Title Page

  • Locality

  • Service

  • Location
  • Completed on

  • Date of previous Audit

  • Audit Summary

1. Asbestos Management

  • Is there an up to date asbestos register on site?

  • Is the register easily accessible?

  • Has the Asbestos Containing Material (ACM) been labels correctly?

  • 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)

  • Is there an up to date COSHH folder on site?

  • Does the folder contain an Index, Training record, Inventory of Items, Material Safety Data Sheets (MSDS), Safe Working Practices (SWP), and COSHH Assessments.

  • Are the MSDS's and COSHH Assessments relevant to the substances being used.

  • Are Chemicals in their original containers and marked appropriately?

  • Have staff employed to use COSHH substances been trained in the use and signed the register?

  • 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

  • Is there an up to date Health and Safety poster on site, with correct team contact details

  • Have Managers completed Managing Health and Safety Course? ( all bands 7s and 8s are Mandatory) or completed the 3 yearly update?

  • Do Team/Management meetings cover Health and Safety?<br>

  • Do staff know how to contact their local Health and Safety Advisor or Representative?<br>

  • Are all relevant risk assessments completed? Do they cover the work being undertaken?

  • Are significant risks identified on the Risk Register?

  • Are all identified controls in place? Do they actively reduce the overall level of risk?

  • 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

  • Are clear fire instructions located throughout the workplace?

  • Is there an up to date Fire Risk Assessment in place?

  • Are fire extinguishers appropriately marked and maintained?

  • 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)

  • Are all staff aware of what to do in the event of a fire?

  • Are Fire Wardens clearly identified and responsibilities understood?

  • Have they had a fire Safety inspection within the last year?

  • Are all Fire Safety Induction complete? (Online, Trust Induction, Local Inductions)

  • 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

  • Is there a First Aid Assessment available?

  • Is there the required amount of trained first aides/ appointed persons on the premises?

  • Are designated first aiders / appointed persons names known to all staff and displayed on notices?

  • Is the first Aid box easily accessible to staff?

  • Is the first Aid box fully equipped and regular, documented checks complete?

  • Are RIDDOR requirements (Both trust reporting and HSE requirements)?

  • 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

  • Are all window restrictors in place? (Check a sample of approximately 10%) <br>

  • Is there a risk assessment in place for any restrictors that have been removed?

  • Has the weekly checks been evidenced?

  • Sources of Information
    - DHC Window Restrictor Policy
    - Site window compliance checklist
    - Visual Inspection
    - Information from the site manager

7. Personal alarm management

  • Is there a suitable alarm system in place?

  • Is the system tested regularly and documented as per policy?

  • If PIT alarms in use, do they cover all patient areas?

  • 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

  • Is there a current in date Ligature Management Plan (LMP) in place?

  • Is there a current in date LMP Summary sheet in place?

  • Are collapsible curtain rails in place and in test date?

  • 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

  • Have Manual Handling Tasks been Risk Assessed?

  • Does the staff undertaking Manual Handling tasks have/wear correct PPE?

  • Have staff that undertake Manual Handling recieved suitable and sufficient training to the level required?

  • 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
    -

10. Display Screen Equipment

  • Are staff aware of Trust procedures for eye tests?

  • Is there evidence of risk assessments that have been reviewed every 12 months?

  • Sources of information
    - Display Screen Equipment Policy
    - WASH Reports
    - DSEAssessments
    - Eye test procedures
    - Training records

11. Lone worker arrangements

  • Do staff have access to the policy and supporting guidance?

  • Are there suitable lone working risk assessments in place?

  • Are there escalation procedures in place? Are these formally documented?

  • Are emergency contact details up to date?

  • Are incidents reported?

  • Are staff aware of after incident support that is available?

  • Sources of Information
    - Information from Staff
    - Lone working Policy
    - Lone worker risk assessments
    - Staff safety procedures
    - Incident data

12. Hot surfaces

  • Is there a hot surfaces risk assessment in place?

  • If there are any hot surfaces identified, are controls put in place in a timely manner?

