purpose 1. To ensure that the Practice operates within the legal framework governing the production, handling, storing, internal transportation and disposal of clinical waste. 2. To ensure that control measures are adequate to prevent or control exposure of employees, patients, contractors, visitors and other members of the public to hazardous clinical waste. References 1. Health and Safety at Work Act 1974 (See Section 5.15) 2. Special Waste Regulations 1996 (as amended) (See Section 5.31) 3. Environmental Protection Act 1990 (See Section 5.9) 4. Environmental Protection (Duty of Care) Regulations 1991 (as amended) (See Section 5.10) 5. Controlled Waste (Registration of Carriers and Seizure of Vehicles) Regulations 1991 (See Section 5.3) 6. Controlled Waste Regulations 1992 (as amended) (See Section 5.4) 7. Control of Substances Hazardous to Health Regulations 2002 (See Section 5.7) 8. Management of Health and Safety at Work Regulations 1999 (See Section 5.23) 9. ‘Safe Disposal of Clinical Waste’ (Health Services Advisory Committee) 1992 10. ‘A Code of Practice for the Safe Use and Disposal of Sharps’, BMA 1990 Procedures 1. A senior member of the Practice will be designated the Clinical Waste Control Officer (CWCO) whose function it will be to ensure safe clinical waste management procedures. 2. The CWCO shall: 1. identify all categories of clinical waste normally produced within the Practice, 2. establish a means of segregation, and Riverside Surgery Health and Safety Manual Key Control Procedures Section no: Page: Version: Date: 4.5 4.5 - 2 2 19/11/03 3. ensure the correct specification of containers/enclosures be used. 3. By means of training and information-giving, clinical staff will be fully conversant with the five main categories of clinical waste (Groups A-E) and of their appropriate and respective safe disposal (See Section 6.2). 4. Each treatment area will have the required colour coded containers/bags to ensure segregated safe disposal (See Section 6.2). 5. All containers/bags ready for disposal will be clearly labelled and identified as to the origin of the waste. 6. Internal transportation will be in the form of a dedicated system (dedicated trolley or wheeled container used solely for this purpose) to the storage area. 7. The CWCO shall ensure that: 1. clinical waste is not stored in a manner which may endanger health; 2. storage areas are secure and sited away from general storage areas and from routes used by the public. They should be well-lit, well-ventilated and clearly labelled; 3. collectors, drivers and other handlers are aware of and trained in the nature and risks of the waste being carried; 4. operatives and staff are familiar with the procedures to be taken in the event of spillage or accidents, and that written instructions, safety equipment and protective clothing are provided (See Sections 4.7 and 4.31); 5. ensure that each treatment area and storage area has a supply of Spillage Kits readily available (See Sections 4.31 and 6.9); 6. ensure that the carrier is a registered carrier and that final disposal complies with the regulations regarding the Duty of Care imposed by Section 34 of the Environmental Protection Act 1990 (See Sections 5.9 and 5.10); 7. copies are on file of the carrier’s licence to transport the clinical waste and of the disposal site’s licence to receive it. The Clinical Waste Control Officer is designated: Acknowledged by: CWCO Date: Check: • Is there an appointed and acknowledged Clinical Waste Control Officer? Yes/No Riverside Surgery Health and Safety Manual Section no: Page: Version: Date: Key Control Procedures 4.5 4.5 - 3 2 19/11/03 • Are you satisfied that these procedure are known to relevant staff? Yes/No • Are you satisfied that the procedures operate as above? Yes/No If the answer to any question is ‘NO’, report it immediately to the Partners. Signed Date Riverside Surgery Health and Safety Manual Key Control Procedures 4.6 Section no: Page: Version: Date: 4.6 4.6 - 1 2 19/11/03 Compressors Purpose 1. To ensure that the required testing of the equipment is carried out. 2. To ensure that the appropriate examinations, servicing and performance testing are carried out at the required intervals. References 1. Health and Safety at Work Act 1974 (See Section 5.15) 2. Pressure Equipment Regulations 1999 3. Pressure Systems Safety Regulations 2000 (See Section 5.27) 4. Management of Health and Safety at Work Regulations 1999 (See Section 5.23) Procedures 1. The Health and Safety Administrator shall ensure that the required tests are carried out to ensure the working efficiency of the equipment. 2. The Health and Safety Administrator shall ensure that the equipment is covered by a regular written scheme of examination prepared by a competent person (engineer) for each compressor. This scheme should also include details of the nature and frequency of the examination required. 