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Table of Contents Page No.Section 1 Safety Policy 6
Section 2 Declaration of intent 8
2.1 General Statement of Policy 9
Section 3 Organisational Responsibilities 11
3.1 General Duties of Employer 11
3.2 Safety Management Structure and Organisational Chart 12
3.3 Safety Management Responsibilities 13
3.3.1 Interim Network Manager 13
3.3.2 General Manager 14
3.3.3 Operational Services Manager 16
3.3.4 Director of Nursing 18
3.3.5 Heads of Department 20
3.3.6 Employees 24
3.3.7 Health and Safety Coordinator 25
3.3.8 Local Risk Advisor 26
3.3.9 Consultant Occupational Health Physician 27
3.3.10 Regional Fire Prevention Officer 28
Section 4 Service Arrangements 30
4.1 Accident / Incident Reporting
4.2 Policies & Guidelines & Safe Work Practice Sheets
4.3 Training & Instruction
4.4 Violence / Assault
4.5 Stress
4.6 Infection Control
2
4.7 OBE (Occupational Blood Exposure)
4.8 PPE (Personal Protective Equipment)
4.9 Latex
4.10 VDU’s (Visual Display Unit)
4.11 Eye & Eyesight
4.12 Pregnant Employees
4.13 Dignity at Work
4.14 Fire Safety
4.15 Waste Management
4.16 Manual Handling
4.17 Chemicals
4.18 Medical Gases
4.19 Electrical Safety
4.20 Slips / Trips / Falls
4.21 Maintenance
4.22 Contractors
4.23 Visitors
4.24 Transport
4.25 Emergency Situations
4.26 Shared Workplace
4.27 Information
4.28 Lone working
4.29 Welfare
3
Section 5 Risk Management Process 50
Risk Matrix 53
Impact Table 54
Principles of Prevention 55
Section 6 Consultation Arrangements 57
6.1 Safety Rep 57
6.2 Safety Committee 59
Section 7 Resources 62
Section 8 Distribution / Access to Safety Statement 64
Section 9 Review / Revision Safety Management Programme 65
9.1 Safety Statement
9.2 Safety Management System
Section 10 Dept. /Unit Safety Statement 66
Introduction
Hazard Identification and Control Measures
(Hazard Relevant to Service Area)
Appendices
Appendix 1 Range of Services 67
Appendix 2 Quality Assurance Programme 70
Appendix 3 Communication Plan 71
4
Document Control
Document Name: Health Services ExecutiveHospital Safety StatementOctober 2010
Document Owner: Margaret Swords
Document Type: Microsoft Word
Last Updated: October 2010
Version: 1
Status: Compliance with Safety, Health & Welfare Legislation
Revision HistoryVersion Date Revised by Revision Details
1 04/10/2010 Denise MeliaOrganisational Responsibilities-Local Risk Advisor Page 26
Distribution List
Name Department DirectorateExecutive Management Board
Senior Management Team
Signature from Group General Manager, Louth/Meath Hospital Group
___________________________________________Group General Manager, Louth/Meath Hospital Group
5
Section 1.0 Safety Policy
1.0 Safety Policy
Since the publication of the Corporate Safety Statement in October 2006, it is
undoubtedly a fact that the HSE has undergone many changes and faced many
challenges.
We would like to take this opportunity to reaffirm our commitment to placing
people at the centre of the organisation. In line with this commitment we consider
that the management of safety, health and welfare is of fundamental importance
in continually improving the quality of the services that we provide, as quality of
service is intrinsically linked to the provision of a safe work environment and the
operation of safe systems.
In striving to continually improve quality and safety, we recognise and accept our
responsibilities for safety, health and welfare. We believe that workplace injuries
and illnesses are preventable, and as a consequence we are committed to ensuring
the safety, health and welfare of our staff and those affected by the work activities
of the HSE.
In order to support the Corporate Plan, we will empower staff to promote and
provide leadership in relation to the management of safety, health and welfare in
the workplace.
We are committed to ensuring the implementation of a safety management system
in the HSE that is consistent with legislative requirements and best practice
standards. An integral component of the plan will be the clear allocation of
responsibility and accountability to managers and employees that will be
supported by the provision of appropriate resources.
6
We will ensure that appropriate channels of communication are in place to
facilitate effective consultation and communication with staff and those who are
affected by the activities of the HSE. The aim of consultation and
communication will be to promote a positive safety culture through enabling staff
to contribute to the decision making process as it relates to safety, health and
welfare at work.
We are further committed to ensuring that the safety management system will be
subject to continual monitoring and review so that we can ensure that the work
environment and systems of work continue to be safe and that they contribute to
quality improvement.
(Ref: HSE Corporate Safety Statement 2009)
7
Section 2.0 Declaration of Intent
2.0 Declaration of Intent
The Safety Statement has been prepared in accordance with the provisions of the Safety
Health and Welfare at Work Act, 2005. The basic intent of the document is to formally
declare the means by which the management of Our Lady of Lourdes Hospital, within
the HSE NE ensures, in so far as is reasonably practicable, the safety, health and welfare
of staff, clients and others such as visitors, and contractors who may be affected by our
activities.
The Safety Statement contains details of Our Lady of Lourdes Hospital, HSE NE, Safety
Management Programme and of the general arrangements for occupational safety, health
and welfare within the service.
Safety is everybody’s business and the success of our safety policy will depend on staff
co-operation. It is important that staff are familiar with the arrangements for health and
safety in the service and incorporate these as an integral part of the tasks performed while
at work.
Members of staff and others are invited to contribute to the improvement of safety in the
service by making suggestions for the improvement of this Statement through their line
manager or Safety Representative.
Signed (General Manager)
Date 10th September 2010
General Statement of Policy
8
2.1 General Statement of Policy
Louth/Meath Hospitals is one hospital on three sites (Our Lady of Lourdes, Louth
County Hospital and Our Lady’s Hospital Navan) and provides an acute hospital range
of services including Medical, Surgical, Paediatrics and maternity to the catchment
area of Louth, Meath and surrounding areas. There are 340 beds and 30 day beds in
Our Lady of Lourdes Hospital. There is 1441 staff employed in this hospital.
It is our policy to do all that is reasonably practicable to prevent injury or ill health to
Staff, Service Users and others who come in contact with our activities. In
recognition of our responsibilities under the Safety, Health and Welfare at Work Act,
2005 and other legislation relevant to our operations, the Service, is committed to
providing and maintaining safe and healthy working conditions by the following
measures:
1. Promote standards of safety, health and welfare that comply with the provisions
and requirements of the Safety, Health and Welfare at Work Act 2005 and other
statutory provisions and codes of practice.
2. Provide and maintain safe, healthy working environments, safe systems of work
and to protect staff, service users and others such as visitors and contractors, in so
far as they come into contact with foreseeable hazards.
3. Information, training and supervision will be provided to all staff to develop
safety awareness, enabling them to work safely and effectively.
4. Identify and define all individuals responsible for Health and Safety
arrangements.
5. Encourage full and effective joint consultation on all health and safety matters.
6. Provide financial and / or staff resources required in so far as is reasonably
practicable.
7. Review this safety statement and its contents or in the event of new development
s or experiences.
9
Review Safety Statement when:
(a) there has been significant change in the matters to which it relates, or
(b) there is another reason to believe that it is no longer valid, e.g. new
legislation, following an accident, introduction of a new process, etc.
This Safety Statement will be brought to the attention of all Staff and Contractors who
come in contact with our service.
The safety and health of our staff is an important service objective.
All staff are responsible for taking reasonable care of their own health, safety and welfare
and that of their service users and others affected by their acts or omissions at work.
Adherence to safety procedures is a condition of employment and wilful negligence will
result in disciplinary action.
10
3.0 Organisational Responsibilities
3.1 General Duties of the Employer
o Managing and conducting all work activities so as to ensure the safety, health and
welfare of people at work (including the prevention of improper conduct or
behavior likely to put employees at risk).
o Designing, providing and maintaining a safe place of work that has safe access
and egress, and uses plant and equipment that is safe and without risk to health.
o Prevention of risks from the use of any article or substance, or from exposure to
physical agents, noise, vibration and ionising or other radiations.
o Planning, organising, performing, maintaining and, where appropriate, revising
systems of work that are safe and without risk to health.
o Providing and maintaining welfare facilities for employees at the workplace.
o Providing information, instruction, training and supervision regarding safety and
health to employees, this must be in a form, manner, and language that they are
likely to understand.
o Cooperating with other employers who share the workplace so as to ensure that
safety and health measures apply to all employees (including fixed-term and
temporary workers) and providing employees with all relevant safety and health
information.
o Providing appropriate protective equipment and clothing to the employees (and at
no cost to the employees).
o Appointing one or more competent persons to specifically advise the employer on
compliance with the safety and health laws.
o Preventing risks to other people at the place of work.
o Ensuring that reportable accidents and dangerous occurrences are reported to the
Health and Safety Authority.
11
Every employer shall manage and conduct his or her undertaking in such a way as to
ensure, so far as is reasonably practicable, that in the course of the work being carried
on, individuals at the place of work (not being his or her employees) are not exposed
to risks to their safety, health or welfare.
3.2 Safety Management Structure and Organisational Chart
The following is the Safety Management Structure within Our Lady of Lourdes Hospital. Each person in the service must ensure the effective implementation of the Safety Statement in their area of responsibility.
12
Interim Network ManagerWillie Rattigan
Group ManagerMargaret Swords
Group Human Resources Manager
Colm Kinch
Operational Services Manager
Yvonne Gregory
Group Finance ManagerNiall Kelly
Director of Nursing & MidwiferyEileen Whelan
Asst Director of Nursing
See page 17
Clinical Nurse/Midwife Managers 3’sSee page 21
Clinical Nurse/Midwife Managers 2’s/CN/MSI/CPC’S
See page 21
CNMM1’s
Employees
Heads of DepartmentSee page 20
EmployeesSafety RepsMary Hewitt
Laura MuckianMartin Smith
Regional Director of OperationsStephen Mulvaney
Risk ManagerIrene O’Hanlon
Organisational Responsibilities
3.3 Safety Management Responsibilities
3.3.1 Interim Network Manager
Mr Willie Rattigan, Interim Network Manager will be responsible for the:
Within their area of responsibility that accountability for safety health and welfare
has been defined and a clear line of accountability has been described to include
roles and responsibilities.
