Information
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Document No.
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Audit Title
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Site
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Conducted on
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Prepared by
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Address
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Personnel
Work Health and Safety Policy
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Work Health and Safety Policy
Anglicare have an up to date health and safety policy authorised by the organisation’s Chief Executive Officer, that clearly states health and safety goal to prevent all work-related injuries and illness and a commitment to improving health and safety performance.
Explanation
A meaningful health and safety program depends on commitment from Site Management.
One method of demonstrating Site management’s WHS intent is to clearly display the poster style Work Health & Safety Policy at the entrance to the site and WHS Noticeboard.
Examples of verification
The authorised Work Health & Safety Policy poster is displayed at the entrance to the site, and site WHS Noticeboard. -
Does the site have the Anglicare WHS Policy Poster on display in the front entry?
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Does the site the Anglicare WHS Policy Poster is on display on the site WHS noticeboard?
- Yes
- No
- N/A
Hazard Management
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Identification and Reporting
Hazard identification and reporting by all workers of Anglicare is one of the cornerstones of Anglicare’s WHS Management system and assists in reducing potential risks to workers preventing injuries and accidents.
Explanation
Anglicare views the identification and control of hazards a key element of providing a safe & healthy workplace, and is an essential element of our Workplace Health and Safety Management System. Anglicare is committed to minimising the risk to all staff, volunteers, clients and visitors in the workplace from Workplace injury and illness.
All Managers must integrate the management of hazards associated with work locations and activities under their control within their day-to-day responsibilities. Anglicare requires all workers, both paid and unpaid, to identify potential workplace hazards, and report them to management. The identification and notification of potential hazards is to be performed by all workers, both paid and unpaid, in their daily routine.
Risk Assessment of Hazards
All Hazards reported using the Anglicare Hazard form will be have their risk level assessed to allow prioritising and assessment of risk elimination or reduction analysis.
Explanation
Workers will assess the risks associated with the identified hazards, this should be done in consultation with a Manager/Supervisor and possibly other employees on site. This is a three-step process.
• Consequence - determine how severely it could injure, or how ill it could make someone.
• Likelihood - determine what LIKELY the severity of the consequence could be.
• Score - by lining up the two selected columns, you will score the risk.
Elimination or Control of Risk
All reported hazards will have the risk control measures put into place to eliminate, or reduce the level of risk associated with the hazard, as far as reasonably practicable, using the hierarchy of control.
Explanation
The WHS Legislation requires that all risk associated with hazards must be eliminated or reduced to the lowest level so far as reasonably practicable, using the hierarchy of control. The hierarchy of control is:
1. Elimination
2. Substitution
3. Isolation
4. Engineering Controls
5. Administration Controls
6. Personal Protective Equipment (PPE)
Close out and Review of Controls
All hazards must be closed out by the manger to which they were reported and then reviewed at a later time to ensure controls are being used and no new hazards have been introduced.
Explanation
The manager is to determine the best control option for the hazard, there could be both short-term and long-term controls. Where the controls identified are considered to be of high cost, approval by a higher manager must be sort, however the responsibility to close the hazard remains with the original manager to which the hazard was reported.
The manager must provide feedback to the employee that reported the hazard.
Monitor and Review
Once all the control measures have been put in place, monitor the hazard to ensure that the controls put in place have:
• Eliminated or reduced the risks as anticipated.
• Not introduced any new hazards.
• Is being used by workers.
• Can be used by workers.
All hazards will be reviewed:
• Whenever work practices change.
• Whenever there is a procedure change.
• When new equipment is sourced.
• At regular intervals at least 3 months after controls have been implemented.
Examples of verification
• Documented follow ups form WHS Toolbox talks
• Documented follow up from staff meetings
• Completed Hazard forms
• WHS Toolbox talks
• Staff meetings
• WHS Site Inspections
• Notes from staff Interviews explaining process. -
Have potential hazards been identified and reported by staff using the Anglicare Hazard Report form?
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Are workers aware of the correct process of reporting hazards?
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Have reported hazards have the risk assessed?
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Have workers made recommendations on controls?
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Have reported hazards been closed out by mangement?
