Manual Handling Policy
Transcription
Manual Handling Policy
Manual Handling Policy Reference Number: 801 Author & Title: Mary Chapman Manual Handling Advisor Estates and Facilities Responsible Director: Director of Estates & Facilities Review Date: 13 May 2016 Ratified by: Howard Jones Director of Estates & Facilities Date Ratified: 19 May 2014 Version: 7.2 Related Policies and Guidelines • • • • • • • • • • Mandatory Training Policy Induction Training Policy Medical Equipment Policy Health and Safety Policy Incident Reporting & Management Policy and Procedure Including the Management of Serious Untoward Incidents Resuscitation Policy Strategic Framework for Risk Management Fire Policy Slips Trips and Falls Policy Bariatric / plus sized Patient Management Policy Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 1 of 41 Index: 1. Policy Summary _______________________________________________ 4 2. Definitions of terms used _______________________________________ 5 3. Roles and Responsibilities ______________________________________ 8 3.1 The Trust’s Board will be responsible for:- ____________________________ 8 3.2 Director of Estates and Facilities ____________________________________ 8 3.3 Executive Directors’ Responsibilities ________________________________ 8 3.4 Ward & Department Managers ______________________________________ 8 3.5 Manual Handling Advisor (MHA)____________________________________ 10 3.6 Departmental Manual Handling Trainer ______________________________ 11 3.7 All staff ________________________________________________________ 12 3.8 Safer Staff Group ________________________________________________ 13 4. Training_____________________________________________________ 14 5. Risk assessment _____________________________________________ 15 6. Patient specific mobility risk assessment and care plan _____________ 16 7. Monitoring __________________________________________________ 17 8. Audit Reporting ______________________________________________ 18 9. Trust’s Manual Handling Action Plan_____________________________ 18 10. Archive and Review ___________________________________________ 19 11. Legislation, Codes of Best Practice and references_________________ 19 Appendix 1: How to follow Manual Handling Regulations 1992____________ 20 Appendix 2: Manual handling Techniques ___________________________ 21 Patient handling techniques __________________________________________ 22 Appendix 3: Equipment __________________________________________ 28 Appendix 4: Non-clinical activity specific equipment __________________ 30 Appendix 5: Manual handling TILEE Assessment _____________________ 32 Document Control Information ______________________________________ 39 Ratification Checklist ________________________________________________ 39 Consultation Schedule _______________________________________________ 40 Equality Impact: (A) Assessment Screening ____________________________ 41 Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 2 of 41 Amendment History Issue Status Date Reason for Change Authorised 5 Approved 17 March 2010 Planned Review Health & Safety Committee 6 Draft 7 Approved November 2012 30 April 2013 8 Approved 19/10/13 9 Approved 19 May 2014 Risk assessment section missing from policy which is an NHSLA requirement Amendments to monitoring and audit criteria and revision of audit of compliance document. Amendments to monitoring and auditing process Minor amendments by Mary Chapman Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Howard Jones Ref.: 801 Status: v7.2 Final Page 3 of 41 1. Policy Summary To fulfill its duties under the Manual Handling Operations Regulations 1992, this Trust will avoid all hazardous manual handling operations where reasonably practicable and make a suitable and sufficient assessment of any hazardous manual handling operations that cannot be avoided. The Trust will also reduce the risk of injury from those hazardous manual handling operations so far as is reasonably practicable. For further guidance on this process please see appendix1. This Manual handling policy sets out the standards of best practice for the safe moving and handling of loads, in relation to both patient and non-patient handling, to ensure that the risk of injury to both staff and patients is reduced to the lowest reasonably practicable level. This policy applies to all staff employed by the Royal United Bath NHS Trust including: Clinical and non-clinical staff Sub-contractors, temporary (Bank or Agency) staff Students Volunteers RUH Staff will be required to implement this Policy in all premises that they work in, such as other NHS and non NHS organisations, e.g. Other Acute Trusts, Primary Care Trusts and the organisations that replace them. Royal United Hospital NHS Trust is committed to providing evidenced based care to all patients / clients ensuring that they are treated with dignity and respect. Royal United Hospital NHS Trust is committed to protecting the health and safety of its staff and patients and recognises that safe manual handling practices are fundamental to the prevention of injury and ill health to staff and patients. The Manual handling policy is a key element of the health and safety management system of the Royal United Hospital Bath NHS Trust. Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 4 of 41 2. Definitions of terms used HSE Manual Handling Operations Regulations 1992 (amended 2002) Provision and Use of Work Equipment Regulations (PUWER1998) Lifting Operations and Lifting Equipment Regulations (LOLER 1998) Reporting od Incidents, Diseases or Dangerous Occurrence Regulations (RIDDOR 1995) amended 2012 ‘Task’ based Risk assessment Risk Hazard Manual Handling TILEE assessment Appendix 6 Patient specific mobility risk assessment and care plan Health and Safety Executive. The requirement is to avoid hazardous manual handling operations where reasonably practicable and assess those that could not be avoided. There is also a need to identify, and implement risk reduction methods that are to be used. Health and Safety Executive (HSE) Regulations stating that all equipment provided and used in the course of your employment should be suitable for the task and environment. The equipment should also be inspected prior to its first use and on a regular basis. The regularity of inspection will depend on the device or piece of equipment being used. A record of the inspection report be held and maintained. HSE Regulations stating that all equipment used for lifting a person, whether it is a hoist, a material sling, or lifts in buildings must be inspected by an appropriately competent person every six months. A record of this inspection should be held and maintained. HSE Regulations which stipulate that certain types of incidents, diseases and dangerous occurrences must be reported to the HSE within stipulated time frames. A ‘Task’ based risk assessment involves identifying the hazards associated with a particular task and identifying whether there are adequate and suitable controls in place to protect staff and others from those hazards and from this making an evaluation of the level of risk. If the level of risk has been reduced to the lowest level reasonably practicable then further controls need to be introduced to ensure safety. The likelihood of the hazard being realized and /or staff, patients and others exposed to the hazard. Something with the potential to cause harm, injury, disease or some loss. An assessment that considers the Task, Individual Load, Environment Equipment related to manual handling. This refers to the official patient mobility / manual handling risk assessment and care plan which should stay with the patients notes Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 5 of 41 Dynamic risk assessment Reasonably practicable Posture Non patient handlers Patient Handlers Patients Safe Working Load The load Ergonomics Employees Employer Departmental manual handling trainer Minimal lifting NBE NMC RCN The continuous assessment of risk in the rapidly changing circumstances of an operational incident, in order to identify hazards and controls ( if any) and evaluate risk and where necessary, implement further control measures necessary to ensure an acceptable level of safety. At the earliest opportunity the dynamic risk assessment should be supported by a written risk assessment using the Trust’s designated risk assessment form. Balancing