The systems, processes and resources necessary to manage safety health and
welfare are in place within all sites/services within their area of responsibility.
The systems and processes in place contribute to compliance with the HSE’s
Safety Management System and relevant legislation.
Safety, health and welfare is integrated into all activities within their area of
responsibility.
The Corporate Safety Statement and its related obligations are communicated
throughout their area of responsibility.
Safety, Health and Welfare legislation is reflected as part of the general
conditions of a contractor’s work specification at all stages of the procurement
process.
Performance indicators in relation to safety, health and welfare are included as
part of the team based performance management
13
Organisational Responsibilities
3.3.2General Manager
Ms Margaret Swords, Group General Manager is responsible for the integration of safety, health and welfare into all activities within his area of responsibility.
Responsibilities include:
Have in place a Site/Service Specific Safety Statement which conforms to the
requirements of the Corporate Safety Statement and is supported by a
documented risk assessment procedure.
Ensure that the systems, processes and resources necessary to manage safety
health and welfare are in place within all sites/services within their area of
responsibility.
To ensure that appropriate systems are in place to communicate the Site/Service
Specific Safety Statement to all employees and other persons who may be
exposed to any specific risk to which the Safety Statement applies at least
annually and at other time following amendment.
To ensure that the Site/Service Specific Safety Statement is reviewed and updated
on a regular basis and in the event of any significant change in work practice.
Oversee the auditing of the safety, health and welfare management system, and
ensure results are acted on through the development of appropriate action plans
Promote the integration of safety, health and welfare into all activities of their
area of responsibility i.e. management team meetings.
Incorporate Safety, Health & Welfare legislation as part of the general conditions
of a contractor’s work specification at all stages of the procurement process
Integrate performance indicators in relation to safety, health and welfare as part
of team based performance management.
Seek advice from specialist health and safety and risk advisors as necessary.
Organisational Responsibilities
14
Ensure that employees have access to safety health and welfare training
appropriate to their role and that a record of each employee’s training is
maintained.
Provide reports from the safety committee to the Network Manager on an annual
basis or more frequently if requested
Report safety, health and welfare risks identified that are not within their ability
to control to the relevant Network Manager
Provide arrangements for the election of safety representatives
Put in place suitable arrangements for an effective and inclusive approach for
safety representatives in the consultation process
15
Organisational Responsibilities
3.3.3 Operational Services Manager
Ms Yvonne Gregory, Operational Services Manager is responsible for the management and integration of safety, health and welfare within her area of responsibility.
Responsibilities include:
The availability of the Site/Service Specific Safety Statement in their area of responsibility. This must be supported by a risk assessment that clearly reflects the risks within their Service.
That the systems, processes and resources necessary to manage safety health and
welfare are in place within their area of responsibility
Report safety, health and welfare risks identified that are not within their ability
to control to the relevant General Manager.
The systems and processes in place contribute to compliance with the Site/Service
Specific Safety Statement and relevant legislation.
Undertake “walk about safety audits” in their area of responsibility, and document
the findings while following up on corrective action to manage identified deficits
Promote the integration of safety, health and welfare into all activities of their
area of responsibility i.e. departmental/service team meetings.
Ensure that the Site Specific Safety Statement and its related obligations are
communicated throughout their area of responsibility.
Empower employees within their area of responsibility to take ownership of
safety, health and welfare risks and promote best practice in the management of
these risks
Distributing documented safe systems of work to nominated responsible people
for action
Integrate performance indicators in relation to safety, health and welfare as part
of team based performance management.
16
Organisational Responsibilities
Monitor the performance of the safety, health and welfare system through
performance indicators and audit and ensure the outcomes of the monitoring
process are acted on through the development of appropriate action plans
Seek advice from specialist health and safety / risk advisors as and when required
Ensure that employees have access to and facilitate their attendance at safety
health and welfare training appropriate to their role.
Maintain a record of each employee’s training.
Ensure that a comprehensive incident management process is in place for all
incidents occurring within the department/service.
Ensure that all safety related records are maintained appropriately.
In addition to the above, the Operational Services Manager is responsible for coordinating the health and safety management programme throughout the Hospital.
17
Organisational Responsibilities
3.3.4 Director of Nursing
Ms. Eileen Whelan, Director of Nursing is responsible for the management and integration of safety, health and welfare within her area of responsibility.
Assistant Directors of Nursing
Mr. Adrian Cleary General Areas
Ms. Marina O’Connor Nurse Prac Dev Co
Ms. Colette McCann Manager for Women & Children’s Health
Ms. Barbara O’Flynn Theatre/CSSD/Endo/Dayward
Ms. Miriam Kelly Midwife Prac Dev Co-ordinator
Ms. Mary Yau Out of Hours
Ms. Mary O’Connor Out of Hours
Ms. Mary McGrane Out of Hours
Ms. Kay Anderson Out of Hours
Ms. Roisin Collier Out of Hours
Ms. Caitriona Crowley, Project Manager - Transformation
Assume the following responsibilities on a day to day basis.
The availability of the Site Specific Safety Statement in their area of responsibility. This must be supported by a risk assessment that clearly reflects the risks within their Service.
That the systems, processes and resources necessary to manage safety health and welfare
are in place within their area of responsibility
Report safety, health and welfare risks identified that are not within their ability to
control to the relevant Local Senior Manager.
The systems and processes in place contribute to compliance with the Site/Service
Specific Safety Statement and relevant legislation.
Undertake “walk about safety audits” in their area of responsibility, and document the
findings while following up on corrective action to manage identified deficits
Promote the integration of safety, health and welfare into all activities of their area of
responsibility i.e. departmental/service team meetings. 18
Ensure that the Site Specific Safety Statement and its related obligations are
communicated throughout their area of responsibility.
Empower employees within their area of responsibility to take ownership of safety,
health and welfare risks and promote best practice in the management of these risks
Distributing documented safe systems of work to nominated responsible people for
action
Integrate performance indicators in relation to safety, health and welfare as part of team
based performance management.
Monitor the performance of the safety, health and welfare system through performance
indicators and audit and ensure the outcomes of the monitoring process are acted on
through the development of appropriate action plans
Seek advice from specialist health and safety / risk advisors as and when required
Ensure that employees have access to and facilitate their attendance at safety health and
welfare training appropriate to their role.
Maintain a record of each employee’s training.
Ensure that a comprehensive incident management process is in place for all incidents
occurring within the department/service.
Ensure that all safety related records are maintained appropriately.
Organisational Responsibilities19
3.3.5 Heads of Department
The following Heads of Department are responsible for the management and integration
of safety, health and welfare within his / her area of responsibility.
Admissions / Bed Management – Mari Gavin
Catering Dept – Vacant
Central Stores – Nicholas McCabe
Clinical Engineering – Brian Sharpe
Dietetics – Grainne Bogue
Finance / HIPE Dept – Niall Kelly
Human Resource Dept – Colm Kinch
Information Technology Dept – Frances McNamara
Infection Control Dept – Mairead Twohig
Laboratory Dept – Eamon Delahunt
Laundry Dept – Donal Leddy
Library – Jean Harrison
Medical Manpower – Deirdre Dineen
Medical Records / Appointments – Fiona Floyd
Maintenance Dept – Vacant
Occupational Health – Dr Peter Noone
Operational Services Manager – Yvonne Gregory
Pharmacy Dept – Elaine Conyard
Physiotherapy Dept – Karen Gunn/Kay Morris/Valerie Reddan
Risk Advisor – Irene O’Hanlon
Social Work – Anne Lennon
Speech & Language – Maura Reynolds
Support Services Dept – A/Roisin McMahon
X-Ray Dept – Jane Richardson
20
Clinical Nurse/Midwife Manager 3’sMs. Edel Kirwan General AreasMs. Mary Lenehan Maternity
Ms. Trish Donnelly General Areas
Ms. Anne Keating Maternity
Ms. Elizabeth Summersby Oncology
Sr. Catherine Mulligan St Therese Building
Ms. Ciara Finnerty A&E Dept
Ms. Grainne Milne Maternity
Ms. Maureen Kennedy A/Clinical Nurse Manager 3 CCU
Ms. Fiona Monaghan Tyer A/Clinical Nurse Manager 3 General Areas
Ms. Ejiro O’Hare Healthcare Assistants
Clinical Nurse Manager 2’s
Ms. Irene Hoey Ground Floor East
Ms. Mary Costello Theatre
Ms. Geraldine Horgan Theatre
Ms. Debbie McDaniel Theatre
Ms. Andrea McCabe Clinical Facilitator Theatre
Ms. Ailsling Moynihan Theatre
Ms. Sharon Fenelon A/Clinical Nurse Manager 2 First Fl East & West
Ms. Eithne Dunhill A/Clinical Nurse Manager 2 Short Stay Unit
Ms. Anne McIlwee Endoscopy/Dayward
Ms. Denise Flynn Walsh 3rd Fl Orthopaedics
Ms. Linda Rickard 3rd Floor Surgical
Ms. Marie Murphy ICU/CCU/HDU
Ms. Debra Taaffe 5th Fl Inf & Tods
Ms. Catherine Connolly A/Clinical Nurse Manager 2 6th Floor East
Ms. Adeline Milne A/Clinical Nurse Manager 2 6th Floor West
Ms. Kathleen Murray Outpatients Dept
Ms. Nicola McShane 1st Floor New Build
Ms. Nuala Rafferty 2nd Floor New Build
Ms. Mary Faulkner King E Dept
Ms. Paula McKenna E Dept
21
Ms. Adrienne Sharkey E Dept
Ms. Cathy Breen E Dept
Ms. Lynn O’Sullivan E Dept
Ms. Sinead Gardiner E Dept
Ms. Lorraine Clerkin A/Clinical Nurse Manager 2 E Dept
Ms. Rosemary Hodgins A/Clinical Nurse Manager 2 E Dept
Ms. Geraldine McCabe GP/Community Liaison E Dept
Ms. Lorraine Reynolds Clinical Facilitator E Dept
Ms. Irene Griffin MAU
Ms Mary Ita Niall Labour Ward
Ms Kathleen O’Brien Labour Ward
Catherine Smith Labour Ward
Siobhan Weldon Labour Ward
Leone Baillie CMM2 Labour Ward
Miriam Maguire Labour Ward
Leone Campbell Labour Ward
Christine McGeough Labour Ward
Tracey Cotter, CMM2 Labour Ward
Mary Sweeney Gynae
Ger Pigott CMM2 Antenatal Ward
Caroline Keegan MLU
Ms Siobhan Hackett NICU
Laurraine Crinion Postnatal Ward
Mary Gorman Antenatal OPD
Responsibilities include:
The availability of the Site Specific Safety Statement in their area of responsibility. This must be supported by a risk assessment that clearly reflects the risks within their department.
