Introduction
This document supports the Organisation’s arrangements for health and safety, as set out in the Health and Safety Policy. The Organisation conducts health and safety risk assessments to assist in controlling health and safety risks.
Scope
This procedure sets out the arrangements for risk assessments relating to health and safety.
Purpose
This procedure seeks to bring clarity and structure to the health and safety risk assessment process, so that appropriate focus and emphasis are targeted at the relevant risks given resource limitations and other practicality considerations. This includes:
- Allowing for a structured approach to the organisation’s health and safety risk assessment process.
- Facilitating the prioritisation of health and safety risk assessments.
- Offering guidance to colleagues on health and safety risk assessment processes.
- Targeting management focus to key and significant health and safety risks.
- Providing a key piece of evidence in litigation cases.
- Ensuring compliance with legislative requirements.
- Fulfilling governance best practice requirements.
- Enabling the identification and ensuing treatment of existing, new and emerging health and safety risks.
Definitions
Colleague – Staff, volunteers, those with honorary contracts and individuals attending incidents on behalf of the organisation.
Hazard – A hazard is anything with the potential to cause harm. In order to manage any risk it is important that hazards are first identified.
Risk – Represents the likelihood of harm occurring.
Risk Assessment – A risk assessment is a careful examination of identified hazards to determine how they could cause harm. The process identifies whether adequate controls are in place and if any further action needs to take place to reduce or mitigate the risk.
Reasonably Practicable – The term reasonably practicable implies that an assessment should be made considering the magnitude of the risks of a particular activity and the cost in terms of the physical burden, time and expenditure to eliminate or minimise those risks.
Risk Measurement and Categorisation Criteria – A risk matrix which is used risk assessment to play the important role of measuring identified hazards and the likelihood for the organisation to effectively prioritise and address risks.
Responsibilities
Chief Executive Officer
The Chief Executive Officer of the organisation has overall responsibility for implementation of this procedure as part of the Organisation’s Health and Safety Policy, ensuring health and safety risks are managed appropriately at all levels in the organisation consistent with regulatory requirements and good practice. This duty is delegated to others within the organisation.
Directors
Directors have delegated responsibility for the management of health and safety, including ensuring that there are suitable and sufficient arrangements and resources for ensuring health and safety risks are reduced to as low as is reasonably practicable. They have the primary responsibility for undertaking suitable and sufficient risk assessments relevant to their directorates. They are required to proactively monitor health and safety risks and the effectiveness of this procedure in relation to their directorates. The requirement to complete risk assessments is further delegated to Heads of Department and Managers.
Managers
Managers have the delegated responsibility for day-to-day management of health and safety risks in their respective areas and are required to appoint relevant and competent managers and/or colleagues within their areas to lead on health and safety risk assessments as they see fit, since they may be more familiar with the subject matter of the risk assessment. They are responsible for:
- Carrying out suitable and sufficient risk assessments relevant to their areas of work.
- Uploading, amending and reviewing of risk assessments uploaded to the Salus3Cloud platform.
- Ensuring health and safety risks are escalated as appropriate, in particular, ensuring any risk assessments scoring 12 or above are escalated to the Risk Management Committee.
- Ensuring colleagues under their jurisdiction are aware of and understand health and safety risks and the control measures in place to protect them.
- Ensuring control measures are implemented to mitigate health and safety risks.
- Ensuring progression and completion of actions assigned to their areas of jurisdiction.
- Regularly monitoring and reviewing the effectiveness of health and safety risk assessments.
Colleagues
Colleagues are responsible for:
- Familiarising themselves with health and safety risk assessments relevant to their area of work.
- Adhering to the risk control measures for all health and safety risk assessments the Organisation has in place as relevant to their circumstances at work.
- Where appropriate, applying the principles of dynamic risk assessment to the tasks/activities they undertake at work to ensure their own and others safety during the conduct of those tasks/activities. Such as in the conducting of tasks during operational incidents, colleagues may have to apply control measures/safe systems of work at the same time and/or quick succession to cope with dynamic nature of the myriad of risks their operational environment and circumstances present.
Health and Safety Team
The Health and Safety Team has the devolved responsibility to monitor the arrangements for health and safety risk assessments in line with the Organisation’s policies and procedures. They will:
- Monitor and administrate the SharePoint platform used for health and safety risk assessments.
- Assist in the review and quality assurance of health and safety risk assessments.
- Guide and advise colleagues and risk owners on health and safety risk assessment matters.
- Facilitate colleague participation and consultation where necessary via the Health and Safety Group.
- Audit compliance with this procedure and provide reports to the Health and Safety Group.
Vehicle Equipment Uniform Working Group (VEUWG)
5.7.1 The VEUWG will ensure risk assessments and safe systems of work are completed as necessary for Organisation vehicles and equipment in accordance with its terms of reference.
Health and Safety Group
The Health and Safety Group is responsible for:
- Monitoring the development and completion of health and safety risk assessments and associated actions.
- Monitoring health and safety risks.
Undertaking a Risk Assessment
Plan the Assessment
Planning the risk assessment involves identifying tasks, objectives, areas, people, etc., on which to undertake the risk assessment. Where possible identification of the relevant statutory requirements that apply and the relevant legal requirements, codes of practice and standards should take place at this stage.
These information sources will assist in identifying any foreseeable hazards. Assessors should also consider any limitations to undertaking the assessment, for example the requirement for additional information, time, need for specialist assistance.