the level of risk against the potential resource input required to complete the activity in order to reduce or remove the risk. Posture is the position in which you hold your body against gravity while standing, sitting or lying down. Good posture involves training your body to stand, walk, sit and lie in position where the least strain is placed on the supporting muscles and ligaments during movement or weight bearing activities. Staff that do not handle patients. Staff that move and handle patients. Refers to an inpatient /out-patient or a deceased patient. The manufacturer's recommended maximum weight load for lifting device or component of a lifting device this will include e.g. hoist and slings. Beds, trolleys, operating tables, X ray plinths and couches this list is an example and may not include equipment in your own area The SWL on any piece of equipment this should never be exceeded Any movable objects including, people and inanimate objects. The means by design which the working environment and working practices are altered to match the individual with aims of reducing the risk of injury Persons working for the Royal United Hospital NHS Bath Trust , including bank and , temporary staff, volunteers, students and staff with honorary contracts Royal United Hospital Bath NHS Trust Refers to a member of staff who has completed a patient handlers / non patient handlers course and has become the ward/ department lead person for updating handling training. This means that although staff may be expected to lift certain loads these must be assessed beforehand and pose no risk to themselves. As such they must undertake an assessment, dynamic or otherwise, in order to remove / reduce the risk to the lowest level. National Back Exchange Nursing and Midwifery Council. Royal College of Nursing. Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 6 of 41 TNA ESR For reporting purposes on Datix, Training Needs Analysis. Electronic Staff Record. • Patient unassisted should relate to incidents where the patient wasn’t able to assist with the incident, such as sedated or unconscious patients. • Patient assisted should relate to patients who have capacity to interact with the procedure and affect its outcome, such as a patient suddenly sitting down whilst mobilising. Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 7 of 41 3. Roles and Responsibilities All staff have a responsibility for ensuring that the principles outlined within this policy are universally applied. This policy applies to all members of staff who are involved in any aspect of manual handling. 3.1 The Trust’s Board will be responsible for:Ensuring appropriate structures are in place to enable the Trust to fulfil its responsibilities with regards the Manual Handling Operations Regulations.1992 Ensuring appropriate structures are in place to effectively implement this policy. Committing those financial, managerial, technological and educational resources necessary to adequately control identified risks from manual handling activities. 3.2 Director of Estates and Facilities The Director of Estates and Facilities has been delegated with the responsibility for health and safety on behalf of the Trust. 3.3 Executive Directors’ Responsibilities Each Director is responsible for the effective implementation of the policy within their respective directorates. Each Director should have an understanding of this policy and the associated arrangements. 3.4 Ward & Department Managers Ward and department managers are required to demonstrate compliance with the implementation of the Manual handling Policy at their individual annual appraisal and objective setting and as part of the health and safety audit programme. Ward and department managers are responsible for: 1. Ensuring that all relevant manual handling risk assessments including ‘Task’ based assessments and Task, Individual Load, Environment Equipment (TILEE) assessments are completed within their area of responsibility and will maintain and complete action Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 8 of 41 plans sending copies of the assessments and action plans to the Manual Handling Advisor. Please see appendix 6 for a copy of the Manual Handling TILEE assessment form. 2. Ensure that, where appropriate, all relevant mobility risk assessments are completed and included in the patient’s care plan. 3. Be directly accountable for managing all manual handling hazards and risks that affect staff, patients and visitors within their sphere of responsibility. 4. Provide staff with access to the necessary information and instruction and training relating to manual handling and provide adequate supervision to enable them to work safely. 5. Ensure that all staff within their sphere of responsibility attend manual handling training 6. Ensuring that all of their staff receive effective training in manual handling. The manager must follow up and manage those who do not attend to ensure compliance. 7. Investigate all manual handling incidents reported by their staff as per the Trust’s Incident reporting system (Datix). As part of their investigation, they should identify causes and put measures in place to prevent a recurrence. They should also complete a post incident risk assessment. This may also involve making other departments within the Trust to implement actions to reduce or prevent re occurrence 8. Report via the incident management reporting system to the Health and Safety team any major or over seven day injuries deemed to be work related in accordance with Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 updated in 2012 For further details on RIDDOR please see information on H&S web page. 9. Assist the Manual Handling Adviser in identification of local department manual handling trainers and support this role within their sphere of responsibility, to enable high standards of compliance with the manual handling policy. 10. Ensure that the manual handling policy assessment of compliance is completed for audit purposes in preparation of an audit. Appendix 5 Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 9 of 41 3.5 Manual Handling Advisor (MHA) The Manual Handling Advisor’s responsibilities are: 1. To produce quarterly reports on manual handling incidents and trends (including incidents reported to the HSE as per RIDDOR; and details of training uptake to the Safer Staff Group who advise the Health and Safety Committee of any significant risks. 2. To review the content of all the manual handling training courses to ensure compliance with current best practice and legislation. 3. To monitor the content of moving and handling training, through regular evaluation and at least annually, to assess the appropriateness of content and relevance to the participants. 4. Upon request, to carry out investigations into reported manual handling incidents and provide a report; and to assist managers with investigations in to reported manual handling incidents. 5. To review the investigations relating to manual handling incidents, in order to provide advice to prevent reoccurrence and to disseminate learning across the Trust. 6. To monitor manual handling incidents including RIDDOR incidents, identifying trends and any areas of risk to the organisation. 7. To advise staff and ward/department managers about appropriate equipment needs and provision. 8. Where appropriate carry out or assist with the carrying out of manual handling risk assessments. 9. To collate ‘task’ based and manual handling (TILEE) risk assessments from department managers. 10. To provide specialist advice to all clinical and non-clinical staff. All clinical and non-clinical staff may access specialist advice by contacting the MHA on Bleep 7157. Ext. 5605 or email [email protected] 11. To advise the Trust on any significant changes in legislation and guidance relative to manual handling. 12. To carry out audits of department. Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 10 of 41 3.6 Departmental Manual Handling Trainer The role of the Department Manual Handling Trainer is: 1. To undertake a manual handling training programme to acquire the necessary skills for the role of Department Manual handling Trainer. 2. To deliver manual handling training in their department and to ensure a record of this training is completed and submitted to the Manual handling Advisor and the Education and Learning Centre. 