22
That the systems, processes and resources necessary to manage safety health and welfare
are in place within their area of responsibility.
Report safety, health and welfare risks identified that are not within their ability to
control to the relevant Local Senior Manager.
The systems and processes in place contribute to compliance with the Site/Service
Specific Safety Statement and relevant legislation.
Undertake “walk about safety audits” in their area of responsibility, and document the
findings while following up on corrective action to manage identified deficits.
Promote the integration of safety, health and welfare into all activities of their area of
responsibility i.e. departmental/service team meetings.
Ensure that the Site Specific Safety Statement and its related obligations are
communicated throughout their area of responsibility.
Empower employees within their area of responsibility to take ownership of safety,
health and welfare risks and promote best practice in the management of these risks.
Distributing documented safe systems of work to nominated responsible people for
action.
Integrate performance indicators in relation to safety, health and welfare as part of team
based performance management.
Monitor the performance of the safety, health and welfare system through performance
indicators and audit and ensure the outcomes of the monitoring process are acted on
through the development of appropriate action plans.
Seek advice from specialist health and safety / risk advisors as and when required
Ensure that employees have access to and facilitate their attendance at safety health and
welfare training appropriate to their role.
Maintain a record of each employee’s training.
Ensure that a comprehensive incident management process is in place for all incidents
occurring within the department/service.
Ensure that all safety related records are maintained appropriately.
Organisational Responsibilities
3.3.6 Employees
23
Employees have the following legal duties under section 13 and 14 of the Safety, Health and Welfare at Work Act 2005:
1. Take reasonable care of their own safety, health and welfare and that of others.
2. Ensure they are not under the influence of an intoxicant to the extent that they may endanger themselves or others.
3. Co-operate with their employer or any other person as appropriate.
4. They must not engage in improper conduct or behaviour (including bullying / harassment).
5. Attend all necessary training.
6. Use safety equipment or PPE provided, or other items provided for their safety, health and welfare at work.
7. Report to your line manger as soon as is practicable:
(i) Any work which may endanger the health and safety of themselves or others.
(ii) Any defect in the place of work, systems of work, articles or substance
(iii) Any breach of health and safety legislation of which he or she is aware.
Employees must not:(i) Interfere with, misuse or damage anything provided for securing the health, safety and
welfare of those at work.(ii) Place anyone at risk in connection with work activities.
Employees must not: Intentionally or recklessly interfere with or misuse any appliance, or safety equipment
provided to secure the safety health or welfare of persons at work.
The Health Service Executive, North East Area has expended considerable time and resources in the preparation of a Safety Management Programme designed to protect the interests of its employees. The programme will not succeed unless each employee co-operates fully.
Failure to comply with the terms of the Safety Statement may result in disciplinary action.
Organisational Responsibilities
3.3.7 Health & Safety Co-ordinator Hospital Network
24
Ms Karen McKiernan
Role of the Health & Safety Co-Ordinator
Co-ordinate the HSE North Eastern Area’s health and safety management programme within Hospital Network and establish structures to ensure it is disseminated, understood and implemented and that managers are familiar with their roles.
Advise on legislation and technical developments relating to the health and safety of staff, patients, clients and visitors.
Monitor health & safety performance in the Hospital Network.
Assist in the co-ordination of the development of health & safety standards, policies and safe work practice sheets and put in place mechanisms to monitor their effectiveness in application.
Ensure health & safety training programmes are devised, presented and evaluated in line with the HSE North Eastern Area’s statutory obligations.
Receive reports on accident trends and target high-risk areas for priority attention.
Provide assistance in ensuring mechanisms are in place for monitoring the implementation of the Hospital consultation process.
Liaise with statutory bodies, including the HSA, in relation to matters of health and safety at work on behalf of the HSE North Eastern Area.
Work closely with the Occupational Health Department in furtherance of the overall objectives of the HSE North Eastern Area’s Safety Management Programme.
Contact Details:
Karen McKiernan,
Health & Safety Co-ordinator,
Dublin Rd,
Kells,
Co. Meath.
Tel: (046) 9280534/536 E-mail: [email protected]
Organisational Responsibilities
3.3.8 Local Risk Advisor Risk Advisor: Ms Irene O’HanlonContact Details: St Theresa’s Building
25
Our Lady of Lourdes HospitalDroghedaTel: 041 – 9875220 E-mail: [email protected]
Dep Risk Advisor: Ms Nora HouriganContact Details: St Theresa’s Building
Our Lady of Lourdes HospitalDroghedaTel: 041 – 9875220 E-mail: [email protected]
Purpose of the job:The role of the Risk Advisor is to advise and support on the management of safety issues in the
hospital towards minimising the risk of harm and achieving the safest and highest standard of
care.
The Risk Advisor supports the development and implementation of Quality Safety & Risk
Management standards through supporting the development of governance structures and
processes as outlined in the Q&R Framework, within Louth/Meath Hospitals.
The Risk Advisor leads on core programmes of work in quality, safety and risk management,
including: development of governance structures with the hospital, clinical effectiveness, service
user & community involvement; risk management & patient safety and service improvement.
The Risk Advisor provides training and education on healthcare risk management issues to staff
including staff safety issues.
The Risk Advisor facilities the development of Risk Registers within specialties & departments
to create a comprehensive, working risk register within the hospital.
The Risk Advisor facilities the data management aspect of the incident reporting system by
ensuring that all adverse incidents & near misses reported are logged on to the STARSWeb
system.
The Risk Advisor monitors incidents reported supports and facilitates incident review towards
ensuring that appropriate measures to reduce or mitigate against reoccurrence of similar
incidents are identified and put in place.
The Risk Advisor works with Health & Safety Personnel and the Hospital Management as
required ensuring that statutory obligations in regard to Health & Safety are complied with.
Organisation and Responsibilities
3.3.9 Consultant Occupational Health Physician
Dr. Peter Noone26
Role of the Consultant Occupational Physician
1. Contribute to the effective strategic management of all staff health, safety and welfare
issues;
2. Assist management in providing a safer, healthier environment for staff, patients and
visitors by recognising, assessing and suggesting ways for managing risks;
3. Be responsible for the process of assessing staff health prior to appointment and in the
ongoing monitoring of staff health for those already in employment.
4. Advise on the medical suitability of an applicant or employee to perform all or any part
of the job description/person specification and assist the personnel department in making
any reasonable adjustment that may be required under the Employment Equality Act
2000;
5. Assist in identifying where sickness absence is a concern and make suggestions for
eliminating identified causes, consequently assisting in its management and reduction;
6. Be aware of the of the organisational and individual causes of work related stress and
advise management on the drawing up, implementation and monitoring of strategies for
dealing with the causes and effects of these;
7. Work with health and safety colleagues to produce strategies for the reduction of
violence to staff as well as providing or arranging for initial assessment of the
counselling needs of those who have been abused;
8. Advise on health risks in the workplace and support employer and employees in
reaching the most appropriate OH strategy or solution to their problem.
Contact Details:
Dr. Peter Noone, Tel: (041) 6857811
Consultant Occupational Physician E.mail: [email protected]
Occupational Health Department,
St Brigids Complex, Ardee, Co. Louth
Organisation and Responsibilities
3.3.10 Regional Fire Prevention Officer
Ms Selina Kavanagh
27
Role of the Regional Fire Prevention Officer
Under the general direction and control of the Technical Services Officer, the Fire Prevention Officer will be responsible, within the HSE North East.
1. Regular inspections of the buildings, means of escape and all fire-fighting equipment and ensuring that all such equipment is properly located, well marked, in good repair and in good working order.
2. Reviewing and, as necessary, drawing up of fire orders, including evacuation schemes for the various types of building and institutions, including schemes for evacuation of all persons with particular regard to mentally ill and non-ambulant patients.
3. Instruction of staff in each institution in:
a. Avoidance of fire hazards.b. Summoning of the fire brigade.c. Operation of the fire alarm and fire equipment, and means of escape.d. Curtailment of an outbreak of fire, pending the arrival of the fire brigade,
prevention of smoke spread and evacuation of danger areas.
4. Arranging regular fire drills in each institution and ensuring that they are properly carried out.
5. Advising as appropriate regarding interpretation of Fire Protection Standards and Building Regulations issued by the Government Departments and ensuring their implementation.
6. Monitoring all means of escape to ensure that they are both safe and adequate and at all times, kept operative and clearly indicated.
7. Keeping proper records of all inspections, fires, evacuation drills, fire-fighting equipment and such other matters relating to his/her office as Fire Prevention Officer.
8. Reporting in writing, to the Technical Services Officer or other delegated Officer, at three-monthly intervals on the state of the fire prevention services in the Board’s buildings and institutions assigned to her. Also, report immediately all outbreaks of fire, breach of the fire prevention orders and failure to perform fire drill at the Board’s buildings and institutions. If so directed, the Fire Prevention Officer will make out an annual report on all aspects of fire and safety pertaining to the Board’s property.
9. To arrange to have the fire prevention work programmes implemented under the direction of the Technical Services Officer.
10. To help in the setting up and alterations to Emergency Plans in all of the boards buildings.
Contact Details:28
Selina Kavanagh Tel: (046) 9280410
Regional Fire Prevention Officer E-mail: [email protected]
Technical Services
Oldcastle Rd
Kells
Co. Meath
Nicola McKenna Tel: (046) 9280410
Asst Regional Fire Prevention Officer Email: [email protected]
Technical Services
Oldcastle Rd
Kells
Co Meath
Section 4.0 Hazard Control Service Arrangements
4.1 Accident / Incident Reporting
All Accidents/Incidents/near misses must be reported immediately to your Line Manager and
recorded in accordance with the HSE Dublin North East Incident Reporting Policy.