Although it is not a recognised function for Union Safety Representatives to carry out risk assessments, their knowledge and experience for a task or process can be invaluable to the Organisation and the risk assessment process. The Organisation therefore encourages the participation of Union Safety Representatives, where practicable, in that process. As such a risk assessor should, where practicable, ensure that a Safety Representative is invited to assist with the carrying out of an assessment.
Additionally and where practicable, colleagues who carry out, or who may be affected by the activities being assessed should be consulted and involved in the assessment process.
Identify the Hazards
To identify hazards in the workplace:
- Walk around the workplace and look at what could reasonably be expected to cause harm.
- Talk to colleagues – they may have noticed things that are not immediately obvious to the assessor.
- Review accident/ incident records.
- Consider long-term hazards to health (e.g. exposure to noise or harmful substances).
Common workplace hazards include (list not exhaustive):
- Asbestos.
- Equipment and machinery.
- Manual handling.
- Fire safety.
- Harmful substances.
- Noise.
- Workplace transport.
Identify Those at Risk
Identify those who may be exposed to the hazard. Consider all groups, e.g. full/part time colleagues, clinical and non-clinical, patients, contractors, the public and stakeholders. Ensure that consideration is given to vulnerable groups e.g. those with a disability or with language difficulties.
Analyse the Risks and Identify Control Measures
The next step in the risk assessment process is to consider how exposure to a hazard takes place. The following points should be considered:-
- What conditions the exposure to hazards takes place.
- How exposure takes place, e.g. routine, non-routine or deviation from normal operation and emergency exposure.
- The likely consequences of exposure.
In order that the Organisation’s risk exposure can be adequately assessed it is necessary to evaluate how the hazards are being controlled. Examples of controls include:
- The elimination of the hazard by changing the activity, using different equipment or substituting the product for a non-hazardous one.
- Prevent access into the area of work by guarding.
- Organise work to reduce exposure from hazards such as barriers between vehicles and pedestrians.
- Develop policies, procedures and guidelines.
- Training.
- Provision of written information and instructions.
- Supervision.
- Welfare provision facilities such as first aid and washing facilities.
- Personal protective equipment.
When evaluating control measures the following should be considered:
- What existing controls are in place?
- Do the controls comply with legislation?
- Do the controls work in practice, i.e. is further training required?
- Are the existing controls adequate? What more should be in place?
Determine Further Controls
Once inadequately controlled risks have been identified it is necessary to consider how they can be controlled or adequately managed to the lowest possible level.
The hierarchy of control should be implemented in order. Consideration must be given to:
- Elimination – Physically remove the hazard.
- Substitution – Replace the hazard.
- Engineering controls – Isolate people from the hazard.
- Administrative controls – Change the way people work.
- PPE – Protect the worker with equipment.
Document the Findings
The risk assessment should be recorded on the organisation’s Health and Safety Risk Assessment Form. An editable copy of the form can be found on the Risk Assessment section of Salus3cloud’s Document Libary.
The risk assessor must identify and agree who will be responsible for action completion and stipulate a time frame for the action to take place.
Taking into consideration the existing risk controls, calculate the risk rating using the Organisation’s Risk Measurement and Categorisation Criteria. The risk assessor will have to apply a level of judgement when deciding on a risk score, in which the Risk Categorisation Criteria includes a number of indicative descriptors which will help the risk assessor in determining the risk rating.
Governance
Once the risk assessment has been completed, the risk assessor must upload the document to the corresponding Directorate’s folder on the Risk Assessment Sharepoint, completing the information in the required columns in accordance with the Risk Assessment Sharepoint Guide.
Heads of Department and Managers are responsible for monitoring completion and review of risk assessments related to their areas, including ratification of scoring. Any risk assessment scoring 12 or above must be escalated to the Risk Management Committee.
The Health and Safety Team will provide reports to the Health and Safety Group on the status of health and safety risk assessments managed through Sharepoint.
Review and Monitor
It is important that the effectiveness of the control measures implemented are regularly monitored. Such monitoring can occur by considering the outcomes of inspections, audits, incident reporting analysis, etc.
Risk owners must ensure risk assessments are regularly. The frequency of the review period will depend on the level of risk but this will be no later than every 3 years. It may require an earlier review, especially in light of changes, for example new colleagues or equipment, and after a serious untoward incident, accident or near miss has occurred.
Managers are responsible for progressing and monitoring completion of actions.
Inform
Health and safety risk assessments affecting colleagues, work practices and arrangements should be made available to colleagues. Managers must ensure their colleagues are aware of health and safety risks associated with their work and the control measures required.
Training
Training will be delivered in accordance with the Organisation’s Training Needs Analysis. Ad-hoc training can also be delivered by the Health and Safety Team where requested.
Persons undertaking risk assessments will understand the subject of the assessment and knowledge of the best practicable means to reduce any risks identified. It should be remembered that competency does not necessarily require a qualification. A competent person is someone with sufficient training and experience or knowledge and / or other qualities. Any colleague required to undertake risk assessments should proactively identify any training needs and request assistance where necessary to their manager in the first instance.
Monitoring
Managers will monitor the day-to-day application of this procedure through management and monitoring of risks related to their areas of jurisdiction.
Directors will regularly monitor and address health and safety risks relevant to their areas of jurisdiction.
The Health and Safety Group will monitor compliance with this procedure, providing assurance to the People Committee.
Associated Documents
Risk Assessment Teams Channel – User Guide.dotx
Risk Measurement and Categorisation Criteria
Health and Safety Policy
Risk Management Strategy
References
Health and Safety at Work etc. Act 1974
Management of Health and Safety at Work Regulations 1999
Risk assessment: Steps needed to manage risk – HSE