  • Sources of information
    - Visual inspection
    - Prevention of burns and scalds policy
    - Incident data

13. Electrical Safety

  • Is there PAT testing in place and up to date?

  • Are good electricity practices being followed

  • Sources of information
    -

14. Collapsible Rails

  • Are daily checks undertaken?

  • Are 6 monthly checks being undertaken?

  • Are staff aware of the requirements of the policy?

  • Sources of information
    - Policy for the management of collapsible rails
    - Service Stickers
    - Collapsible rail record
    - Information from staff
    - Incident data

  • Is pre-employment screening carried out for all new starters?

15. Latex Management

  • If use of latex is required, are risk assessments carried out for staff and patients identified?

  • Are staff trained and informed on how to manage a patient with a latex allergy?

  • Have powdered gloves been removed from use?

  • Sources of information
    - The Management and use of Latex Policy
    - Incident data

16. Slips, Trips and Falls

  • Are slips, trips and falls assessed?

  • Are slips, trips and falls managed suitably?

  • Are slips, trips and falls incidents recorded and investigated as necessary?

  • Sources of information
    - Slips, trips, and falls policy
    - Risk Assessments
    - Information from Staff
    - Incident data

17. Safe Marking of Equipment

  • Are staff aware of the requirements to identify and remove defective equipment?

  • Sources of information
    - Safe a Marking of Equipment Policy

18. Contractor Management

  • Are Health and Safety inductions complete?

  • Are RAMS available for all works? (Spot check records)

  • For larger projects progress data available which shows safe working?

  • Sources of information
    - Health and Safety Policy
    - Health and Safety Induction Documents
    - Control of Contracts and Contractors Policy
    - Incident data

19. Welfare

  • Are there suitable number of toilets available at site? Are they in a good state of repair?<br>

  • Are there suitable rest areas away from work areas (especially in clinical areas)?

  • Is there enough space in the work environment to carry out work activities?

  • Is there sufficient lighting?

  • Is there sufficient ventilation?

  • Sources of information
    - Welfare Regulations
    - HTMs

20. Dermatitis Prevention

  • Are dermatitis checks carried out?

  • Do managers know what to look for when inspecting hands?

  • Sources of information
    - Prevention and management of dermatitis policy
    - Information from staff managers
    - Information from staff

21. Sharps Management

  • Are the use of sharps avoided as much as reasonably practical?<br>

  • Are sharps bins provided? Not overfilled?

  • Are safer sharps used where possible?<br>

  • Do staff receive proper instruction and training in the safe use, Handling, storage, and disposal of sharps?

  • Are staff who use sharps immunised against hepatitis B?

  • Are staff aware of the procedure for needle stick injuries?

  • Are all needlestick injuries reported?

  • Sources of information
    - Sharp Instruments in Healthcare Policy
    - Training records
    - information from the manager
    - Information from the staff
    - Incident data

22. Smoke free environments

  • Are staff aware of the smoke free environment policy?

  • Are incidents reported?is there a decline in the incidents at site. Or do they remain constant?

  • Are referrals made through to the smoking cessation service?

  • Sources of information
    - Smoke free environment policy
    -Incident data
    -Referral data
    - Information from Managers
    - Information from staff

23. Workplace Assessment of Safety and Health

  • Has a WASH been completed for this location?

  • Are any missing items identified in action plans or on the risk register?

  • Sources of information
    - WASH Policy
    - Risk Register
    - Information from Managers
    - Information from staff

24. Vehicular Use

  • Have Risk assessments been completed where required? And communicated to those affected?

  • Have driver checks been completed?

  • Has trust driver training been completed (where required, e.g mini buses, trailers)?

  • Are Mandatory vehicle checks been completed?

  • 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

25. Falls from Heights

  • Do risk assessments highlight falls from height?

  • Are maintenance checks on windows up to date? (Estates)

  • If any restrictors removed, has the deviation process been followed and documented?

  • 4) Are all window declarations up to date?

26. Use of Mobile Phones

  • Staff understand where it is appropriate to use personal mobile phones?

  • Staff understand where it is okay to use trust or personal mobile phones?

  • Audit Compliance Grade

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