Dorset HealthCare NHS Trust - Health and Safety Audit V3

• Locality

• Service

• Location
  Address

• Completed on

  Date

• Date of previous Audit

• Audit Summary

1. Asbestos Management

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

  Yes

  No

  N/A

• Is the register easily accessible?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are Chemicals in their original containers and marked appropriately?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are significant risks identified on the Risk Register?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are fire extinguishers appropriately marked and maintained?

  Yes

  No

  N/A

• 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)

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are Fire Wardens clearly identified and responsibilities understood?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is the first Aid box easily accessible to staff?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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>

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Has the weekly checks been evidenced?

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

• Are there suitable lone working risk assessments in place?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are emergency contact details up to date?

  Yes

  No

  N/A

• Are incidents reported?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

• Are good electricity practices being followed

  Yes

  No

  N/A

• Sources of information
  -

14. Collapsible Rails

• Are daily checks undertaken?

  Yes

  No

  N/A

• Are 6 monthly checks being undertaken?

  Yes

  No

  N/A

• Are staff aware of the requirements of the policy?

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

15. Latex Management

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Have powdered gloves been removed from use?

  Yes

  No

  N/A

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

16. Slips, Trips and Falls

• Are slips, trips and falls assessed?

  Yes

  No

  N/A

• Are slips, trips and falls managed suitably?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

• Sources of information
  - Safe a Marking of Equipment Policy

18. Contractor Management

• Are Health and Safety inductions complete?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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>

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is there sufficient lighting?

  Yes

  No

  N/A

• Is there sufficient ventilation?

  Yes

  No

  N/A

• Sources of information
  - Welfare Regulations
  - HTMs

20. Dermatitis Prevention

• Are dermatitis checks carried out?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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>

  Yes

  No

  N/A

• Are sharps bins provided? Not overfilled?

  Yes

  No

  N/A

• Are safer sharps used where possible?<br>

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are staff who use sharps immunised against hepatitis B?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are all needlestick injuries reported?

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are referrals made through to the smoking cessation service?

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

• Have driver checks been completed?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are Mandatory vehicle checks been completed?

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 4) Are all window declarations up to date?

  Yes

  No

  N/A

26. Use of Mobile Phones

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Audit Compliance Grade