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Are control actions reviewed after close out?
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Comments
Hazardous Substance Management
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All hazardous substances that are not a domestically supplied item must be risk assessed and approved by site management before it can be used on any Anglicare site.
Explanation
Prior to hazardous substances being used on an Anglicare worksite, the site management will ensure that all products are risk assessed, and have assessed the current SDS to ensure ability to comply with requirements. All approved hazardous substances will be listed in a site specific Hazardous Substance Register.
All workers and contractors are to:
• Ensure that hazardous substances in use on site are identified, labelled and SDS’s are available and accessible to all personnel;
• Ensure a safe system of work is implemented for working with hazardous substances;
• Ensure that persons who could be exposed are provided with information and training on the hazardous substance;
• Ensure that suitable controls are available to control hazardous substances and are used;
• Ensure PPE is provided to workers as required, and safe work practices are communicated;
• Ensure appropriate storage provisions exist for all hazardous substances;
• Ensure emergency procedures and equipment are in place for hazardous substances and that staff have access to all emergency equipment;
• Ensure that emergency services have access to information on hazardous substances, and
• Where practicable ensure the material with the lowest possible hazard capability that meets the technical requirements for the job will be used.
• All storage and use of hazardous substances will be in accordance with the SDS. All hazardous substances will be stored in their original containers with the label intact at all times.
For all sites that receive the Hazardous Substances under the contract, the Site Manager is required to ensure that they are in receipt of SDS’s for the Hazardous Substance. -
Does the site have SDS' s for hazardous substances purchased from non domestic suppliers used by workerson site?
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Have all non domestic supplied hazardous substances been risk assessed and approved by site management?
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Are workers aware of location of safety information, including SDS's, for hazardius substances used?
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Are hazardous substnces being stored as per manufacturer guidance?
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Comments
WHS Site Inspection
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The regular schedule inspection of the worksite to identify hazards on site is a vital task to be performed by site management.
Explanation
Anglicare views WHS Site inspections as a key component workplace to identify the potential hazards in our workplace. WHS Site inspections are to be carried out every six months by the Site Manager, and include wither a Health & Safety Representative (HSR), WHS Committee Member, or a representative of the workers of the site.
The purpose of the WHS inspection is to identify hazards that may have been overlooked during the regular daily events that occur in the workplace, and utilise the WHS Site Inspection form to help lead the inspecting party to potential problem areas.
The Site Manager is responsible for ensuring the WHS Site Inspection is carried out and must inform the HSR, WHS Committee Member or worker representative of the WHS Site inspections the day before it is to occur.
Consultation with workers is the most important aspect of the inspection process. It enables workers to discuss issues with their Site Management, HSR, WHS Committee Member or worker representative and gain feedback on WHS initiatives. Gaining feedback and advice from workers is important when determining whether policies and procedures are achieving their objectives.
Observation of workers performing their everyday duties provides the Site Management, HSR, WHS Committee Member or worker representative with an understanding of the types of hazards and associated risks that exits. Observation can also indicate deficiencies in the WHS Management System.
Examples of verification
• Site WHS inspection forms -
Are WHS Site Inspections being conducted every 6 months as per schedule?
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Are WHS Site Inspections attended by both site management and HSR/WHS Committee Member or other worker?
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Are Hazard forms completed for hazards identified during site inspections?
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Comments
WHS Incident Report and Investigation
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Incident Reporting
The reporting of all WHS Incidents is a vital part of monitoring how Anglicare is performing on all aspects of WHS, and is key in helping to prevent recurrence in the future.
Explanation
A “WHS incident” is an unplanned event resulting in, or having a potential (i.e. near miss) for injury, illness, damage or other loss.
When there is a WHS incident involving any person or property damage at an Anglicare workplace, or offsite involving an Anglicare staff member whilst in the process of performing the duties, the WHS incident is to be reported at the earliest possible time after the occurrence.
SafeWork NSW Report Requirements
Under the work health and safety (WHS) laws, incidents such as fatalities, serious injuries and illnesses, and dangerous incidents must be notified to SafeWork NSW immediately, and incident records must be kept for five years. It is the responsibility of the site manager where one of these incidents occur to ensure that SafeWork NSW is notified immediately.