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The following process is undertaken in respect of incident reporting. An incident report form is
completed in triplicate.
White copy: The first copy is forwarded to the Risk Management department.
Yellow copy: In the case of non clinical related incidents, these are submitted to the Operational
Services department for review and action if necessary. . The clinical incidents are reviewed by
the Nursing Management/Head of Department and assessed by the Risk Manager.
Pink copy: The third copy is retained by the department in which the incident occurred. The
review of the accident/incident investigations will be carried out in a timely manner by the line
manager. The purpose of review is to determine the immediate and root cause of the
accident/incident and to prevent recurrence.
All employees are required to co-operate with such reviews and to provide any information,
which may be useful in establishing the circumstances surrounding the accident/incident.
Corrective action will be taken where necessary and recorded.
Accident data will be periodically analysed by line manager with a view to improving safety
performance. Where appropriate, the Safety Statement (including risk assessments) will be
reviewed in light of any accident/incident.
Part X Safety, Health and Welfare at Work (General Application) Regulations 1993
(Notification of Accidents and Dangerous Occurrences) requires that certain accidents and
dangerous occurrences are reported to the Health and Safety Authority. These include the
following categories:
- An accident resulting in the death of an employee;
- An accident resulting in the absence of an employee for more than 3 working days (not
including the day of the accident);
- An accident to any person not at work caused by a work activity which causes loss of
life or requires medical treatment (e.g. member of the public); and
- Certain dangerous occurrences, which have the potential to cause serious injury, whether
or not they did cause serious injury.
The Operational Services Department is responsible for reporting any such accidents/
dangerous occurrences to the Health and Safety Authority.
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It is the responsibility of the Office of The Director of Nursing to forward details of any
such incidents/occurrences into the Operational Services Manager.
Reporting will be done on the prescribed forms IR1 (accidents) or IR3 (dangerous
occurrences) and forwarded to the Health & Safety Authority.
H.S.A contact details:
The Health & Safety Authority
The Metropolitan Building
James Joyce Street,
Dublin 1 (Tel. No. (01) 6147000)
4.2 Policies & Guidelines & Safe Work Practice Sheets
A number of policies, guidelines have been developed and detail the appropriate methods and
practices to reduce risks associated with unsafe behaviour. A number of safe work practice
sheets are been developed.
List of Policies and Guidelines are as Follows:
1. Guidelines for the Management of Chemical Waste 2004
2. Guidelines for Biological Substances Category B UN3373, 2007
3. Guidelines for the Transport of Infectious Specimens Category A, UN 2814, 2007.
4. Guidelines for the Management of Healthcare Risk Waste, 2004
5. Gloves Use Guidelines for practice – 2009
6. Moving & Handling Policy, 2008
7. Guidelines on the Management of Violence and Aggression in the Workplace –
2007
8. Occupational Blood and Body Fluid Exposure and Administration of Post
Exposure Prophylaxis Guidelines 2010
9. The Stress Management Policy - 2002
It is imperative that each Line Manager ensures that they have copies of all relevant Policies,
Guidelines and Safe Work Practice Sheets relevant to their department. If Line Manager’s
require copies of any such documents, please liaise with Yvonne Gregory, Operational Services
31
Manager. It is essential that all employees carefully read, understand and work in accordance
with these documents.
4.3 Training & Instruction
Heads of Service are required to undertake a training needs analysis for all staff and hold
training records for all their staff. A central repository of attendance names of training
delivered in Fire Safety, Manual Handling, Risk Assessment Technique and Health and Safety
Awareness Training are held in the Operational Services Management department for all staff.
Training shall be provided to employees at Our Lady of Lourdes Hospital a) on recruitment b)
in the event of the transfer of an employee or change of task assigned to an employee c) on the
introduction of new work equipment, systems of work or changes in existing work equipment or
systems of work and d) on the introduction of new technology.
The following training is provided based on legislative requirements and the risk assessment
process
• Fire Safety Training
• Infection Control to include hygiene and decontamination Training
• Professional Management of aggression and violence (is currently being organised)
• Risk Assessment Technique training for Heads of Service
• Biological Agents Risk Assessment Technique training for Heads of Service
• Safety Representative training
• Health & Safety Awareness training
• Manual Handling Training
• Dangerous Goods Safety Training
• Safe Pass Training
• Additional Health and Safety training is provided through the H.S.E. course prospectus
which can be obtained from the REC in Ardee.
4.4 Violence / Aggression
The hospital recognises that violence and aggression is on the increase in the health care sector.
Our Lady of Lourdes Hospital does not tolerate any form of violence and aggression to any staff
member. It is the responsibility of each Head of Service to carry out a physical environment
32
risk assessment which includes identifying the hazards associated with violence in the
department in consultation with staff to ensure appropriate controls are in place.
On completion, these risk assessments are required to be sent to the Operational Services
Manager in order for an action plan to be developed.
Based on risk assessments the following controls are in place throughout the hospital.
These are as follows:
Security
Our Lady of Lourdes Hospital provides a 24/7 security service to maintain a secure working
environment for both staff and all service users. Security can be contacted on Bleep 285.
Equipment
There are 24 C.C.T.V. cameras placed in strategic positions around the hospital.
Some locations in the hospital have an intercom system, these areas include Area 4 OPD,
Cardiac Rehabilitation, Social Work, Palliative Care, Dermatology, The Bungalow, ICT Dept.,
Maternity, Oncology and St. Therese’s Building. There is a swipe system in some areas of the
Hospital i.e. Utility Rooms, ICU/CCU, Laboratory.
Training
On a regional basis, the Hospital has access to trained Professional Management of Aggression
& Violence (PMAV) instructors, which provide specific training sessions, based on risk
assessment on violence and aggression to Hospital staff (this is currently in the process of being
organised). Staff are encouraged to report all incidents of violence and aggression to ensure
appropriate and effective control measures are put in place. Line Managers should be aware of
the whereabouts and proposed itinerary of staff if working away from their base.
In the case of an incident of violence and aggression, staff may contact the Staff Care Line on
1800 409388. Further information on the above may be obtained from the Occupational Health
Department (OHD) on 041 6857811.
4.5 Stress
The Health Service Executive recognises its greatest asset is its employees. Some staff
experience stress which can be the result of pressures within personal life or within the
workplace. Such stress needs to be managed in order for staff to avoid “burnout” or becoming
ill as a result of exposure to such stress
The Occupational Health Service offers a confidential service to employees who maybe
suffering from the effects of stress, whatever the cause. The Occupational Health Department 33
can be contacted on 041 -6857811. The Confidential Counselling Service can be accessed
through the Occupational Health Service also or by using the freephone number which is on the
back of the Staff ID badges (1800409388). The Human Resources Department and can also
provide support.
Further information in relation to the management of stress can be sought from the Health
Service Executive’s Stress Management Policy 2002, which is available in each department.
4.6 Infection Control
The prevention and control of infection is achieved by utilizing standard precautions. See RICG
L/M 0002 (2006).
All staff should be aware of and have access to relevant policies and guidelines pertaining to
infection control. Staff are obliged to inform line managers if they have been exposed to any
infectious disease that may be a risk to themselves colleagues or patients. First aid management
of occupational blood and body fluid exposure is outlined in RICG L/M 00003 (2006) and this
should be followed in the event of occupational blood / body fluid exposure. Relevant
vaccinations are offered by the Occupational Health Department.
Staff should attend the mandatory annual hand washing up-dates.
Transmission based precautions is utilised for all patients requiring isolation. Colour coded
signage is in place and all HCWs should make themselves aware of this.
For further guidance on infection control, please refer to the following:
HSE North East Louth Meath Hospital’s Infection Control Guidelines 2006 (currently
being updated due out in Dec 2010)
Immunisation for Healthcare Employees 2002
Glove Use Guidelines for Practice 2009
Waste Management Guidelines 2004 (Currently being updated)
WHO Hand Hygiene Guidelines 2009
Prevention of blood borne diseases in Health Care setting 2005
Norovirus Guidelines 2003
National Aspergillus Guidelines 2002
SARI MRSA Guidelines 2006 (Currently being updated nationally)
HPSC Clostridium Difficile Guidelines 2008
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TB Guidelines 2010
Prevention of Intravascular Catheter Related Infection in Ireland 2009
Guidelines for Antimicrobial Stewardship in Hospitals 2009
Legionella Guidelines 2009For further support and information please contact the infection prevention & control department ext
2514. Bleep 113.145.
4.7 OBE (Occupational Blood Exposure)
Due to the nature of work within our service, staff may be at risk to exposure to blood,
bodily fluids and sharps injuries.
Healthcare workers should be familiar with the first aid procedures in the event of such
injuries/exposures.
Encourage bleeding by gentle squeezing, but do not suck the area
Wash with soap and running water
Treat mucosal surfaces such as the mouth or conjunctive of the eye by rinsing with
warm water or saline
Following first aid all injured employees should immediately seek further advice from the local
Accident & Emergency Department regarding further treatment or prophylaxis. The
Occupational Health Service provides advice to Accident & Emergency who provide follow-up
for employees with significant injuries. All Needlestick and occupational blood/body fluid
exposures must be reported to the Department Head/Line Manager and an incident report form
completed. For further guidance, please refer to the H.S.E.Policy on Occupational Blood and
Body Fluid Exposure and Administration of Post Exposure Prophylaxis Guidelines 2010.
The Occupational Health Dept will provide the Health and Safety Committee with 6 monthly
OBE incident reports.
4.8 PPE (Personal Protective Equipment)
Where it is not practicable to eliminate certain risks, the Hospital will provide adequate and
suitable personal protective equipment based on risk assessment to reduce the risk to an
acceptable level. Instruction and practical training in use of P.P.E. will be given prior to issue
of such equipment.
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Employees are obliged to wear personal protective equipment during the applicable activity.
