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?

Do staff know how to contact their local Health and Safety Advisor or Representative?

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%)

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
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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
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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?

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?

Are sharps bins provided? Not overfilled?

Are safer sharps used where possible?

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

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.