The Site Manager responsible for the worksite must also preserve the incident scene until an inspector attends, or directs otherwise. Render assistance, if it is required, and allow police and ambulance officers to fulfil their functions.
Incident Investigation
An investigation into the root cause of a WHS incident will allow Anglicare to prevent recurrences of similar WHS incidents and assist in minimising impact of WHS incidents on our staff, clients, contractor and visitors to our worksites.
Explanation
The objective of the investigation shall be to establish the real cause(s) of the WHS incident, so that corrective action aimed at preventing a recurrence of the event can be implemented.
Investigation must be conducted by an investigative team within 4 weeks of being reported.
The investigative team must consist of:
1. A representative of Site Management
2. A HSR (Health and Safety Representative)/WHS Committee member or other member of staff
It is important to fully understand the sequence of events before any analysis can take place. Only gather the facts that will assist in giving a true overall picture of the incident. The use of pictures, graphs, photos and sketches may also assist in the gathering of factual information with regard to the accident. Witness reports/statements along with reports/statements from the injured parties will further assist those investigating the accident.
The importance of investigating incidents cannot be underestimated. When an incident occurs, it usually indicates that there has been a breakdown in the WHS Management System (WHSMS). Instead of laying blame, we should be looking at why a mistake was made. Was it:
• Inadequate training
• Fatigue
• Inadequate procedures, or
• Inadequate supervision
It is important to ask these questions to ensure that improvements are made to the WHS Management System and to avoid targeting individuals. Blaming or targeting individuals will result in lowered moral and in turn, higher rates of absenteeism.
Incident Close Out Actions
To ensure that the highest level of WHS is maintained, the WHS incident will need to have corrective actions put in place to prevent recurrence include training, changes to process etc.
Explanation
After the root cause has been identified, the manager will put in place corrective actions to reduce the likelihood of a similar incident recurring.
The close out may include:
• Changes to safe work practices, process, policies, etc;
• Additional training for specific or general staff;
• Additional recourses to an area of concern;
• Implementation of new processes, safe work practice, policies, etc;
• General communication to staff, contractor, clients, etc;
Once the corrective actions have been decided they must be implemented in a timely manner. All WHS Incidents must be closed out with 12 weeks of them being reported.
The manager must provide regular feedback to the employee that reported the WHS Incident. This feedback should be in writing, and should include controls being implemented, and if any proposed controls are not to be used with reasoning for decision.
Review of Controls
Once all the control measures have been put in place, monitor the hazard to ensure that the controls put in place have:
• Eliminated or reduced the risks as anticipated.
• Not introduced any new hazards.
• Is being used by workers.
• Can be used by workers.
All hazards will be reviewed:
• Whenever work practices change.
• Whenever there is a procedure change.
• When new equipment is sourced.
• At regular intervals at least 3 months after controls have been implemented.
Examples of verification
• WHS Incident Report and Investigation forms
• SafeWork NSW Reports
• Incident Register
• Witness reports
• Manager notes, drawing, pictures, etc
• Training records
• Amended safe work practices
• WHS Toolbox talks
• Policy or procedure updates
• Staff meetings -
Are WHS incidents being reported by workers as per Anglicare policy?
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Are workers aware of the correct process of reporting incidents, including time frames?
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Have SafeWork NSW reporting requirements been followed?
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Has the root cause been identified by the manager responsible for the reported incidents?
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Have the reported incidents been closed out by the manager responsible?
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Are control actions reviewed after close out?
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Comments
WHS Consultation
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Consultation is Carried out On Site
Anglicare will consult its staff in implementing safe work practices and systems ensuring their health, safety and welfare. Staff involvement at all levels is critical for ensuring a safe workplace.
Explanation
The Health and Safety legislation place a duty to consult on Anglicare. In accordance with this duty, Anglicare will consult with staff to enable staff the opportunity to contribute to the making of decisions affecting their health, safety and welfare at work.