Failure to do so can result in disciplinary action and prosecution under Safety, Health and
Welfare at Work Act 2005.
Details of specific personal protective equipment provided in each department are contained in
the department safety statement.
Further advice on appropriate personal protective equipment or medical suitability to use such
equipment can be obtained from the Health and Safety Department and/or Occupational Health
Service.
4.9 Latex
Latex gloves are still the most effective barrier against viral penetration. Staff who have
concerns in relation to developing sensitivity to latex should immediately advise their direct
Head of Service, and be referred or self refer to the Occupational Health Service on ph: 041
6857811 or Speed dial 7271. The use of latex gloves is only recommended for contact with
potentially infected materials or body fluids.
It is recommended that non-latex gloves be used for all other activities that are not likely to
involve contact with infectious materials (e.g. food preparation, routine house keeping and
maintenance). For further details please refer to the latex policy which is available from the
Head of Service or the Occupational Health Department. Also available is the Glove use
guidelines for practice
4.10 Visual Display Units
Under the Safety, Health & Welfare at Work (General Application) Regulations 2007, all
hazards associated with display screen equipment (VDU’s) must be identified and any risk to
the health and/or safety of the user must be assessed.
If an employee’s work situation changes e.g. change of work location, a VDU assessment
should be carried out. VDU assessments should be carried out for all new employees.
A copy of the VDU Risk Assessment template and guidance notes are available within each
department.
VDU Assessors
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Name Location Extension
Emily Maguire Medical Records 2266
Linda Halton Library 4672
Francis McArdle Risk Management 4751/5220
Ian McGovern Physiotherapy Dept 4662
4.11 Eye & Eyesight
All staff who are regular and significant users of Visual Display Units (i.e. they use a VDU for
one continuous hour or more as part of an everyday work routine) are entitled to have an eye
test completed under the Safety, Health and Welfare at Work (General Application)
Regulations, 2007, as follows:
Before commencing VDU work
At three yearly intervals thereafter.
If an employee develops or experience visual difficulties that may be due to VDU work.
In this case, the employee must advise the Line Manager and a referral be made to
Occupational Health outlining the difficulties being experienced.
Eye sight testing may be carried out by the Occupational Health Department and if any
abnormality is found on screening, you will be referred to an Optometrist.
For additional information, please refer to the Staff Handbook.
4.12 Pregnant Employees
In accordance with the Safety, Health & Welfare at work (General Applications) Regulations
2007, Chapter 2 of part 6 Protection of Pregnant, Post-natal and Breast Feeding Employees, a
risk assessment requires to be completed as soon as reasonably practicable after notification of
the pregnancy to the Line Manager.
Notification can be made verbally and accompanied by written confirmation from the GP, the
latter being a legal requirement.
The Line Manager is responsible for completing this risk assessment with the pregnant
employee, advice may be sought if required from the Occupational Health Department.
37
Where there are complex issues requiring further assessment, the employee should be referred
to the Occupational Health Department as a standard management referral. Controls that are
identified are reviewed accordingly and kept in personnel file.
4.13 Dignity at Work
The anti-bullying policy was reviewed under a national partnership initiative and the revised
policy 'Dignity at Work' has formerly become the policy. The HSE Dublin North East
recognises the right of all employees to be treated with dignity and respect in an environment
which is free form all forms of bullying, sexual harassment and harassment. The Dignity at
Work Policy protects employees from bullying, sexual harassment and harassment regardless of
whether it is carried out by a work colleague, patient/client, member of the public, business
contact or any other person with whom employees might come into contact during the course of
their work.
There is a comprehensive complaints procedure in place for further guidance please refer to the
‘H.S.E. Employee Handbook’ or the 'Dignity at Work' Policy. The ‘Dignity at Work’ policy is
available from the Human Resources Department which may be contacted at extension 4655.
4.14 Fire Safety
Fire Detection and Alarm System
Our Lady of Lourdes Hospital has an Analogue Addressable Fire Alarm System. This is
installed in compliance with IS 3218, “Code of Practice for Fire Detection and Alarm Systems
for Buildings. – System Design, Installation and Servicing”
The main Fire Alarm panel is located in the telephone exchange room. Repeater Panels are
displayed at Nurses Stations and various other locations throughout the premises. Smoke
Detectors are located in all rooms except bathrooms and kitchens. Heat Detectors are located
within the Kitchen / Canteen areas. The Fire alarm and emergency lighting system is serviced
on a quarterly basis as per current Fire Regulations.
Emergency Lighting
38
The hospital has an adequate means of emergency lighting. These emergency lights are put in
place to:
Facilitate the means of escape from the building during any interruption or the general
lighting system.
Indicate clearly a route to a protected area.
Identify the location of portable fire fighting equipment.
Fire Fighting Equipment
The purpose of portable fire fighting equipment is as follows:
To extinguish incipient fires
The extinguishers that are provided are only to be used if it is safe to do so. They are installed
in accordance with the recommendations of B.S. 5306: Part 3:1985 code of Practice for the
installation and maintenance of portable fire extinguisher.
An external contractor (MasterFire Protection) maintains all fire response equipment. The
contractor carries out a check on all equipment, including hoses; extinguishers, etc and ensures
that they are in good working order.
The following fire fighting equipment is available throughout the premises
Fire Blankets
Multi Purpose Powder Fire Extinguishers
Water Fire Extinguishers
Water Hose Reels
CO2 Gas Fire Extinguishers
Fire Drills
Employees will be instructed, during their training, on the evacuation procedures within the
hospital. Demonstrations also take place on the use of Fire Fighting extinguishers during
training sessions. A fire drill should be undertaken at least twice a year and recorded in the fire
log book on site.
The Fire Log Book will be a record of:
Date of fire drill
39
Staff attendance
Type of Fire Lecture (Prevention, Control or Evacuation)
Issues arising from the drill
Fire Orders
Where Fire Orders are displayed throughout premises, the procedures shown on these Fire
Orders are to be followed in an emergency situation. All employees should read these Fire
Orders and make themselves familiar with the procedures.
The Regional Fire Prevention Officer Ms. Selina Kavanagh and Asst Regional Fire Prevention
Officer Ms. Nicola McKenna, Technical Services, Kells, can be contacted at 046-9280414.
4.15 Waste Management
All waste must be segregated and disposed of in a safe and responsible manner. Particular
care is needed in disposal of sharps and healthcare risk waste. Clinical Waste must be disposed
of in accordance with the H.S.E’s ‘Guidelines for the Handling and Storage of Healthcare
Waste’2004. Our Lady of Lourdes complies with guidelines for the Management of Chemical
Waste 2004 and in the disposal of Chemical Waste.
The Maintenance Department is responsible for arranging the collection of healthcare waste
from each Department and also responsible for the removal of chemical waste as required.
Collections of healthcare risk waste takes place on a daily basis at regular intervals. Dangerous
Goods Safety Audit is carried out by the Dangerous Goods Safety Advisor in consultation with
the Health & Safety Department. Reports are issued and recommendations addressed on an
ongoing basis.
4.16 Manual Handling
An operational plan is currently being developed with regard to manual handling for the
hospital. Training will be provided by qualified and competent Instructors as per the Moving
and Handling Policy. (Refer to page 16 of the Moving & Handling Feb 08 for arrangements for
the provision of training)
Manual Handling Instructors
Name Location
Ian McGovern, Co-Ordinator Physiotherapy
40
Grainne Vavasour Physiotherapy
Miriam Gamble Physiotherapy
Rosie Clarke Post-natal
Felicity Parkes 5th Floor
The Operational Services Manager is responsible for organising and coordinating the training
programme for the Hospital. The coordinating of this training programme is delegated to Ian
McGovern, Physiotherapy Department. Copies of all manual handling records are held in the
Operational Services Department. All Manual Handling tasks must be risk assessed and lifting
avoided where possible by provision of equipments e.g. hoists, sliding sheets trolleys etc, or
other mechanical devices e.g. (lifts, etc). Where manual handling cannot be avoided, the Head
of Department undertakes a risk assessment in consultation with employees to identify control
measures required to minimise the risks from manual handling.
For further information in relation to Manual Handling, please refer to HSE Dublin North East
Moving and Handling Policy 2008.
4.17 Chemicals
Under the Safety Health and Welfare at Work (Chemical Agents) Regulations 2001 it is the
duty of the employer (Line Managers) to complete a Chemical Risk Assessment for hazardous
products. In order to complete this assessment, a Safety Data Sheet with sixteen headings must
be obtained from the supplier. Details can also be obtained from the label of the product. On
completion of this Risk Assessment, the details must be communicated by the Line Manager to
all relevant staff in that area. Training in the completion of Chemical Risk Assessment will be
provided as appropriate to Heads of Departments.
All chemicals/cleaning agents are stored in accordance with manufacturer’s instructions in
appropriate locked storage cabinets.
For further information, please refer to Safe Work Practice on Chemical Safety – SWPS 1- Use
of Chemicals.
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4.18 Medical Gases
Medical Gas Cylinders are stored in a locked storage area based at the lower ground floor in the
Maintenance yard. These gas cylinders are stored in accordance with manufacturer’s
instructions e.g. stored upright, chained etc. Safety data sheets for all BOC gases are provided
and located in the storage area. Any replacement cylinders required in clinical areas are carried
out by the hospital porter with the use of a purpose made trolley,
Boilerhouse staff attend training in the management of liquid oxygen and BOC gases.
All empty cylinders must be returned to this storage area by porter. Appropriate hazard warning
signs are displayed at the locked storage area and at the liquid bulk oxygen tank.
Relevant orientation is given to new employees by the Support Services Department in relation
to the transport and setting up of medical gas cylinders.
For further information please refer to Safe Work Practice on Gas Cylinders – ref no. SWPS
12-Gas Cylinders.
4.19 Electrical Safety
Electrical installations and portable electrical appliances must comply with current Health &
Safety and electrical installation regulations.
Faulty or defective leads, plugs, switches, sockets of electrical equipment must be taken out of
service, appropriately labelled and reported to Line Manager or supervisor.
Repairs to all electrical equipment and appliances are carried out by a competent person.
It is the responsibility of all employees to ensure that electrical leads and cables are distributed
in such a manner as not to cause an electrical risk or trip hazard.