3. The competent person shall provide the Health and Safety Administrator with a report on Form F59. Records of all inspections should always be kept. (See Section 7.16) 4. The Health and Safety Administrator shall ensure that the requisite Insurance Certificate is filed and available for inspection. Note: It is important to recognise that inspection for safety reasons is not equivalent to servicing and performance testing. These should be carried out according to the manufacturer’s instructions. Check: • Are you satisfied that this procedure is known to relevant staff? Yes/No Riverside Surgery Health and Safety Manual Section no: Page: Version: Date: Key Control Procedures • Are you satisfied that this procedure operates as above? If the answer to any question is ‘NO’, report it immediately to the Partners. Signed Date 4.6 4.6 - 2 2 19/11/03 Yes/No Riverside Surgery Health and Safety Manual Key Control Procedures 4.7 Section no: Page: Version: Date: 4.7 4.7 - 1 2 19/11/03 Cross-Infection, AIDS, HIV Purpose 1. To ensure that basic infection control guidelines are made easily available to and understood by all staff. 2. To ensure that all relevant and current information concerning controls with regard to AIDS and HIV are available and accessible to staff. 3. To ensure that these are reviewed and updated on a regular basis. References 1. Health and Safety at Work Act 1974 (See Section 5.15) 2. Workplace (Health, Safety and Welfare) Regulations 1992 (as amended) (See Section 5.33) 3. Management of Health and Safety at Work Regulations 1999 (See Section 5.23) 4. Guidelines for Clinical Health Workers: Protection against infection with HIV and Hepatitis Viruses (HMSO, 1990) 5. Occupational Exposure to HIV and use of Zidovudine (DoH, 1992) 6. AIDS and the Workplace: A Guide for Employers (HSE, 1992) 7. Gluteraldehyde and You (HSC, 1992) Procedures 1. A risk assessment will establish high, intermediate and low risk items and the appropriate handling procedures. 2. The Partners shall ensure that cross-infection guidelines are produced that include: effective hand hygiene, sterilisation of instruments, before/during/after patient treatment procedures, correct use of protective clothing and gloves, decontamination of equipment, safe handling and disposal of sharps, inoculation accident policy, disposal of clinical waste, care and management of patients with specific infections, e.g. HIV and Hepatitis B, treatment of spillages of blood and body fluids, and safe handling of specimens. Riverside Surgery Health and Safety Manual Section no: Page: Version: Date: Key Control Procedures 4.7 4.7 - 2 2 19/11/03 3. All clinical staff will receive the relevant training/updating concerning the management of cross-infection and AIDS and HIV infection. 4. The Health and Safety Administrator will ensure that the relevant employees understand and comply with the Practice’s stated procedures in these areas and make use of the appropriate control measures when and as required. Check: • Cross-infection guidelines have been produced, staff are aware of them and make use of them in appropriate circumstances? Yes/No • An up-to-date risk assessment has been prepared, together with the appropriate handling procedures? Yes/No • Staff have received the appropriate and up-to-date training in the Practice procedures? Yes/No • Are you satisfied that this procedure operates as above? Yes/No If the answer to any question is ‘NO’, report it immediately to the Partners. Signed Date Riverside Surgery Health and Safety Manual Key Control Procedures 4.8 Section no: Page: Version: Date: 4.8 4.8 - 1 2 19/11/03 Display Screen Equipment (DSE) Purpose 1. To ensure compliance with the legislation. 2. To ensure that none of the staff designated as ‘users’ of DSE will knowingly be subjected to possible hazards associated with such equipment. References 1. Health and Safety at Work Act 1974 (See Section 5.15) 2. Health and Safety (Display Screen Equipment) Regulations 1992 (as amended) (See Section 5.17) 3. Management of Health and Safety at Work Regulations 1999 (See Section 5.23) Procedures 1. All work stations will be examined to assess the risks to the Health and Safety of every user. The intention is to reduce the risks to the lowest possible level. (See Section 6.4) 2. A ‘user’ is considered to be anyone who uses DSE continually for periods in excess of one hour at a time, on a daily basis. 3. To help achieve policy on DSE, each work station will be examined adopting an ergonomic approach to office furniture, office equipment and the immediate work environment relating to the operator. (A set of self-assessment forms to assist this is included in Section 6.5) 4. Users will have their work routines set up such that changes in work activity will reduce the time periods spent operating the DSE. 5. A way of achieving this would be to work at DSE equipment for approximately 50 minutes in any one hour period, then to carry out some other work for the remaining period. This would be repeated every hour. 6. Note that the breaks away from DSE cannot be accumulated to give longer breaks, and a break in this context does not