A consultation structure consisting of either:
• Health & Safety Committees
• Health & Safety Representatives (HSR), or
• other agreed arrangements
All sites must have consulted with their workers every 3 years on what method will be used.
Any person on a WHS Committee or HSR must be a volunteer and attend the 2-day WHS Consultation course within 6 months of starting the role.
WHS Committees
Sites that have WHS Committees must ensure that minutes are kept for all meeting, and that the Chairperson is a Worker representative and not a management/Anglicare appointed member.
Examples of verification
• WHS Hazard forms
• WHS Incident Report and Investigation forms
• WHS Toolbox talks
• WHS Site Inspections
• Staff meetings -
Are meetings held with workers at least every 3 months where WHS is a line agenda item?
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Are meeting minutes available for these meetings?
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Are WHS Toolbox talks conducted by site management, workplace trainers, HSR's or WHS Committee Members?
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Does the site have a HSR?
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Was the HSR nominated and wanting to carry out the HSR role?
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Has the HSR undertaken Anglicare 2 day Consultation training?
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Has the HSR undertaken training as per SafeWork NSW guidelines?
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Comments
Safe Work Practices
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WHS Legislation requires anyone in control of the workplace to identify the potential hazards of the proposed work, assess the risks involved and develop controls to eliminate, or reduce the risk to an expectable level.
Anglicare will conduct task analysis’ of all tasks perform by staff and contractors, and develop Safe Work Practices to help maintain a healthy and safe workplace for all.
Explanation
Development of Safe Work Practices (SWP) for all tasks performed by staff across Anglicare is a vital part of Anglicare’s Hazard Management and Health & Safety Management System. Managers are responsible for ensuring that a SWP is developed for all tasks performed by workers.
The development of a SWP requires a task analysis of the task to highlight potential hazards of the task, assess the risk of the hazard, record what controls measures will be used to eliminate or reduce the risk to the lowest possible level, (so far as reasonably practicable). The SWP that is developed from the task analysis will demonstrate that Anglicare understands the risks involved in the work and the typical controls used.
Inline with Health & Safety legislation, all Safe Work Practices will be completed in consultation with staff completing the task, and approved by the Manager. For tasks that are performed by multiple sites or programs, Managers should also consult with other teams to make the process easier, and ensure all hazards, risks and controls have been considered.
Training
The Manager will ensure all Anglicare worker that will perform the task after the development of the SWP, will be trained in the SWP prior to completing the task. All Anglicare workers will sign the SWP that they understand and agree to perform the task as detailed in the SWP.
Examples of verification
• Task Analysis and Safe Work Practice Forms
• Team meeting minutes
• WHS Toolbox talks
• Training records -
Are safe work pratices developed for tasks carried out by workers of the site?
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Are workers trained in developed Safe Work Practices?
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Have workers been consulted during the development of the Safe Work Practices?
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Comments
Emergency Planning
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Anglicare is committed to the implementation of safety practices. Anglicare worksites will ensure that in the event of a bomb or arson threat, fire, intruder, armed hold-up, or any situation that will require the need for a site evacuation to take place, that there will be minimal threat to staff, clients and visitors.
Explanation
An emergency in a building can develop from a number of causes including fire, intruder (armed & unarmed), bomb threat, release of chemical, biological material, gas leakage, structural fault, etc. A prompt and organized response by occupants in such an emergency is essential for the welfare of occupants and for the preservation of Anglicare assets.
Emergency Planning Committee
An Emergency Planning Committee (EPC) must be formed at all sites. The EPC will be made up representatives of occupant groups, building specialist (if applicable), and shall include the Chief Warden. An External consultant may also be used by the EPC.
The EPC is responsible for the development and maintenance of the Emergency Control Organisation (ECO) in accordance with Legislation and Australian Standards.
For Residential Homes, the EPC will consist of the Facility Manager, a trained level 1 FSO and one other staff.
Emergency Control Organisation
All sites will have in place a site-specific ECO, that will facilitate the safe and orderly implementation of the Emergency Planning Processes, including the evacuation of the occupants from the worksite when appropriate.
The ECO is to be a structured group of trained people employed within the worksite who will take command on the declaration of an emergency, pending the arrival of the fire brigade or other emergency service.