All electrical sockets are protected by residual current devices and by fuses or MCBS to protect
against over current or short circuit. In the interest of safety, these devices must be reset by
authorised personnel only. The use of extension blocks are confined to computer equipment
and equipment approved by the Electrical Department.
All Electrical installations are carried out by approved contractors under supervision and
direction of consulting engineers.
42
All workshops within the Hospitals maintenance department are provided with battery operated
hand tools. All other portable tools, e.g. hand grinders, kango hammers, heavy duty drills etc are
110 volt. Contractors carrying out works on the hospital site must ensure that their workers are
provided with 110 volt or battery powered equipment.
The use of 110-volt supply for portable tools is mandatory, but the use of battery-operated tools
is encouraged where possible.
4.20 Slips / Trips / Falls
Employees must take responsibility for their safety particularly in their own immediate working
environment. Defective equipment and hazards in the environment must be reported
immediately. Neat and tidy working is part of this responsibility. The facilities for storage of
files should be used effectively by employees. Files or other such items are not to be stored on
the ground or in positions where trips or collisions with them could occur.
All loose electrical and telephone leads are routed away from pedestrian areas and fed through
cable ports / cable tidies. The Maintenance Department should be contacted where more
permanent re-arrangement of leads and cables is required. The following Safe Work Practise
Sheets exist in relation to house-keeping:
- SWPS 1 (Safe use of Chemicals)
- SWPS 28 (good house-keeping/accident prevention)
- SWPS 53 (cleaning operations)
It is essential that all relevant employees read, understand and work in accordance with the
above SWPS.
All Line Managers undertake risk assessments of their working environment and are required to
put control measures in place to minimise the hazard of slips and trips.
4.21 Maintenance
Maintenance work is carried out in all the hospital’s buildings and grounds by the Hospital’s
Maintenance team and external contractors are used as necessary.
Fire alarm systems and fire extinguishment equipment are serviced annually by external
specialist contractors. Acceptance checks are carried out on all newly delivered medical devices 43
by the Clinical Engineering Department. The service and maintenance of medical equipment is
managed by the Clinical Engineering Department who determines as to whether the service and
maintenance of medical equipment is serviced in-house or by external specialists or on a shared
basis between the Clinical Engineering Department and relevant external specialists.
Statutory inspections of certain equipment such as steam boilers, calorifiers, pressure vessels,
elevators, hoists etc are carried out by qualified personnel as required by legislation.
Many of the hazards identified in the Risk Assessment are being eliminated in the course of
routine building maintenance work.
4.22 Contractors
Contractors will be provided at pre-contract stage with a copy of the Hospital safety statement,
in addition to the relevant Department Safety Statements as will visitors who may be affected by
our work activities e.g. inspectors, suppliers, etc.
They will sign the documents to indicate that they have read and understood them. They will
perform their work in accordance with H.S.E. requirements. It is implied in this condition that,
in its work activities, the contractor or visitors will adhere to recognised standards and
regulations relevant to their works.
Contractors will be required to submit relevant sections of their own safety statement and
method statements at pre-contract stage for examination. Those relating to buildings and their
services will be examined by the Operational Services Manager, Maintenance Manager as
appropriate and a representative of the Estates Department where necessary.
Persons can direct the contractor to amend the statement to ensure safe work conditions.
4.23 Visitors
Visitors are obliged to comply with the HSE NHO Visiting Policy. Visitors are obliged to
follow any instructions given by Hospital Personnel. Visitors should not enter “Restricted”
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areas. Public fire safety notices are posted throughout the Hospital complex. The no smoking
policy must be adhered to by all members of staff, patients, visitors and service users
4.24 Transport
Based on risk assessment a Traffic Management policy is in place for the Service yard to ensure
the safety of staff and service users. The speed limit in the Service Yard is 5mph, 8km. A
Traffic Marshall is on duty from 8am to 4.30pm Monday to Friday, to manage traffic flow and
pedestrian safety. Appropriate training has been provided to all Traffic Marshals. Pedestrian
traffic in the yard area is managed by means of clearly defined and barrier protected walkways.
Interface between traffic and pedestrians are managed on the hospital campus by providing
walkways and pedestrian crossings. Appropriate signage is in place where necessary. Control
barriers and speed ramps are used to restrict vehicular traffic and control access and egress.
Five parking spaces are reserved for service personnel while on duty in the hospital. All
security staff outside the barrier protected area must wear hi-vis jackets.
A number of designated disabled parking bays are available on both the main hospital site and
also at Crosslanes Car Park. A dedicated shuttle bus service is available to transport patients
and visitors from Crosslanes car park to the main hospital site.
4.25 Emergency Situations
In the event of total electrical failure the hospital’s emergency generator will maintain supply to
all areas and systems. The generator will distribute power within twenty seconds, during this
brief situation; a plan is in place to mitigate against a number of potential occurrences. In the
event of electrical outages, the generator service will kick in at the hospital preventing any
undue risk to patients or staff. Presently an internal emergency plan is being developed in Our
Lady of Lourdes Hospital.
4.26 Shared Workplace
Where the Health Service Executive Dublin North East share a workplace with another
employer, employees can suffer accidents or ill health when they are not aware of the risks they
face which may be generated by one or other of the various employers sharing the workplace.
45
The arrangements at Our Lady of Lourdes Hospital has in place with Primary Community and
Continuing Care (PCCC) within the hospital include the following:
A copy of this safety statement is forwarded to PCCC managers who are located in this
hospital.
Fire Safety training is available to all occupants within the building including PCCC
staff.
4.27 Information
The HSE Dublin North East has acquired published safety material relevant to its work
activities. This material includes legislation, standards, guidance notes and codes of practice
together with some journals and publications from occupational safety and health organisations.
Sources of health and safety information are as follows:
Safety Data Sheets
Manufacturers/Suppliers Manuals
HSE DNE Policies and Procedures
Safe Work Practice Sheets
Standard Operating Procedures
Occupational Health Department
Health and Safety Department
Risk Management Department
4.28 Lone Worker/Lone Working
Lone Workers are staff who work by themselves without close or direct contact with colleagues i.e. staff working out of hours in Laboratory & X-ray Departments.
A Risk Assessment for Lone Working is completed by the Head of Department in consultation with staff and attached to Section 10 of this document.
4.29 Welfare
Our Lady of Lourdes hospital recognises that staff will experience ill health from time to time
and therefore support the staff in order to improve or maintain their health by
Keeping in regular contact with staff member who is on sick leave
Referral to Occupational Health Department where appropriate
46
Informal return to work meetings with staff who have been on long term sick leave.
Discuss additional training needs with staff if relevant(The above as per Management
Attendance Policy)
Other arrangements in place include:
Dining Room/Canteen provided for staff usage
Water coolers at strategic points throughout the hospital.
Rest Room available for staff to Breast Feed
Provide information leaflets on Staff Counselling. Staff Care provides counselling
services to HSE Dublin North East Employees. This service can be accessed directly by
phoning the free phone Careline, on 1800 409388. When contacted, the Staff Care
Counsellor will respond sensitively to the employees’ needs. All Staff Care Counsellors
are professionally qualified with relevant counselling experience. For further details
please refer to brochure on Staff Care which is available from your Head of Department
or from Occupational Health.
Our Lady of Lourdes hospital aims to promote and change the physical, mental and social well-
being of its employees, the following are available to staff in Our Lady of Lourdes hospital.
Smoke Free Policy & Provide Smoking Cessation Assistance, contact Martin Smith on
0857439448 .Staff are entitled to One month’s free nicotine Replacement Therapy if
seen by service
Health promotion days & initiatives, contact Health Promotion Corner at 4732/ 4790
Specific Staff health checks are carried out in conjunction with relevant National
campaigns (i.e. Irish Heart Foundation’s Blood Pressure Awareness Day)
Our Lady of Lourdes hospital has received Silver level status in the health Promoting
Hospital’s Breastfeeding Supportive Workplace Award.
Ongoing staff information and advice on healthy lifestyle is available at the Health
Promotion Corner
The HP department also facilitate ongoing programmes / training and awareness/
information initiatives for staff
Our Lady of Lourdes Initiatives:
47
Secure bicycle racks for staff are situated at the back entrance to the hospital ( Beside
laundry)
Special price reductions for staff members have also been negotiated with local leisure
centres.
Physical activity programmes for staff are held regularly in collaboration with the regional
physical activity coordinators i.e. ‘ Operation Transformation’
The hospital participates each year in the health promoting hospital network’s national
“Challenge Day” in May. Our Lady of Lourdes hospital has won its category in this
competition for the last three years.
The staff dining room has been audited externally and has obtained the Irish Heart
Foundation’s Happy Heart at Work Award and offer health options to all hospital staff.
Smoke-Free at Work – A policy for the Health Service Executive
Smoking is strictly prohibited within all buildings owned or occupied by the Health Service
Executive including offices, hallways, waiting rooms, restrooms, lunchrooms/canteens,
elevators, meeting rooms and all community work areas. This policy applies to all employees,
clients, contractors and visitors. It also should be noted that Health Service Executive vehicles
are regarded as a place of work under the Act, and so smoking is also prohibited in all vehicles
owned, or leased to the Health Service Executive. Smoking will be permitted at a reasonable
distance outside any enclosed area where smoking is prohibited to ensure that environmental
tobacco smoke does not enter the area through entrances, windows, ventilation systems or any
other means. Smoking will not be permitted in any circumstances during normal working time,
and employees wishing to smoke may only do so during their official break periods.
Our Lady of Lourdes hospital is a member of the European Smoke Free Hospital Network and
the local committee audits the smoke free status of the hospital each year. Our Lady of
Lourdes hospital has been awarded silver status for the past three years. The hospital’s smoke-
free multidisciplinary committee monitors the policy and related signage at all entrances. All
staff are reminded of the policy at induction and there is a smoking cessation counsellor
available free to any staff wanting to quit. Staff can also receive a free months’ supply of
Nicotine replacement therapy when attending the counsellor.
