ANNUAL HEALTH AND SAFETY SELF AUDIT

• Date of Audit:

  Date

• Ward/Department:

• Division:

• External Auditor: From another area

  Sign

• Lead Auditor to assist: From within the ward or department

  Sign

1. Procedures/Safe Systems of Work

• Is a copy of the Trust Health and Safety policy Statement from the CEO available in the Health and Safety File?

  Yes

  No

  N/A

• Is a copy of the Division/Service Health and Safety arrangements available in the Health and Safety File or local server and available to staff?

  Yes

  No

  N/A

• Have you instructed staff to read the local arrangements and do they know where to find them?

  Yes

  No

  N/A

• Are staff made aware that the Health and Safety at Work Act 1974 poster is available outside Damers restaurant on the noticeboard and on the noticeboard outside East wing lift - left hand side opposite REI?

  Yes

  No

  N/A

• Are there safe systems of work specific to your work area? Safe Systems of Work are normally the result of an action plan needed to control remaining hazards. If yes! Please list them.

  Yes

  No

  N/A

2. Control of Substances Hazardous to Health (COSHH)

• Are COSHH substances used within the Dept/ward area?

  Yes

  No

  N/A

• Have COSHH assessments been carried out? (Attach the Inventory of COSHH Items/Assessments)

  Yes

  No

  N/A

• Do you have sufficient COSHH assessors? If not why not?

  Yes

  No

  N/A

3. Moving & Handling

• Have Moving & Handling assessments been carried out?

  Yes

  No

  N/A

• Has all staff completed mandatory training?

  Yes

  No

  N/A

• Does your Dept/ward have a Moving & Handling cascade trainer?

  Yes

  No

  N/A

• Do staff receive instruction on slips, trips and fall within the local department? e.g. inspecting the area and ensuring spills are cleaned up immediately?

  Yes

  No

  N/A

4. Display Screen Equipment (DSE)

• Is DSE used in the Dept/Ward area?

  Yes

  No

  N/A

• Have all DSE check lists been completed by those identified as users and are these available at each work station?

  Yes

  No

  N/A

• Do managers understand that if items are identified as insufficient by the check list that action must be taken and the health and safety manager is notified in order to carry out a full DSE assessment?

  Yes

  No

  N/A

• Do all workstations generally comply with the DSE Regulations?

  Yes

  No

  N/A

5. Electrical Safety

• Are visual checks carried out of electrical equipment before use?

  Yes

  No

  N/A

• Is a register of electrical equipment kept?

  Yes

  No

  N/A

• Is Portable Appliance Testing (PAT) in date and regularly checked in accordance with the health and safety inspection regime?

  Yes

  No

  N/A

6. Equipment/Machinery

• Is all equipment/machinery in full working order?

  Yes

  No

  N/A

• Are before use checks carried out?

  Yes

  No

  N/A

• Are records of inspections kept within the dept/ward area?

  Yes

  No

  N/A

• Has staff been trained to use equipment?

  Yes

  No

  N/A

• Are records kept of the training?

  Yes

  No

  N/A

• Are staff aware that they must immediately quarantine faulty equipment to ensure it cannot be used or harm other staff or patients?

  Yes

  No

  N/A

7. Workplace/Welfare Facilities

• Are secure facilities provided for staff possessions?

  Yes

  No

  N/A

• Are washing facilities provided?

  Yes

  No

  N/A

• Are rest breaks provided?

  Yes

  No

  N/A

• Are facilities available for staff to take rest breaks away from the workplace?

  Yes

  No

  N/A

• Are staff hands checked regularly to ensure they have no signs of dermatitis and is this recorded?

  Yes

  No

  N/A

• Do staff have a supply of emollients for hand care available in staff rooms and areas where staff would generally congregate?

  Yes

  No

  N/A

• Are staff regularly reminded they should not bring attractive items into the workplace and that any items they do bring in must be secured and are they informed that a locked changing room is not sufficiently secure?

  Yes

  No

  N/A

8. Emergency Procedures

• Is First Aid available throughout the shift/working day? Areas with registered nurse (must be named e.g. senior sister in Department) can carry out this task. Areas without a registered nurse should have an appropriate staff member qualification in first aid.

  Yes

  No

  N/A

• Is First Aid information clearly displayed?

  Yes

  No

  N/A

• Is a first aid box complete with contents list available? Or a treatment room that has the contents of the box contained therein. The latter must be recognisable with the appropriated green square with a white cross.

  Yes

  No

  N/A

• Are all staff aware of the fire evacuation procedures?

