Title Page
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Locality
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Service
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Location
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Completed on
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Date of previous Audit
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Audit Summary
1. Asbestos Management
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Is there an up to date asbestos register on site?
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Is the register easily accessible?
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Has the Asbestos Containing Material (ACM) been labels correctly?
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Sources of information
-Asbestos Register and location list
-DHC Asbestos Management Policy
-HSE Asbestos Essentials
-Visual inspection of labelling
-Estates Asbestos Manager
-Wash Reports
-Incident Reports
2. Control of Substances Hazardous to Health (COSHH)
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Is there an up to date COSHH folder on site?
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Does the folder contain an Index, Training record, Inventory of Items, Material Safety Data Sheets (MSDS), Safe Working Practices (SWP), and COSHH Assessments.
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Are the MSDS's and COSHH Assessments relevant to the substances being used.
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Are Chemicals in their original containers and marked appropriately?
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Have staff employed to use COSHH substances been trained in the use and signed the register?
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Sources of information
- Information from the Site Manager
- Information from Staff
- DHC COSHH Policy
- Site COSHH folder (usually yellow, containing, MSDS, COSHH Assessments, SWPs)
- HSE COSHH Basics
- COSHH Regulations 2002
- WASH Reports
3. Management of Health and Safety
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Is there an up to date Health and Safety poster on site, with correct team contact details
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Have Managers completed Managing Health and Safety Course? ( all bands 7s and 8s are Mandatory) or completed the 3 yearly update?
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Is there an up to date WASH Assessment for all departments covered by this Audit?
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Do Team/Management meetings cover Health and Safety?<br>
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Do staff know how to contact their local Health and Safety Advisor or Representative?<br>
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Are all relevant risk assessments completed? Do they cover the work being undertaken?
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Are significant risks identified on the Risk Register?
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Are all identified controls in place? Do they actively reduce the overall level of risk?
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Sources of information
- Information from Site Managers
- Information from Staff
- Visual Inspection
- Consult Learning and Development
- Certification for Courses
- Management of Health and Safety at Work Regulations 1999
- WASH Reports
- Management/ Team meetings
- Agendas and Minutes from meetings
- Risk Assessments
- Risk Register
- Action Plans
4. Fire Safety
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Are clear fire instructions located throughout the workplace?
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Is there an up to date Fire Risk Assessment in place?
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Are fire extinguishers appropriately marked and maintained?
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Are fire drills or table top exercises carried out at least once a year? (Insert date of last exercise and date of next exercise if known)
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Are all staff aware of what to do in the event of a fire?
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Are Fire Wardens clearly identified and responsibilities understood?
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Have they had a fire Safety inspection within the last year?
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Are all Fire Safety Induction complete? (Online, Trust Induction, Local Inductions)
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Sources of Information
- Visual Inspection
- Information from Site Manager or FSA
- Information from Staff
- Inspect Fire Extinguishers
- Fire evacuation exercise reports
- DHC Fire Policy
- Regulatory Reform (Fire Safety) Order 2005
- HTM 05
- WASH Reports
- Induction Checklists
- Staff Training records
5. First Aid
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Is there a First Aid Assessment available?
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Is there the required amount of trained first aides/ appointed persons on the premises?
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Are designated first aiders / appointed persons names known to all staff and displayed on notices?
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Is the first Aid box easily accessible to staff?
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Is the first Aid box fully equipped and regular, documented checks complete?
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Are RIDDOR requirements (Both trust reporting and HSE requirements)?
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Sources of Information
- DHC First Aid Policy
- HSE First Aid Guidance
- The Health and Safety (First Aid) Regulations 1981
-Information from the Site Manager
- Information from Staff
- WASH Reports
- COSHH Folder
6. Falls (Window) Management
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Are all window restrictors in place? (Check a sample of approximately 10%) <br>
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Is there a risk assessment in place for any restrictors that have been removed?
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Has the weekly checks been evidenced?
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Sources of Information
- DHC Window Restrictor Policy
- Site window compliance checklist
- Visual Inspection
- Information from the site manager
7. Personal alarm management
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Is there a suitable alarm system in place?
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Is the system tested regularly and documented as per policy?
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If PIT alarms in use, do they cover all patient areas?
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Sources of Information
- Information from Site Manager
- Information from Staff
- WASH Reports
- Risk Assessment
- Testing Schedule
- Site Staff Safety Procedures
- Local Induction Records
-DHC Lone Worker Policy
8. Ligature Management
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Is there a current in date Ligature Management Plan (LMP) in place?
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Is there a current in date LMP Summary sheet in place?
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Are collapsible curtain rails in place and in test date?
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Sources of information
- Visual Inspection
- Information from the Site Manager
- Information from the Staff
- Ligature Management Plan (LMP)
- LMP Summary sheet
- Ligature Risk Reduction Policy
- Ligature Management Group
- Reports/ Agendas/ Minutes
9. Moving and Handling
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Have Manual Handling Tasks been Risk Assessed?