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Section 5.0 Risk Management Process
5.1 Risk Assessment
A Risk Assessment is a systematic and critical examination of the workplace for the
purpose of identifying hazards, assessing the risk and recommending controls of the
hazard where appropriate. Where hazards cannot be eliminated, control measures will
be recommended to reduce the risk to an acceptable level
In accordance with Section 19 Safety Health and Welfare at Work Act 2005, Risk
Assessments have been completed for Our Lady of Lourdes Hospital.
Within the Risk Assessment persons responsible for ensuring that additional
recommended controls are implemented within agreed timeframes are named.
Employees will be made aware of the Risk Assessments relevant to their work
activities. A Risk Assessment will be reviewed where:
(a) there has been significant change in the matters to which it relates, or
(b) there is another reason to believe that it is no longer valid, e.g. new
legislation, following an accident, introduction of a new process, etc.
Following the review, Risk Assessments will be amended as appropriate.
The selection and implementation of the most appropriate method of risk or hazard
control is a crucial part of the risk assessment process.
Persons carrying out Risk Assessments will have regard to Schedule 3 of Safety
Health and Welfare at Work Act 2005
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5.2 The Risk Management Process as outlined in Figure 1 below comprises of
the following four steps:
Step 1 Identification of the Hazard
Step 2 Identify the Risks associated with the hazard
Step 3 Assess (i.e. Rate) the risks
Step 4 Identify any additional control measures (if any) required (i.e.
Evaluate and Treat the Risks)
Communicate and Consult:
Describe the communication and consultation process in relation to risk
assessment.
Figure 1 below outlines the Risk Management Process.
Each of the 4 steps in the risks management process are described in detail below.
Com
mun
icat
e an
d C
onsu
lt
Monitor and R
eview
Assess (Rate) the Risks
Identify the Risks associated with the Hazard
Identify any additional control measures if required
(Evaluate and Treat the Risks)
Identify the Hazard
Figure 1 – Risk Management Process
50
Step 1 Identification of hazards
The first step in safeguarding safety, health and welfare is to identify hazards.
To help identify hazards it is useful to categorise hazards as the following
Physical
Chemical
Biological
Psychosocial
Step 2. Identification of risks associated with hazards
This step starts with describing the risks associated with and persons affected by each
of the hazards identified. It is important that the description of each risk provided,
accurately and comprehensively captures the nature and impact of the risk.
As the information from this process may be included in the relevant risk register the
risks should be described using the following process:
The ‘ICC approach’ to risk description
o Risk is inherently negative, implying the possibility of adverse
impacts. Describe the potential area of Impact if the risk were to
materialise.
o Describe the Causal Factors that could result in the risk materialising.
o Ensure that the Context of the risk is clear, e.g. is the risk ‘target’ well
defined (e.g. staff. Patient, department, hospital etc.)
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Step 3. Assess (Rate) the Risks
The next step in the process is to rate the risk associated with the hazard (risk
analysis). Rating of risk is carried out taking account of existing control measures.
Two elements need to be determined when assessing the level of risk posed:
i.e.
1. The likelihood that a specified event may occur or reoccur.
and
2. The impact of harm to patients, staff, services, environment or the
organisation as a result of the undesired event occurring.
HSE Risk Matrix (Combining Impact and Likelihood)
Risk Matrix Negligible(1) Minor(2) Moderate(3) Major(4) Extreme(5)
Almost Certain
(5)
5 10 15 20 25
Likely (4) 4 8 12 16 20
Possible (3) 3 6 9 12 15
Unlikely (2) 2 4 6 8 10
Rare/Remote (1) 1 2 3 4 5
Example 1: Likelihood of 3 (Possible) x Impact of 2 (Minor) = 2 x 3 = 6 (Amber) M6
Example 2: Likelihood of 2 (Unlikely) x Impact of 3 (Moderate) = 3 x 2 = 6 (Amber) M6
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Step 4 Identify any Additional Control Measures that are required
(Risk Evaluation and Treatment)
There is a requirement to do all that is reasonably practicable to minimise the risk of
harm to staff, service users and visitors. Therefore once a hazard is identified and the
risk assessed, the necessary control measures must be developed and implemented to
protect safety, health and welfare. Best practice is to remove the hazard, if it cannot be
removed, control measures must be put in place to reduce the risk.
An action plan should be devised for each risk where the assessment completed indicates
that further control measures are required. It is advised that when completing action
plans that high risk hazards are dealt with as a priority. Time frames must be compiled
for the actioning of each hazard identified. Actions must be realistic and timely.
Immediate actions and long term actions must be considered in order to eliminate the
hazard or reduce the risk to an acceptable level.
The General Principals of Risk Prevention are as follows:
o The avoidance or risks.
o The evaluation of unavoidable risks.
o The combating of risks at source.
o The adaptation of work to the individual, especially as regards the design of places
of work, the choice of work equipment and the choice of systems of work, with a
view, in particular, to alleviating monotonous work and work at a predetermined
work rate and to reducing their effect on health.
o The adaptation of the place of work to technical progress.
o The replacement of dangerous articles, substances or systems of work by non-
dangerous or less dangerous articles, substances or systems of work.
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Recording your Risk Assessment:
The results of the risk assessment must be documented in accordance with legislative
requirements
Monitoring and Review
Once control measures have been developed and implemented a systematic and regular
review must be implemented to ensure that the control measures are working effectively.
Control measures must be monitored and evaluated on a regular basis. Sooner or later new
equipment, procedures or substances will be introduced that could lead to new hazards – if
there is any significant change the risk assessment should be amended to take account of
these new hazards and brought to the attention of the relevant personnel. All assessments
should be reviewed on an annual basis. It is the responsibility of the HOD to complete the
RA in consultation with staff. Once these risk assessments are completed a copy is
forwarded to Operational Services Dept and a meeting is organised with Line Manager to
discuss and develop an action plan.
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Section 6.0 Consultation Arrangements
The Health Service Executive recognises that all staff has an integral role to play in the
adoption and management of health and safety and should have effective means for
consultation and representation on health & safety matters.
In accordance with S20 of the Safety, Health & Welfare at Work Act 2005 consultative
structures have therefore been established to facilitate participation by management, staff
delegates and Safety Representatives.
The effectiveness of the consultation arrangements will be reviewed at regular intervals.
Our Lady of Lourdes Hospital have the following consultation mechanisms in place:
Safety Representative
Safety Committee
Health & Safety is an agenda item at staff meetings
6.1 Safety Representatives:
Section 25 of the 2005 Act states that employees are entitled to select and appoint one of their
number to represent them in matters of health, safety & welfare.
Safety Representatives are nominated/elected on a three-year cycle. The Safety Representatives
for Our Lady of Lourdes Hospital are :
Martin Smith, Health PromotionTel: 041 9874732 Bleep 358Email; [email protected]
Laura Muckian, Labour Ward Tel: 041 9837601 ext 2122Email: [email protected]
Mary Hewitt, Support ServicesTel: 041 9874649Email: [email protected]
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Training of Safety Representatives is ongoing. Time off as may be reasonable is given to Safety
Representatives to carry out their functions and to acquire training and information on matters of
safety, health and welfare.
Section 25 of the Safety, Health & Welfare at Work Act 2005 states that the Safety Representative
may:
Make representations to their employer on any aspects of safety, health and welfare at the
place of work.
Inspect the place of work after giving reasonable notice to their employer. The frequency
and schedule of inspections must be agreed between the Safety Representative and the
employer in advance
Inspect the place of work in the event of an accident, dangerous occurrence or a situation
of imminent danger or risk to health and safety.
Investigate accidents and dangerous occurrences provided they do not interfere with or
obstruct any person fulfilling their legal duty.
After giving reasonable notice to their employer, investigate complaints made by
employees whom they represent.
Accompany a HSA Inspector on a tour of inspection.
At the discretion of the HSA Inspector, accompany the Inspector while they are
investigating an incident or dangerous occurrence.
Make oral or written representations to the HSA Inspectors on matters relating to health,
safety and welfare at the place of work.
Receive advice and information from the HSA Inspectors on matters relating to health,
safety and welfare at the place of work.
Consult and liaise with other Safety Representatives appointed in the organisation.
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Consultation Arrangements
6.2 Safety Committees:
There is a Safety Committee in place which meets at 2 monthly intervals. Members as follows:
Margaret Swords, Group General Manager (Chair) Tel: 041 9874693 Email: [email protected]
Yvonne Gregory, Operational Services ManagerTel: 041 9874773Email: [email protected]
Karen McKiernan, Health and Safety Advisor DNETel: 046 92 80554Email: [email protected]
Denise Melia, Occupational Health and SafetyTel: 041 9874701Email; [email protected]
Roisin McMahon A/Support Services Manager Tel: 041 [email protected]
Martin Smith, Safety Rep Health PromotionTel: 041 9874732 Bleep 358Email; [email protected]
Laura Muckian, Safety Rep, Labour Ward Tel: 041 9837601 ext 2122Email: [email protected]
Mary Hewitt, Safety Rep, Support ServicesTel: 041 9874649Email: [email protected]
Bernadette Boylan, Catering Officer II Tel: 041 9837601 ext [email protected]
Aoife Carroll, Occupational HealthTel: 041 6857811Email: [email protected]
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Adrian Cleary, Assistant Director of NursingTel: 041 9874636Email: [email protected]
Mairead Twohig, CNS, Infection Control DeptTel: 041 9837601 Ext 2514 Email: [email protected]
Rose Byrne, Health PromotionTel: 041 9874732Email: [email protected]
Ian McGovern, PhysiotherapyTel: 041 9874662Email: [email protected]
Frances McNamara, ICTTel: 041 9874695Email; [email protected]
Elaine Conyard, PharmacyTel: 041 9837601 Ext 2604Email: [email protected]
Niall Kelly, FinanceTel: 041 9805721Email: [email protected]
Irene O’Hanlon, Risk AdvisorTel: 041 9837601 Ext 2226Email: [email protected]
All Safety Committee meetings will be minuted and the minutes circulated to Heads of Service with a request to discuss with staff for information and action as appropriate.
Terms of Reference as follows:
Make recommendation on the amendments to the Safety Statement when:
a) There has been significant change in the matters to which it relates, or.
b) There is another reason to believe that it is no longer valid, e.g. new legislation,
following an accident, introduction of a new process, etc.