3. To provide guidance on specific local safe handling techniques, handling aids and equipment including hoists to new staff as part of their departmental induction programme. 4. To ensure all staff within their area are made aware of appropriate and significant changes in regulations, best practice and/or policies and procedures in terms of manual handling. 5. To set a good example of safe manual handling practice at all times and to address and/or report any concerns or bad practice to their line manager and the Manual Handling Advisor. 6. Where appropriate carry out or assist with the carrying out of manual handling TILEE risk assessments Appendix 6 7. To send all completed task based and TILEE risk assessments to the Manual Handling Advisor and Health and Safety Team. 8. To liaise with the Manual Handling Advisor for any advice, via Bleep 7157, Ext. 5605 or email : [email protected] Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 11 of 41 3.7 All staff All staff have a responsibility to: 1. Take reasonable care for their own health and safety and that of others who may be affected by their actions or omissions at work. 2. Attend manual handling training, taking note of the information, instruction and training in manual handling activities relevant to their job role; and attend any appropriate refresher training at regular intervals as stated in the Trust’s training matrix for their specific role. 3. It is the staff members’ responsibility to ensure that they access this training in accordance with the Trust’s training needs analysis Staff must refer to the induction and mandatory training policies on the intranet site: http://webserver/development/mandatory/index.asp to identify what training in relation to manual handling is relevant to their role and identify when training needs to be undertaken 4. Where it’s not possible to carry out a full manual handling TILEE assessment, then they must carry out a dynamic risk assessment before commencing any manual handling tasks using “Task, Individual capability, Load, Environment, Equipment (TILEE) risk assessment” process. 5. Be aware of their individual physical capabilities; endeavour to keep fit and healthy to carry out their duties safely. 6. In the event of any doubt regarding their health, fitness or ability to undertake any form of manual handling, report this to their line manager and consider referral to the appropriate Occupational Health and Safety Service. 7. Only use manual handling equipment aids if they have received formal training from the Manual Handling Advisor or their Department Manual handling Trainer. Staff should only use equipment that they have received training on. 8. Report any manual handling incidents in accordance with the Trust’s Incident reporting system (Datix). 9. Assist and co-operate with any investigations into manual handling incidents 10. Alert their line manager, other staff and visitors if any equipment they are using is identified as faulty and to bring this to the attention of all by clearly labelling and removing the equipment from use until rectified. 11. Must wear appropriate clothing and footwear when carrying out any manual handling tasks. 12. Where appropriate weigh patients and check that the equipment they are assisting or placing the patient onto is able to withstand the patient’s weight. Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 12 of 41 13. Employees should always use the safest practical means of manual handling without compromising the saving of life. 14. Check the safe working / operating load of the equipment and identify whether or not it is suitable for the patient. 3.8 Safer Staff Group The Safer Staff Sub-group is a sub-group of the Health & Safety Committee. It is responsible for: 1. Reviewing the Manual Handling Advisor’s manual handling report every quarter, identifying areas of non-compliance. 2. Identifying required actions to achieve compliance and assessing the implications of these actions for the Trust. 3. Identifying these actions to the accountable organisational lead and their Executive Director. Wherever possible this should be via the relevant sub-group member. 4. Identifying any significant risks and reporting these to the Health & Safety Committee. Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 13 of 41 4. Training 4.1 All staff that may be required to undertake manual handling operations that may cause injury will be provided with appropriate information, instruction and training, and, where necessary, will be supervised when carrying out manual handling tasks. 4.2 Once training has been provided it will then need to be refreshed or updated on a regular basis. It is the staff members’ responsibility to ensure that they access this training in accordance with the Trust’s training needs analysis. 4.3 Training should enable employees to: a. Recognise potentially hazardous handling activities. b. Gain a clear understanding of why they should avoid or modify operations, where possible, making full use of appropriate equipment and good handling techniques. 4.4 The syllabus for manual handling training meets the requirements of the Strategic Health Authority approved Cheshire and Merseyside core skills framework. 4.5 Manual handling techniques change, therefore manual handling techniques specific for the relevant work area at that time are the basis of any teaching session and the emphasis is on risk assessment. 4.6 The Mandatory Training policy identifies how training non-attendance will be followed up and managed and is available on the intranet at http://www.ruh.nhs.uk/about/policies/documents/non_clinical_policies/black_hr/HR _148.pdf 4.7 The departmental manual handling trainer will record all attendance and notify the Education and Learning Centre for central recording on ESR. A copy of all manual handling training records must also be sent to the Manual handling Advisor. Failure to ensure attendance records are sent to the Education and Learning Centre will mean that individual and ward records are not compliant The process for documenting manual handling training is available on the Trust’s manual handling intranet pages. 4.8 All specialist personnel (i.e. Physiotherapists, Occupational Therapists and other Professionals Allied to Medicine) must endeavour to keep professionally updated in their specialist handling techniques as deemed appropriate by their individual governing bodies, etc. In addition to this, they must adhere, so far as is reasonably practicable; to the Royal United Hospital Bath NHS Trust core manual handling principles. Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 14 of 41 5. Risk assessment 5.1. ‘Task’ based risk assessments and manual handling(TILEE) assessments need to be conducted to ensure that all day to day activities and other foreseeable eventualities are planned for to ensure safe working practice and environment. When carrying out a manual handling TILEE assessment the following should be consider: a. b. c. d. e. Task Individual capability Load / Logic Environment Equipment 5.2. The procedure should be in accordance with the Manual Handling Operations regulations 1991.line with the guidelines of Health and Safety legislation and guidance including MHOR1992, and in accordance with the Trust’s Strategic Framework for Risk Management and Health and Safety Policy. 5.3. Once the assessment has been made, then written action plans should be produced, recorded and implemented as soon as is practicable. 5.4. The minimum requirement to review risk is annually, however there may be occasions when this is done more frequently i.e. when there are significant changes to the environment or new equipment or working practices are implemented; and or following incidents. 5.5. The undertaking of the assessments is the responsibility of the departmental/ward/line manager. The manual handling TILEE proforma is on Appendix 5 and further advice is available from the Manual Handling Advisor. 5.6. Where it is not possible to carry out a full manual handling TILEE risk assessment, then a dynamic risk assessment must be carried out when carrying out any manual handling activity. When doing this staff should consider task, individual capability, load, environment and equipment. Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 15 of 41 6. Patient specific mobility risk assessment and care plan 6.1 Patients’ admitted to the Trust will have initial nursing risk assessments carried out within six hours of admission. If the patient has been identified as having an existing or new mobility problem or is unable to stand, is immobile or assistance is required to mobilise then a full patient mobility and fall’s risk assessment and plan of care must be completed. 6.2 Patient specific mobility assessments must be completed for any individual patient/client who requires handling and where there are any specific safety issues to address. To ensure a seamless approach for handling these patients the mobility risk assessment and action plan to reduce risk must be recorded on the Trust’s designated forms. 6.3 The Mobility Risk Assessment /Care Plan must be used and are available from stores order number 1WRU108. 6.4 Once the assessment has been undertaken and the action plan developed, the action plan must be implemented as soon as practicably feasible and the full assessment retained within the patient’s health records. 6.5 The live loads assessment should be reviewed every three days, as a minimum, or if the patient’s condition or environment changes. 6.6 Planning for a possible emergency or unforeseen event should be undertaken wherever possible. 6.7 A seamless approach to patient handling requires the patient specific Mobility Risk Assessment and Care Plan to be transferred with the patient’s notes for any interdepartmental transfers for investigations and treatments. 6.8 Where it is not possible to carry out a written risk assessment beforehand then a dynamic risk assessment must be carried out for every activity. Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 16 of 41 7. Monitoring 7.1 The Safer Staff Group receive a quarterly report from the Manual Handling Advisor which include details on the following this will report on: • All Datix incidents relating to employees who are not adopting the agreed techniques for manual handling of patients and objects, whether or not injury occurred. :- Patient unassisted should relate to incidents where the patient wasn’t able to assist with the incident, such as sedated or unconscious patients. Patient assisted should relate to patients who have capacity to interact with the procedure and affect its outcome, such as a patient suddenly sitting down whilst mobilising. • The number and type of requests relating to the Manual handling Advisor being asked to provide specific advice re moving and handling of load and patients. • The manual handling ‘task’ based risk assessments and manual handling TILEE assessments completed and submitted to the MHA and share any learning points from the risk assessments with the group • Report on progress of action plans resulting from task based risk assessments /TILEE assessments and ensure these are monitored and followed up. • Number of manual handling incidents in each quarter and correlation against the previous 12 months. • Review and investigate any trends that are identified from review of Datix incidents. • Manual handling incidents that have been reported to the Health and Safety Executive in accordance with RIDDOR. Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 17 of 41 8. Audit Reporting 8.1 The Manual Handling Advisor will carry out a variety of manual handling audits to show how the policy is being implemented. The manual handling assessment of compliance will be used to audit a department. A report on the audit will be shared with relevant manager and a copy sent to their senior line manager. A summary of these reports will also be included in the Manual Handling Advisor’s report to the Safer Staff Group. 8.2 Moving and handling audit of risk assessment, mobility risk assessment/ care plans, incident reports, training figures, moving and handling department trainer/s will be conducted every three years in all in patient, out- patient and support services areas. 8.3 Based on risk profile and type of manual handling high risk areas such as Emergency Department will be reviewed annually. This is based on known risk profile and incident reporting /lack of incident reporting trends. 8.4 Audits will take place when sickness data relating to work related musculoskeletal disorders is above 1% over the previous three month period data set and when a significant number of manual handling incidents have happened in one area over a specific period of time. An investigation will be carried out when sickness data relating to WRMSD is a)-1% increase over previous quarter b) – An increased number of MH incidents are reported by one ward /department within a 3 month period. 9. Trust’s Manual Handling Action Plan 9.1 The Manual Handling Advisor will, working with their manager, devise an annual manual handling Action plan. To include risk assessment development and progress with the audit program. 9.2 Actions from the manual handling reports that have strategic importance will be transferred to the Trust Risk Register and may become part of the manual handling action plan which the Manual Handling Advisor will share with the Health and Safety Committee at the time of submission. 9.3 All identified responsible persons will be required to provide assurances that recommendations and actions have been implemented. Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 18 of 41 10. Archive and Review This document will be reviewed every three years and updated in line with the Trust procedure. 11. Legislation, Codes of Best Practice and references This Manual handling Policy has been produced to take into account the requirements of the: • • • • • • • • • Health & Safety at Work Act 1974 Equality Act 2010 Management of Health and Safety at Work Regulations 1999 Manual Handling Operations Regulations 1992 ( amended 2002) The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (amended 2012) Provision and use of Work Equipment Regulations 1998 Lifting Operations and Lifting Equipment Regulations 1996 Care Standards Act 2000 Human Rights Act 1998 The Royal United Hospital Bath NHS Trust promotes a minimal lifting policy in line with the following Agencies and Codes of Best Practice: • • • • • • • • • • • • • • • • • • • The Health and Safety Executive (HSE) Manual Handling Operations Regulations 1992 amended 2002 http://www.opsi.gov.uk/ACTS/acts1990/ukpga_ 19900019_en_1 www.hse.gov.uk/legislation/hswa.htm http://www.hse.gov.uk/pubns/indg291.pdf The Provision and Use of Work Equipment Regulations 1998 Health and Safety Executive 1998 Simple guide to the Lifting The Chartered Society of Physiotherapy (CSP) A guide to Manual handling in Physiotherapy 2008 The College of Occupational Therapy (COT) The Management of Health, Safety and Welfare issues for NHS staff .2005 The National Back Exchange (NBE) The Guide to Handling of People (HOP6) 2011 Standards In Manual Handling third edition 2010 Derbyshire Inter Agency Group Code of Practice 2011 Manual Handling of Children Volume 2 2011 Manual handling people and illustrated guide by Sue Ruszala 2010 Moving and Handling of Plus Size People NBE 2013 Safer Moving and Handling in the Perioperative Environment NBE 2014 Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 19 of 41 Appendix 1: How to follow Manual Handling Regulations 1992 HOW TO FOLLOW MANUAL HANDLING REGULATIONS 1992 REGULATION 2 (1) Do the regulations apply – i.e. does the work involve Manual Handling operations? No Yes REGULATION 4 (1) (a) Is there a risk of injury? No Yes/Possibly Is it reasonable practicable to avoid moving the loads Yes No Is it reasonably practicable to automate or mechanise the operations? Yes Does some risk of manual handling injury remain? No No REGULATION 4 Carry out risk assessment Yes/Possibly REGULATION 4 Determine measures to reduce risk of injury to the lowest level practicable Implement the measures Yes Is the risk of injury significantly reduced? No End of initial exercise Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 20 of 41 Review if conditions change significantly REGULATION 4 (2) Appendix 2: Manual handling Techniques Non patient handling practices The nature, type and frequency of moving and handling activities undertaken the risks of injury to staff may be considerable and need to be minimised, manual handling techniques specific for the work area at that time are taught. The emphasis is on ‘Task’ based risk assessment and manual handling Task Individual capability Load Environment, Equipment (TILEE) assessments; and, if these types of assessments cannot be carried out because of circumstances, then a dynamic assessment should be carried out. However, during training there is an introduction to anatomy and physiology, causes and prevention of back pain/injury with a practical element of manual handling nonlive loads using base movement (ergonomic working posture). This next section will give some practical ideas for reducing the amount of effort needed to complete some everyday task’. e.g:• Kinetic lifting/ adoption of base movement (ergonomic working posture) with your spine in line and with flexed hips and knees. • Only filling refuse/clinical waste bins 1/3rd full (to avoid spillage) • Only filling linen bags 1/3full • Use of mechanical aids to move larger objects If appropriate aids are not available to move larger objects then suppliers should be called in to move the load. • If Roll Cages are moved and being pushed then the cage should be 2/3 full only. Only one at a time pushed using two hands over a short distance of 20 metres otherwise they should be towed or power driven. If being pushed in busy areas a ‘safety spotter’ or a ‘second person’ must assist to prevent hitting pedestrians. • Hospital beds / patient 4 wheeled trolleys: one person to move around a bed space. 2 people to move around ward/ interdepartmental transfer of a patient • 5 wheeled patient trolleys: one person may move the trolley if the patient’s weight / size is appropriate. • Bariatric bed movement may require up to 4 staff dependant on the weight of the patient and environmental factors. Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 21 of 41 • Clinical / general refuse bins: Lid to be lifted using two hands from the side of the bin and rest the lid against the wall is possible then place the bags into bin. • The large wheelie bins should only be moved singularly and pushed forward (never pulling). • No lifting for one person of a load greater than 5kgs and for a distance not more than 10 metres unless previously risk assessed and deemed acceptable. • Workstations should be ergonomically set up and this should also include appropriate and adequate seating ( staff using display screen equipment for a significant time should carry out their own assessment this can be found on the Risk management page of the intranet • Medical records bags should not be over filled, stacked on the floors or placed in corridors. When lifting of medical records and /or medical records bags the use of kinetic lifting methods must be used with the adoption of good core stability and a safe working posture, keeping your spine in line with flexed knees and hips. Unsafe handling techniques On no account should any member of staff push and pull equipment at the same time or move two pieces of equipment together i.e:-trollies, cages, or environmental bins at the same time Any member of staff found to be practising any of the manoeuvres in this section or modified versions, having attended a moving and handling course underwritten by the MHA, may be subject to disciplinary action. Patient handling techniques Patient handling techniques vary and should also take into account the individual patient’s needs. Safer patient handling techniques can be found below. Safe patient handling techniques The following patient handling techniques have been deemed appropriate and safe for RUH clinical personnel by the MHA following training, in accordance with the HSE, RCN and NBE Communication is key to moving patients and the national guidance states that only the commands of:‘Ready‘ ‘Steady’ Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 22 of 41 Turn Slide Stand Roll, Push Pull • Supine lateral transfers using a lateral transfer board and slide sheets using a two stage move; • Turning/rolling a patient with a slide sheet and or hoist; • Sliding patient up/down the bed with staff standing sideways at 45 degree angle to the patient and transfer weight from front to back foot ( i.e. NOT whilst facing each other across the bed); • Encourage the patient to help themselves with/without aids; • Palm to palm/fist grasp, sit to stand, supported walking and stand to sit with 1 or 2 handlers with/out handling belt; • Assisting a patient to reposition themselves in a chair; • Buttock shuffle with/without assistance; • Moving a patient up/down bed using a slide sheet with 1 or 2 handlers; • Assisting patients on/off bed with use of appropriate aids; • Use of hoists with appropriate hoist sling and size; • Use of stand aids with appropriate slings and straps; • Use the electric profiling bed to maximize mechanical assistance with patients’ mobility whilst in bed; • Use slide sheets to assist the mobility of patient in bed; • Use of appropriate aids to assist patients in/out bath/shower/toilet etc; • Verbally prompting the patient to get up from floor with minimum assistance ( provided the patient is able); • Hoisting patients from the floor if the patient unable to get up themselves or with minimum of assistance; • Sliding patient to floor prior to resuscitation if arrested in a chair at least 2 staff to carry this task out; • Administer basic life support on the floor if the patient has arrested on the floor or in a chair; • Using a slide sheet to evacuate a fallen patient from a confined space; • Where the situation allows all the above handling practices must be assessed as appropriate for use for each individual patient by completion of a patient Mobility Risk Assessment / care plan prior to any patient handling being undertaken. This should be placed in the Care Plan and reviewed regularly. Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 23 of 41 Handling babies and children with complex needs Children and young people with complex health needs, and particularly those with physical disability, may be at greater risk of injury from poor handling techniques. Each child or young person will have specific handling needs and these will undoubtedly change as they develop and grow. All staff who care for children, and particularly those children with complex needs, have a duty of care to each child and his/her carers which includes safe handling for the child or young person and themselves. A Mobility Risk Assessment and Care Plan will then be created and implemented as part of the child’s care plan. All staff involved in the care of individual children should be aware of the need to review and update the mobility risk assessment / care plan as changes occur. It is important that any changes are reported to trained staff immediately so that these changes can be addressed and documented. Advice can be given by clinical staff and/or the Manual Handling Adviser if necessary. Management of the heavier or plus sized patient An overweight or heavy patient may be defined as a person who has ”abnormal or excessive fat accumulation that presents a risk to health” (WHO, 2006). A Body Mass Index (BMI) is sometimes used as a measure and can be calculated using the patient’s weight in kilograms divided by their height in metres squared. A patient who has a BMI over 40 is often considered obese but this can be considered only as a rough guide as it may not correspond to the same degree of heaviness in different body types. However, in practice heavy patients may also include those whose weight exceeds the Safe Working Load (SWL) of equipment in everyday use including chairs, beds and toilet facilities etc. and some more specialist equipment such as hoists. It is essential to obtain an accurate weight of these patients is essential and there are scales that are kept in the Central Pre Operative Unit for measuring the weight of heavy patients. The bariatric beds (SWL410kg) and hoist (SWL300KG) with slings are available via the Medical Equipment Library on ext. 6446 The bariatric patient hoist may be obtained out of hours via the Porters who have access to the out of hour pump store. Site managers are sent a list at the close of each day that identifies where on site the special equipment is and if it is in use already. Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 24 of 41 For further details please refer to the Bariatric / Plus sized patient management policy The falling and fallen patient Staff are strongly discouraged from the natural tendency to try and catch a falling patient especially a patient who is falling forwards and away from them, unless they are satisfied beyond all doubt that it would be wholly safe to do so. Wherever possible staff should gently nudge or manoeuvre a patient towards a chair or bed. Staff should always attempt to protect the patient’s head from trauma as far as is reasonably practicable. The patient should be medically assessed to rule out any serious injury and reassured and made comfortable on the floor. They should then be hoisted back to bed/chair if they are unable to get themselves up with verbal prompting. If the patient has fallen in a confined space, then if possible the furniture should be moved carefully to gain access provided this does not expose staff to undue risk of injury. If this is not possible then the patient should be evacuated by being slid from the area on a slide sheet. After the event an incident form should be completed as soon as possible. A falls risk assessment must also be completed. Resuscitation In accordance with the Resuscitation Council (UK) Guidelines, (www.resus.org.uk) any patient who is on the floor and requires basic life support, should receive any lifesaving technique on the floor. If the environment itself is hazardous, such as water on a bathroom floor or a confined space, then the patient should be moved to a safer area by being transferred on a slide sheet rather than being lifted onto a bed, etc. No patient is to be lifted either manually or mechanically onto a bed from the floor or seated position prior to commencement of resuscitation. . Any patient who is sitting on a chair or wheelchair and requires lifesaving treatment should be quickly but gently slid to the floor prior to commencement of resuscitation techniques. This technique requires a minimum of two people/staff to perform it. Training is required before this manoeuvre should be attempted. It is recommended that, post resuscitation, the patient should be transferred from the floor by means of a hoist, provided they are assessed as stable, and it is deemed appropriate by a competent person. Try to keep the patient as horizontal as possible. If the patient re-arrests whilst being transferred in a hoist then return them Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 25 of 41 to the floor or complete the transfer to bed depending on which is the quickest, easiest or best method for the patient. Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 26 of 41 Unsafe patient handling techniques Staff must use their professional knowledge and judgement to assess the situation and make a balanced decision taking into account the best interests of the patient and their own health and safety. On no account should any member of staff manually lift patients as common practice. It is to be done as a last resort after all other options have been considered, if faced with an unforeseeable or emergency event. The Royal United Bath NHS Trust will enforce a ZERO TOLERANCE on the following controversial patient handling techniques: • • • • • • • • • Poles and Canvas Dead Man Lift * Orthodox lift Top and Tail Lift * Neck Hold* Lifting a Patient from the Floor as common practice * Drag Lift * Pivot Transfer/Bear Hug Transfer* Australian Lift/Glide Through arm lift/slide* Using sheets as transfer aids Using 1-2-3 LIFT as a comma Any member of staff found to be practising any of the manoeuvres marked * or modified versions, having attended a moving and handling course underwritten by the MHA, may be subject to disciplinary action. Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 27 of 41 Appendix 3: Equipment Patient related equipment management: procurement, use and maintenance This section should be read in conjunction with the ‘Medical Equipment Policy’ which describes the Royal United Hospital Bath NHS Trust’s arrangements for purchasing, maintenance and repair of all medical equipment, including manual handling aids. Any item of patient lifting equipment supplied by the Trust and asset registered with Medical Equipment Library MEL will: i) have a clearly identified Safe Working Load. ii) have a unique identifying mark or number. iii) be subject to a thorough inspection and examination carried out by a competent person at an interval identified and recorded by the competent person but not exceeding twelve months. iv) undergo a thorough examination following any repair, alteration or damage to the equipment. As soon as equipment is found to be defective, staff must be take the item out of use, clearly mark that it should not be used and the procedure for reporting faulty equipment (detailed within the ‘Medical Equipment Policy’) Pre-use requirements No lifting equipment will be procured or bought into use by the Trust without the knowledge and written agreement of the Manual handling Advisor and MEL. Irrespective of whether equipment is maintained through contracts, all equipment should be visually inspected and assessed by staff prior to them using it. Maintenance The Medical Equipment Library (MEL) is responsible for ensuring that service contracts are implemented for equipment subject to maintenance and/or statutory examination. For example, patient hoist electric profile beds. Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 28 of 41 Basic handling aids Each clinical area should have access to a hoist and bridging board. 1. Soft manual handling equipment provision is the responsibility of the department manager e.g. slings in a selection sizes and slide sheets, handling belts, hand blocks etc., 2. The majority of patient slings used in the Trust are patient specific (disposable) and should never be laundered. 3. Patient fabric slings/ transfer belts should be placed in a red alginate bag and taken to the linen room. 4. Slide Sheets; an exchange service has been established for slide sheets. Maximum number of 6 slide sheets should be placed in a red alginate bag and taken to the linen room. There is no need to complete any documentation on the ward but you will be asked to sign for the clean slide sheets that you receive. You will be given the same number of slide sheets as those you take to the linen room in replacement. Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 29 of 41 Appendix 4: Non-clinical activity specific equipment Definition ‘Non-personnel lifting equipment’ is for the purposes of this policy, any equipment, plant or installation whose primary function is the vertical lifting or lowering of an inanimate (non-patient or personnel) mass with a static load exceeding 25kg. This definition excludes lifters, bars, levers or keys consisting of a simple mechanical lever or single fulcrum specifically supplied for the moving of inanimate objects. Registration The Trust’ s mechanical engineer manager will maintain a register of all such ‘Non personnel’ lifting equipment. Equipment Any item of lifting equipment supplied by the Trust and appearing in the Estates Lifting Equipment register will: i) have a clearly identified Safe Working Load. ii) have a unique identifying mark or number. iii) be subject to a thorough inspection and examination carried out by a competent person at an interval identified and recorded by the competent person but not exceeding twelve months. iv) undergo a thorough examination following any repair, alteration or damage to the equipment. Provision Lifting equipment will only be provided by the Trust as a result of the completion of a manual handling risk assessment where existing control measures are not adequate. Any such lifting equipment provided by the Trust must be suitable and sufficient for its intended purpose and used only for its intended purpose. No lifting equipment will be used, without an appropriate risk assessment and a standard operating procedure No lifting equipment will be provided by the Trust without the knowledge and written agreement of the Manual Handling Advisor and the Hospital Engineer. All lifting equipment provided by the Trust must be accompanied by risk assessments and standard operating procedure a Safe System of Work. Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 30 of 41 Use of the equipment Lifting equipment provided by the Trust must only be used and operated by Trust personnel who have received sufficient information, instruction and training, in the safe and proper use of that equipment. A visual examination of the equipment must be carried out by the user prior to any use. Any defects identified should be reported to the Estate's Department immediately. If the defect is significant, the equipment must be removed from use immediately and clearly marked as defective. Lifting equipment must be used with a risk assessment and manual handling TILEE assessments with a standard operating procedure. Any deviation from the standard operating procedure must be reported through the incident reporting system (Datix) and sent to the Risk Management. Maintenance Lifting equipment appearing on the Estates Lifting Equipment Register will be subject to a maintenance regime in addition to and in support of the thorough examination records will be kept. Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 31 of 41 Appendix 5: Manual handling TILEE Assessment Ref No: Department Speciality Job Activity: Task: Does this task involve: Is this task carried out regularly? Holding loads away from trunk? Twisting? Stooping? Gripping? Reaching upwards? Large vertical movements? Long carrying distances over 10m? Strenuous pushing or pulling Unpredictable movement of loads? Frequent or prolonged physical effort Insufficient rest and recovery? Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Date of assessment: Assessment team Age ranges of patients Yes / No/ NA Please provide brief further information Frequency of task carried out Frequency X per hour Frequency X per day Frequency X per year Ref.: 801 Status: v7.2 Final Page 32 of 41 Current control measures (If any) Load: Load - is it: Yes / No/NA Please provide brief further information Current control measures (if any) Yes / No/NA Please provide brief further information Current control measures ( if any) Yes / No/NA Please provide brief further information Current control measures (If any) Heavy? Bulky? Difficult to grasp? Unstable/unpredictable? Intrinsically harmful?, e.g. sharp, hot etc Environment: Environment - are there: Space constraints preventing good posture? Uneven, slippery floors? Variation in floor levels? Poor lighting conditions? Hot / cold / humid conditions? Individual Capability: Does the: Task requires unusual strength or height? Task puts at risk those who are pregnant or have an existing health problem? Wearing of personal protective equipment hinder the users posture? Task require special knowledge or training for its safe performance? Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 33 of 41 Specific equipment: Does the task require specific equipment: Yes / No /NA Does the task include the use of equipment? Type of equipment? What is the safe working load of the equipment? Does the e Equipment need a Planned Preventative Maintenance (PPM) arrangement? Is the PPM in place? Do staff require specific training to use the equipment? Has the training been provided? Are there any other issues? Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Please provide brief further information Make: Model: Evidence must be available Ref.: 801 Status: v7.2 Final Page 34 of 41 Current control measures (if any) History of previous incidents When completing this please state, whether you know if there has been any of the following when carrying out manual handling activity Yes . No/ NA Please provide further brief details. Staff injury Patient injury Staff sickness levels RIDDOR reportable injury When assessing the risk score staff need to use the risk assessment matrix and risk descriptor to score both the severity and likelihood … Initial risk S= Severity X score S X L = L= Likelihood Further controls measures required action plan Date for completion Completed by : Final risk score S X L = Review dates Date Signature A copy of all manual handling task based risk assessments must be sent electronically to the Manual Handling Advisor for monitoring. Action plans must be completed which include a list of dates for completion of all identified further actions. Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 35 of 41 Risk assessment matrix Acceptable Risk Risk is tolerable as long as it is well managed and controlled. In addition to identified hazards, all incidents claims and complaints will be risk assessed according to the following process and investigated according to the severity or the consequence and likelihood of (re)occurrence. All Risk Assessments within the Trust will identify: I. The hazards within the Task/ area being assessed inherent in the work undertaken II. who and how many people would be affected III. how often specific events are likely to happen (may be based on frequency of previous occurrence): IV. how severe the effect or consequence would be V. how controllable the hazards are. Acceptable risk will be determined using the following traffic light system: Severity/consequence Given the (in)adequacy of the control measures, how serious the consequences are likely to be for the group, patient or Trust if the risk does occur (using the matrix). Consequence score (severity levels) and examples of descriptors Domains Impact on the safety of patients, staff or public (physical/psychologi cal harm) 1 2 3 4 5 Negligible Minor Moderate Major Catastrophic Minimal injury requiring no/minimal intervention or treatment. No time off work Minor injury or illness, requiring minor intervention Moderate injury requiring professional intervention Requiring time off work for <7 days Requiring time off work for 7-14 days Increase in length of hospital stay by 1-3 days Increase in length of hospital stay by 4-15 days RIDDOR/agency reportable incident Quality/complaints/a udit Peripheral element of treatment or service suboptimal Informal complaint/inquiry Overall treatment or service suboptimal Formal complaint (stage 1) Local resolution Single failure to meet internal standards Minor implications for patient safety if unresolved Reduced performance rating if unresolved Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman An event which impacts on a small number of patients Treatment or service has significantly reduced effectiveness Formal complaint (stage 2) complaint Local resolution (with potential to go to independent review) Repeated failure to meet internal standards Major injury leading to longterm incapacity/ disability Requiring time off work for >14 days Multiple permanent injuries or irreversible health effects Increase in length of hospital stay by >15 days An event which impacts on a large number of patients Mismanagement of patient care with long-term effects Non-compliance with national standards with significant risk to patients if unresolved Multiple complaints/ independent review Low performance rating Major patient safety implications if findings are not acted on Incident leading to death Critical report Ref.: 801 Status: v7.2 Final Page 36 of 41 Totally unacceptable level or quality of treatment/service Gross failure of patient safety if findings not acted on Inquest/ombudsman inquiry Gross failure to meet national standards Consequence score (severity levels) and examples of descriptors 1 Domains Negligible Human resources/ organisational development/ staffing/ competence Short-term low staffing level that temporarily reduces service quality (< 1 day) 2 Minor Low staffing level that reduces the service quality 3 4 Moderate Major Catastrophic Late delivery of key objective/ service due to lack of staff Uncertain delivery of key objective/service due to lack of staff Non-delivery of key objective/service due to lack of staff Unsafe staffing level or competence (>1 day) Low staff morale Poor staff attendance for mandatory/key training Statutory duty/ inspections No or minimal impact or breech of guidance/ statutory duty Unsafe staffing level or competence (>5 days) Loss of key staff Very low staff morale No staff attending mandatory/ key training Enforcement action Breach of statutory legislation Single breech in statutory duty Reduced performance rating if unresolved Challenging external recommendations/ improvement notice Multiple breeches in statutory duty Improvement notices Low performance rating Adverse publicity/ reputation Rumours Potential for public concern Local media coverage – short-term reduction in public confidence Local media coverage – long-term reduction in public confidence Elements of public expectation not being met Business objectives/ projects Finance including claims Insignificant cost increase/ schedule slippage Small loss Risk of claim remote <5 per cent over project budget 5–10 per cent over project budget Schedule slippage