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Does the staff undertaking Manual Handling tasks have/wear correct PPE?
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Have staff that undertake Manual Handling recieved suitable and sufficient training to the level required?
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Sources of information
- Visual inspections (including correct footwear and equipment)
- Information from the site manager and staff
- WASH Reports
- Training Records
- Risk Assessments
- Moving and Handling Policy
- Incident Data
- HSE Manual Handling checklists
- Patient Moving and handling risk assessment checklist
- Hoist and sling checklists
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10. Display Screen Equipment
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Are staff aware of Trust procedures for eye tests?
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Is there evidence of risk assessments that have been reviewed every 12 months?
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Sources of information
- Display Screen Equipment Policy
- WASH Reports
- DSEAssessments
- Eye test procedures
- Training records
11. Lone worker arrangements
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Do staff have access to the policy and supporting guidance?
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Are there suitable lone working risk assessments in place?
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Are there escalation procedures in place? Are these formally documented?
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Are emergency contact details up to date?
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Are incidents reported?
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Are staff aware of after incident support that is available?
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Sources of Information
- Information from Staff
- Lone working Policy
- Lone worker risk assessments
- Staff safety procedures
- Incident data
12. Hot surfaces
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Is there a hot surfaces risk assessment in place?
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If there are any hot surfaces identified, are controls put in place in a timely manner?
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Sources of information
- Visual inspection
- Prevention of burns and scalds policy
- Incident data
13. Electrical Safety
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Is there PAT testing in place and up to date?
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Is there any evidence of poor practice? (Daisy chaining etc)
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Sources of information
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14. Collapsible Rails
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Are daily checks undertaken?
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Are 6 monthly checks being undertaken?
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Are staff aware of the requirements of the policy?
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Sources of information
- Policy for the management of collapsible rails
- Service Stickers
- Collapsible rail record
- Information from staff
- Incident data
15. Latex Management
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If use of latex is required, are risk assessments carried out for staff and patients identified?
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Are staff trained and informed on how to manage a patient with a latex allergy?
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Is pre-employment screening carried out for all new starters?
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Have powdered gloves been removed from use?
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Sources of information
- The Management and use of Latex Policy
- Incident data
16. Slips, Trips and Falls
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Are slips, trips and falls assessed?
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Are slips, trips and falls managed suitably?
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Are slips, trips and falls incidents recorded and investigated as necessary?
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Sources of information
- Slips, trips, and falls policy
- Risk Assessments
- Information from Staff
- Incident data
17. Safe Marking of Equipment
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Are staff aware of the requirements to identify and remove defective equipment?
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Sources of information
- Safe a Marking of Equipment Policy
18. Contractor Management
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Are Health and Safety inductions complete?
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Are RAMS available for all works? (Spot check records)
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For larger projects progress data available which shows safe working?
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Sources of information
- Health and Safety Policy
- Health and Safety Induction Documents
- Control of Contracts and Contractors Policy
- Incident data
19. Welfare
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Are there suitable number of toilets available at site? Are they in a good state of repair?<br>
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Are there suitable rest areas away from work areas (especially in clinical areas)?
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Is there enough space in the work environment to carry out work activities?
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Is there sufficient lighting?
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Is there sufficient ventilation?
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Sources of information
- Welfare Regulations
- HTMs
20. Dermatitis Prevention
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Are dermatitis checks carried out?
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Do managers know what to look for when inspecting hands?
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Sources of information
- Prevention and management of dermatitis policy
- Information from staff managers
- Information from staff
21. Sharps Management
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Are the use of sharps avoided as much as reasonably practical?<br>
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Are sharps bins provided? Not overfilled?
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Are safer sharps used where possible?<br>
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Do staff receive proper instruction and training in the safe use, Handling, storage, and disposal of sharps?
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Are staff who use sharps immunised against hepatitis B?
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Are staff aware of the procedure for needle stick injuries?
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Are all needlestick injuries reported?
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Sources of information
- Sharp Instruments in Healthcare Policy
- Training records
- information from the manager
- Information from the staff
- Incident data
22. Smoke free environments
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Are staff aware of the smoke free environment policy?
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Are incidents reported?is there a decline in the incidents at site. Or do they remain constant?
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Are referrals made through to the smoking cessation service?
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Sources of information
- Smoke free environment policy
-Incident data
-Referral data
- Information from Managers
- Information from staff
23. Workplace Assessment of Safety and Health
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Has a WASH been completed for this location?
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Are any missing items identified in action plans or on the risk register?
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Sources of information
- WASH Policy
- Risk Register
- Information from Managers
- Information from staff
24. Vehicular Use
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Have Risk assessments been completed where required? And communicated to those affected?
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Have driver checks been completed?
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Has trust driver training been completed (where required, e.g mini buses, trailers)?
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Are Mandatory vehicle checks been completed?
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Sources of information
- Trust Patient Carrying Vehicle Policy
- Occupational road risk policy
- Information from the manager
- Information from staff
- Weekly checks records
- Driver check documentation -
Audit Compliance Grade