  Yes

  No

  N/A

• Are all staff aware of the procedure in the event of a Improvised Explosive Device (I.E.D) Bomb Policy being identified?

  Yes

  No

  N/A

• Have all staff received their annual Fire Safety training?

  Yes

  No

  N/A

• Are staff aware that they must report all accidents, incidents and near misses via DATIX?

  Yes

  No

  N/A

• Is feedback provided following accident reporting and how do you implement feedback?

  Yes

  No

  N/A

• Do staff know the emergency number 2222 and under what circumstances they can use this?

  Yes

  No

  N/A

• Has a general security/violence & aggression risk assessment and security procedure been carried out for the department?

  Yes

  No

  N/A

• Has your area been identified as higher risk of violence and aggression and subsequently sufficient numbers of staff for each shift been identified for enhanced training beyond CRT? E.g. physical interventions. If it has, how many staff do you have trained?

  Yes

  No

  N/A

• Are appropriate safety signs, posters etc. displayed?

  Yes

  No

  N/A

• Are members of staff expected to work alone? If Yes, what are you undertaking to avoid the situation?

  Yes

  No

  N/A

• Do you have a list of all lone workers?

  Yes

  No

  N/A

• Has the generic risk assessments been adapted for lone workers in your area?

  Yes

  No

  N/A

• Do you have person specific lone worker assessments?

  Yes

  No

  N/A

• Do staff working in the community know how to complete the paper based risk assessment before any visit?

  Yes

  No

  N/A

• Do staff working in the community know how to communicate with their department to confirm their safety on a regular basis?

  Yes

  No

  N/A

• Do staff (where issued) know how to use personal attack alarms?

  Yes

  No

  N/A

• Do staff know how to raise the alarm under general conditions if they are experiencing any difficulty or have concerns regarding violence and aggression?

  Yes

  No

  N/A

9. Communication/Consultation with Employees

• Do you organise monthly dept/ward health and safety meetings?

  Yes

  No

  N/A

• Are all employees able to attend to this meeting?

  Yes

  No

  N/A

• Are all employees aware of the monthly meeting?

  Yes

  No

  N/A

• Are adequate arrangements in place for consultation with employees?

  Yes

  No

  N/A

• Do you ensure all staff receives a briefing on the contents of the meeting if they are unable to attend the meeting in person?

  Yes

  No

  N/A

10. Trust Audit

• Have all action points from the last year’s health and safety audit been completed?

  Yes

  No

  N/A

11. Stress

• Is the department manager aware of the Trusts policy for controlling stress?

  Yes

  No

  N/A

• Does your staff have access to support in relation to stress issues?

  Yes

  No

  N/A

• Have you carried out stress risk assessments?

  Yes

  No

  N/A

12. Risk Assessment

• Is the manager satisfied that all necessary risk assessments have been carried out and included those listed under emergency procedures/lone workers?

  Yes

  No

  N/A

• Are all actions taken as a result of these assessments?

  Yes

  No

  N/A

• Are these risk assessments reviewed annually in date and signed?

  Yes

  No

  N/A

• Are completed assessments kept in the Department (Health and Safety File)? If not please explain why!

  Yes

  No

  N/A

• Does the Dept/ward have competent staff capable of carrying out risk assessments General and COSHH?

  Yes

  No

  N/A

13. Inspections

• Are the Trust health and safety inspections being carried and held in the health and safety file?

  Yes

  No

  N/A

• Ward/Department

• Division

• Date of writing Action Plan

  Date

• Action Plan written by

  Sign
ACTION PLAN

• LOCATION

• ISSUE/ ACTION REQUIRED

• ACTION TO DATE

  Date

• PERSON RESPONSIBLE FOR ACTION

• EXPECTED COMPLETION DATE

  Date

• COMMENTS

DIVISIONS Risk Assessment Register (non-clinical)

• Details of all risk assessments (including COSHH) must be inserted in the risk register, alternately a spread sheet showing current status of risk assessments in the dept/ward can be attached to the audit pack prior to submission. The spread sheet must contain all the headings of the table below. All person specific lone worker assessment must also be inserted in the table below. The register/chart must be signed and dated by the Manager.

• Division/ Dept/ Ward

Assessment

• Assessment Name

• Risk assessment completed

  Yes

  No

  N/A

• Date of initial assessment

  Date

• Action Plan complete

  Yes

  No

  N/A

• Insert the date the risk assessment was reviewed (All reviews must occur annually, therefore no assessment should be out of date beyond I year)

  Date

• Manager's Name and Signature

  Sign

• Date

  Date