Emergency Drill
Emergency drills are a most important part of the staff training associated with emergency procedures. Emergency drills should be carried out at least every yearly.
The Chief Fire Warden is responsible for the planning and implementing of all evacuation drills, and should superintend the drill, record the time required to complete the evacuation, and note any problems and deficiencies.
Some sites may utilise a desk top exercise, where workers will talk and walk through the evacuation process. This will be completed at least once a year and will recording as detailed in the site specific Emergency Management Plans.
Site Evacuation Map
All sites are required to have a Site Evacuation Map, which must be displayed at prominent locations through-out the site. Sites with multiple levels will require a Site Evacuation Map for each floor. Site Management is responsible for ensuring the Site Evacuation Maps are in place.
Maintenance of Site Fire Equipment
Fire equipment is to be located at every Anglicare site as directed by Anglicare’s Fire Safety Consultants. This equipment is to be maintained in line with the recommendation of the Fire Safety Consultants.
Handling Emergencies Manual
All sites will develop a Site Handling Emergencies Manual which will detail all emergency procedures to be followed at that site.
Training Requirements
Chief Fire Wardens are to ensure that all workers under take the relevant training. The requirements are:
• All site staff - Workplace First Response Fire Training.
• ECO Members - Fire Warden & Evacuation Training. This will equip the ECO with the skills required to safely evacuate the workplace.
• Chief Fire Wardens - Chief Fire Wardens Training Course. This will develop skills to ascertain the extent of onsite workplace emergencies and supervise evacuation of the workplace.
Residential Homes
Residential homes are required to comply with NSW Health Guidelines and the Regulations of the Nursing Homes, Private Hospitals and Day Procedure Centres, and specific training is available for staff at these sites. Each site will require a least one trained Level 1 FSO.
Examples of verification
• Site Handling Emergencies Manual
• Emergency Reports
• Emergency drill debrief note, forms, etc
• Training records -
Has the site developed a emergency plan?
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Have relevant staff undertaken training?
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Have emergency drills been conducted at least yearly in line with Anglicare schedule?
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Comments
Safe Home Visits
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Anglicare is committed to providing a work environment that is pleasant for workers to work in and conducive to good workplace relations and includes ensuring that workers can carry out their duties in safety when required to complete home visits.
Explanation
Prior to any worker attending to a Client, their supervisor must ensure that a Client Assessment has been conducted. This assessment must be completed and recorded in the Clients records. Workers must be able to view the Client Assessment prior to conducting the home visit, to allow them to be aware of any potential hazards in relation to the client.
Management must also ensure that any workers working with the Client has adequate skills and competencies to ensure that the safety and well-being of the Client and worker is maintained.
An assessment of the Clients home environment should be undertaken. This assessment must be recorded in the Client records. Part of the home assessment should include an evaluation and development of an Emergency Evacuation Plan for the home.
Workers who conduct a home visit must be able to view the Home Assessment to allow the worker to be aware of any potential hazards and the planned evacuation route as identified by the assessment.
Examples of verification
• Client Profile assessment
• Client home assessment
• Training records -
Are WHS risk assessments carried out on clients homes and viewed by workers prior to visiting the clients home?
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Are client assessments conducted and viewed by workers?
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Comments
Smoke Free Workplace
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With the goal of protecting the health of Anglicare workers and visitors, all site will make all efforts to eliminating exposure to environmental tobacco smoke in and around all Anglicare buildings and facilities, including vehicles, to effect change in smoking culture and practice by staff and clients.
Explanation
Anglicare has a legal obligation to provide a safe and healthy workplace under legislation including The Smoke-free Environment Act 2000 which covers exposure to smoke in public areas. A workplace includes both indoor and outdoor places within sites, as well as Anglicare motor vehicles, and client’s homes during home visits.
A smoke free environment will be maintained in all Anglicare buildings, including Anglicare Offices, all Anglicare vehicles, and lunch rooms. Smoking on Anglicare property will be allowed in designated outdoor areas only, under conditions outlined below.