Schedule slippage Loss of 0.1–0.25 per cent of budget Loss of 0.25–0.5 per cent of budget Claim less than £10,000 Claim(s) between £10,000 and £100,000 Critical report National media coverage with <3 days service well below reasonable public expectation Ongoing unsafe staffing levels or competence Loss of several key staff No staff attending mandatory training /key training on an ongoing basis Multiple breeches in statutory duty Prosecution Complete systems change required Zero performance rating Severely critical report National media coverage with >3 days service well below reasonable public expectation. MP concerned (questions in the House) 10–25 per cent over project budget Total loss of public confidence Incident leading >25 per cent over project budget Schedule slippage Schedule slippage Key objectives not met Uncertain delivery of key objective/Loss of 0.5–1.0 per cent of budget Key objectives not met Non-delivery of key objective/ Loss of >1 per cent of budget Claim(s) between £100,000 and £1 million Purchasers failing to pay on time Service/business interruption Environmental impact 5 Failure to meet specification/ slippage Loss of contract / payment by results Loss/interruption of >1 hour Loss/interruption of >8 hours Loss/interruption of >1 day Loss/interruption of >1 week Claim(s) >£1 million Permanent loss of service or facility Minimal or no impact on the environment Minor impact on environment Moderate impact on environment Major impact on environment Catastrophic impact on environment Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 37 of 41 Likelihood Given the (in)adequacy of the control measures for each risk, decide how likely the risk is to happen according to the following guide. Scores range from 1 for rare to 5 for very likely. Score 1 Descriptor Rare 2 Unlikely 3 Possible 4 Likely 5 Very Likely Description Extremely unlikely to happen/recur – may occur only in exceptional circumstances – has never happened before and don’t think it will happen (again) Unlikely to occur/reoccur but possible. Rarely occurred before, less than once per year. Could happen at some time May occur/reoccur. But not definitely. Happened before but only occasionally - once or twice a year Will probably occur/reoccur. Has happened before but not regularly – several times a month. Will occur at some time. Continuous exposure to risk. Has happened before regularly and frequently – is expected to happen in most circumstances. Occurs on a daily basis Risk Score is determined by Severity x Likelihood 1 insignificant 5 2 Minor 10 Consequence 3 Moderate 15 4 Major 20 5 Catastrophic 25 4 - Likely 3 – Possible 4 3 8 6 12 9 16 12 20 15 2 – Unlikely 1 - Rare 2 1 4 2 6 3 8 4 10 5 Likelihood 5 – Almost certain Tolerance level Action to be taken following identification of risk score 1–4 5–9 10 – 15 16 – 24 25 Insignificant Low Medium risk High Extreme Action may be long term. The majority of control measures are in place. Risks subject to aggregate review, use for trend analysis Risk subject to regular review should be reduced as part of directorate long term goals There is moderate probability of major harm of high probability of minor harm, if control measures are not implemented. Prioritised action plan required with timescales. To be monitored and reviewed annually Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Significant probability that major harm will occur if control measures are not implemented. Urgent action is required. Consider stopping procedures. Actions to be audited until in control. Review three monthly Where appropriate and in discussion with the lead clinician/manager stop all action IMMEDIATELY. Controls to be implemented immediately and audited until risk score reduced. Review weekly Ref.: 801 Status: v7.2 Final Page 38 of 41 Document Control Information Ratification Checklist Dear Howard Jones Please review the following information to support the ratification of the below named document. Name of document: Manual handling Policy Name of author: Mary Chapman Job Title: Manual Handling Advisor I, the above named author confirm that: • The Policy presented for ratification meets all legislative, best practice and other guidance issued and known to me at the time of development of the Policy; • I am not aware of any omissions to the Policy, and I will bring to the attention of the Executive Director any information which may affect the validity of the Policy presented as soon as this becomes known; • The Policy meets the requirements as outlined in the document entitled Trust-wide Policy for the Development and Management of Policies (v4.0); • The Policy meets the requirements of the NHSLA Risk Management Standards to achieve as a minimum level 2 compliance, where applicable; • I have undertaken appropriate and thorough consultation on this Policy and I have documented the names of those individuals who responded as part of the consultation within the document. I have also fed back to responders to the consultation on the changes made to the Policy following consultation; • I will send the Policy and signed ratification checklist to the Policy Coordinator for publication at my earliest opportunity following ratification; • I will keep this Policy under review and ensure that it is reviewed prior to the review date. Signature of Author: Name of Person Ratifying this policy: Howard Jones Job Title: Director: Estates & Facilities Signature: Date: 19 May 2014 Date: 19 May 2014 To the person approving this policy: Please ensure this page has been completed correctly, then print, sign and post this page only to: The Policy Coordinator, John Apley Building. The whole policy must be sent electronically to: [email protected] Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 39 of 41 Consultation Schedule Name and Title of Individual Head of Health and Safety Head of Patient Safety ED Manager Director of Nursing Head of Nursing Surgical Head of Nursing Corporate Head of Nursing Medical Head of Patient Experience Medical Equipment Library Manager Tissue Viability Nurse Nutrition Nurse Matrons Medical Matrons Surgical Resuscitation team Education heads Estates and facilities Mechanical Engineering Manager ` Information Governance Manager Security Manager Date Consulted 05/06/12 05/06/12 20/08/12 20/09/12 The following people have submitted responses to the consultation process Name and Title of Individual Francesca Thompson Director of Nursing Sharon Bonson Assisted Director of Nursing /Fiona Vallis Training Compliance Manager David Hyde Medical Equipment Manager Keith Pascoe Mechanical Engineer Manager Simon Edwards Information Governance Manager Howard Jones Director of Estates and Facilities John Dunn Head of health and Safety Date responded 06/06/12 15/06/12 12/06/12 07/06/12 08/08/12 22/08/12 Name of Committee Date of sent out for comment 03/12/12 Health and Safety Committee Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman 08/10/12 26/11/12 Ref.: 801 Status: v7.2 Final Page 40 of 41 Equality Impact: (A) Assessment Screening To be completed when submitted to the appropriate Executive Director for consideration and approval Initial Screening Person responsible for the assessment: Name: Job Title: Mary Chapman Manual Handling Advisor Does the document/guidance affect one group less or more favourably than another on the basis of: Yes/No Race Yes No Yes No Yes No Yes No Culture Yes No Religion or belief Yes No Sexual orientation Yes No Age Yes No Disability Yes No Is there any evidence that some groups are affected differently? Yes No If you have identified potential discrimination, are there any valid exceptions, legal and/or justifiable? Yes No Is the impact of the document/guidance likely to be negative? Yes No If so, can the impact be avoided? Yes No N/A What alternative is there to achieving the document/guidance without the impact? Yes No N/A Ethnic origins (including gypsies and travellers) Nationality Gender (including gender reassignment) Comments (learning disabilities, physical disability, sensory impairment and mental health problems) Yes No If the answer is NO to all categories, the assessment is now complete. Can we reduce the impact by taking different action? If any of the answers are YES please complete the Equality Impact: (B) Full Analysis Document name: Manual Handling Policy Issue date: 21 May 2014 Author: Mary Chapman Ref.: 801 Status: v7.2 Final Page 41 of 41