Designated Smoking areas
If deemed appropriate, Anglicare may allow smoking in designated areas at selected service sites. Site management are responsible for ensuring that when a designated smoking area is required, the area:
Be located 4 metres from any Anglicare building, thoroughfares or access paths, (unless less distance is approved by General Manager);
Every care should be taken to prevent the drift of smoke into workplaces;
Be located away from public areas so there is no impact on either service or visitors;
Is a small area designed for smoking rather than a gathering point for social interaction;
Is sign posted as a designated smoking area;
Is located in a discrete position out of direct view of social areas;
Were possible, have posters up advertising the health risks associated with smoking, and contact details for accessing quit smoking programs, and a copy of this policy, and;
Has ashtrays, sand trays or buckets available for the disposal of cigarette butts and matches;
No smoking signs should also be posted indicating that No Smoking is allowed in areas that might look attractive to clients to smoke, particularly if an area has in the past been used for smoking and is now being moved away from buildings and entrance/pathways under this policy.
Examples of verification
• No smoking on site, unless in designated area
• Designated area located inline with restrictions -
Is the designated smoking area compliant to policy?
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Are no smoking signs posted on site?
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Comments
Maintenance, Repair and Alteration of Plant
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There are procedures for unsafe items and equipment which are identified as unsafe and will allow them to be withdrawn from service. This criterion includes systems such as air conditioning.
Explanation
Procedures should be developed to ensure that workers and others can report items or equipment that appears unsafe and which may be in need of maintenance or replacement.
Once the item is confirmed as unsafe, the procedure should enable the identification and timely removal of the item of plant or equipment from service. Methods of isolation may include using a quarantine area, attaching a locking device, removing the energy source, tagging the equipment etc.
Examples of Verification
• A procedure that includes a reporting mechanism and action for removal of an unsafe item from service.
• Evidence of the use of an identification and isolation procedure on unsafe plant / items.
• Evidence of external organisations that have been contracted to repair damaged or faulty items. -
Have workers on site reported maintenance or replacement issues to management?
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Have issues raised been rectified?
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Comments
Training Needs Analysis
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Training Needs Analysis
The site has identified the health and safety training needs of all personnel.
Members of the executive and senior management need to participate in WHS training, which should include an explanation of legal obligations and health and safety management principles and practices. This should include any volunteer (what to do in an emergency).
Explanation
It is essential that senior management is aware of their legal obligations for health and safety and has an understanding of how to go about meeting those obligations.
The participation of senior management in health and safety training provides them with this knowledge and signals their commitment to improving their management skills in this area.
Examples of verification
• Job descriptions detailing skills / competencies required.
• Task skills matrix showing individual competencies and further training needs.
• Personal development plans for individuals.
• Records of attendance at appropriate health and safety training. -
Are WHS training needs analysis conducted on workers and training planned to meet requirements?
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Comments
Site Induction
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Worker
Relevant and appropriate training is provided to all workers to enable them to perform their tasks without risk to health and safety.
Explanation
The organisation should ensure that workers undertaking specific tasks have the competency required to undertake these safely. This includes new workers and those transferring from another site or department. Safety should be incorporated in all aspects of training, including work procedures. Records of all training should be maintained, including “on the job” training.
The organisation should determine the various task/position competencies and examine what additional training is needed for individual workers to meet those competencies.
Contractor
The site has an induction program for all contractors, which incorporates instruction in the organisation's health and safety policy and procedures. This is to ensure those associated with the organisation are included in the organisations WHS training strategy.
Explanation
All contractors regardless of level or position, should undertake induction in health and safety policy and procedures, emergency procedures, accident reporting, hazard reporting, consultative arrangements applicable to the host PCBU etc. The level of risk associated with the undertaking should determine the extent of training.
Examples of Verification
• Training records that show all workers have had job specific health and safety training.
• Documentation showing the content of the training.
• Documentation setting out the arrangements or induction.
• Documentation that outlines the content of the induction training.
• Records of attendance at induction for all visitors, volunteers and contractors, including those that manages them. -
Are all workers inducted into the site when they first commence work at the site?
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Are contractors inducted onto the site during their first visit?
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Comments
Signature of Auditor
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