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To ensure that the risk assessment process meets the requirements of the Act in the terms of a
comprehensive assessment of all hazards and risks, existing and foreseeable, relating to
buildings, equipment, work practices and work systems.
Monitor the implementation of the remedy and controls recommended for hazards in each
location.
To carry out an on-going review of all relevant policies and practices.
Act as the forum for consultation with staff and for dealing with occupational health, safety &
welfare issues at the location within their control.
Review accident and incident trends and identify and advise on measures to reduce same.
Identify and advise on training needs.
Our Lady of Lourdes Hospital Health & Safety Committee are represented at the Quality
Assurance Programme Working Group which monitors the compliance with Health & Safety
Audit and Quality Improvement Plans. This Group report progress on compliance of the Seven
Standards Programme, which includes Health & Safety to the Louth / Meath Quality & Risk
Committee.
The Quality & Risk Committee in turn provides assurance to the Executive Management Board.
Health & Safety issues are also discussed at Senior Management Team Meetings. See Appendix 2
for Quality and Risk Programme.
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Section 7.0 Resources
7.1 Resources
It is necessary to expend resources in order to achieve the implementation of the safety
management programme. This takes the form of personnel, time and finance.
Personnel
Considerable time resources have been expended by management in implementing the Safety
Management Programme, developing Safety Statements, monitoring and reviewing Risk
Assessments, Safe Work Practice Sheets and consulting with employees. Additional specialist
input is made by the Health and Safety Coordinator, Moving and Handling Instructors, VDU
Assessors, Safety Representatives, Occupational Health Department, Estates Department,
Infection Control Department and Fire Officer among others.
Maintenance
Dedicated efforts of the maintenance department in terms of time, materials and services are
directed to improving plant, equipment and facilities with consequent improvements in the
hospitals Health & Safety management programme.
Training
The training mentioned in Section 4.5 is provided to all relevant employees in Our Lady of
Lourdes Hospital. This consumes financial and direct resources (time, materials and equipment).
Personal Protective Equipment
Adequate and suitable personal protective equipment is provided to employees based on the risk
assessment requirements at considerable financial and time cost to Our Lady of Lourdes Hospital
Management are committed to the provision of such protective equipment as is deemed
necessary.
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Direct Costs
There are direct costs involved in eliminating or reducing hazards, purchase of personal
protective equipment, warning signs, guards, on a needs basis etc. The Operational Services
Manager estimates these costs, which are submitted to the General Manager with other budgetary
requirements from Health and Safety Risk Assessment.
Direct costs may be estimated under the following headings:
Personal Protective Equipment
Warning Signs
Health and Safety related training courses
Implementation of Risk Assessments
Safety Representative Consultations
Information Workshops
Immunizations/prophylactic treatment
Health Surveillance
Occupational Hygiene Monitoring for Work Exposures
Others
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Section 8.0 Distribution / Access to the Safety Statement
On completion of the Hospital Safety Statement, this will be forwarded to all departments
in hard copy format. Sections 1-9 will be completed and revised by Hospital
management. Section 10 must be completed by the Heads of Departments. It is
imperative that the Line Manager discusses all aspects of the Safety Statement during
their team meetings with their employees. The Safety Statement should be an agenda
item at team meetings. It must be located in the Health & Safety folder for all staff to
access. There is a responsibility on all employees to read, understand and work in
accordance with its contents. Communication Plan being devised which details how
documentation relating to Health and Safety is to be communicated to employees. (See
Appendix 3)
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Section 9.0 Review/ Revision of the Safety Management Programme
9.1 Safety Statement
This Safety Statement and associated Risk Assessments are required to be reviewed when:
(a) There has been significant change in the matters to which it relates, or
(b) There is another reason to believe that it is no longer valid, e.g. new
legislation, following an accident, introduction of a new process, etc.
(c) If there is direction from the Health & Safety Authority following
inspection to have the Safety Statement amended.
This Safety Statement will be reviewed by the responsible persons. Section 1-9 will be
reviewed by hospital management in consultation with the safety committee and section
10 will be reviewed in accordance with the above statements by the Line Managers.
9.2 Safety Management System
Safety and Health Audit Tool for the Health Care Sector (HSA) is carried out on an
annual basis and a quality improvement plan is developed from the findings. Progress is
reported on a quarterly timeframe basis as required by the National Hospitals Office.
Actions are continuously been implemented. The following Key Performance Indicators
were identified and agreed to monitor safety and health performance:
1. The organisation has completed the annual health and safety self-assessment and
identified areas for improvement.
2. The self-assessment results and associated list of quality improvement plans (QIPs) have
been reviewed and signed-off by the clinical governance (or appropriate) committee
3. The organisation has a documented safety and health policy
4. Organisation has in place up-to-date safety statement, in accordance with requirements
5. The content of the safety statement is brought to the attention of all employees at least
annually
6. Percentage of Managers trained in Risk Assessment process.
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Section 10.0 Department / Unit Safety Statement
10.1 Introduction
This is the Department Safety Statement and associated risk assessments for Our Lady of Lourdes Hospital, Drogheda, Co. Louth
This section should contain all relevant department / unit risk assessments e.g.
Physical environment to include the management of violence Biological Agents Chemical Agents Lone Working VDU
This is not an exhaustive list.
Signed: ___________________
Date: ___________________
Appendix 1
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The range of acute services is as follows
MEDICAL SERVICES:General MedicineEmergency MedicineCardiologyEndocrinology/Diabetes OncologyDermatologyGeriatric MedicineRespiratory Medicine Physical MedicinePalliative Care
SURGICAL SERVICES:General SurgeryOrthopaedics UrologyIntensive CareE.N.T
Anaesthetics
SPECIALIST SERVICES:OphthalmologyPaediatric & Neonatal Obstetric/Gynaecology Nursing & Midwifery ServicesHaematology Clinical Support PathologyRadiology
Bed Complement
The current bed complement is as follows
Our Lady of Lourdes, Drogheda Louth County Hospital, Dundalk
Inpatient Beds;o Medicine 90 71o Surgery 52 32o Orthopaedic 27o Paediatrics 40o Obstetrics 57o Gynaecology 18o ICU 4 2o CCU 3 4o HDU 3o NICU 16o Day Surgery 14o Five Day Ward 14
Total 310 (of which 99 are private) 137
There are also 30 day beds in Our Lady of Lourdes Hospital.The following is also located in the grounds of Louth County Hospital:
16 Bed High Support Mental Health Unit 150 Bed Geriatric nit Psychiatric Unit Alzheimer’s Unit
Current Configuration of Consultants and Services
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All recent Consultant posts in Our Lady of Lourdes have cross site commitments to either Louth County Hospital or Our Lady’s Hospital, Navan.
Our Lady of Lourdes Louth County HospitalMedicine:
7 Consultant Physicians. 3 Consultant Physicians 1 Specialising in Geriatrics, 1 Specialising in Geriatrics, 1 Specialising in Respiratory, 1 Specialising in GIT 1 Specialising in Cardiology, 1 Specialising in Endocrinology, 1 Specialising in Dermatology, 1 Specialising in Palliative,
A second Consultant Cardiology post has been approved for the hospital group.
Surgery: A joint department of surgery was established in 2004 between Louth County, Dundalk
and Our Lady of Lourdes Hospital, Drogheda. There are 6 consultants with a special interest in Breast, paediatric and upper and lower
GIT. There is a one stop shop for breast services which caters for the North East Region.
Radiology: 9 Radiologists. 2 of whom have a sessional commitment to Louth County Hospital. In 2005 an MRI scanner was installed and house in portacabin on site at Our Lady of
Lourdes Hospital, Drogheda. CT for Louth County, Dundalk, Our Lady’s Hospital, Navan are all carried out in Our
Lady of Lourdes Hospital, Drogheda.
Our Lady of Lourdes Louth County HospitalAnaesthetics:
9 consultant anaesthetists. 3 consultant anaesthetists (one recently appointed)
One of which specialises in Intensive Care
Accident and Emergency: 3 Emergency Medicine Consultants. 2 of whom have sessional commitments to Dundalk and Navan.
Orthopaedics Surgery: 8 Consultant Surgeons. Regional Orthopaedics services are deliver across two sites Our Lady’s Hospital Navan
for elective operations and Our Lady of Lourdes Hospital Drogheda for Trauma operations
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Obstetrics and Gynaecology: There are 7 consultant Obstetricians/Gynaecologists. One of which specialises in Maternal Foetal Medicine. In June 2004 a new midwifery led unit was launched.
Paediatrics/Neonatology: There are 6 paediatric consultants. 1 of whom specialises in community child health. 2 of whom are neonatologists who supply neonatology service to the entire North East
Region.
Pathology:There are 3 Histopathologists and 1 recently appointed Haematologist.
Sessional Consultants:
Sessional services are provided for the following areas, Occupational Health Urology ENT Surgery Oncology Ophthalmology Endocrinology and Diabetes Mellitus Rheumatology Infectious Diseases
Appendix 2 Quality Assurance Programme
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Appendix 3 Communication PlanHealth and Safety
Communication Plan –Reviewed Sept 2010
Mode of Details of Use Frequency Responsible Evidence of
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Communication
effectiveness
Email Periodically messages/updates will be sent out via ‘T’ Drive to disseminate key Health and Safety Documentation including OLOL Safety Statement and all new and revised Health and Safety Policies and Procedures.
As required Denise MeliaOperational Services
Random checks call to wards/departments
Safety Audit
Notice boards Notice boards identified and will be used to display Health and Safety updates namely back stairs, canteen area.
Monthly Denise MeliaOperational ServicesHealth and Safety Committee
Questionnaire on H & S knowledge to be developed
Team/Departmental
Meetings
Health and Safety is a standing agenda item at the Louth/Meath Senior Management Team Meetings
Health and Safety Committee meeting feedback to the Management Team on a bi monthly Basis.
Health and Safety is also an agenda item on all ward/ departmental meetings, CNM111, ADON’s /CNM 11 Multidisciplinary team meetings
Minutes of Health and Safety Committee Meetings will disseminated to all departments via T Drive
Bi Monthly Denise MeliaOperational ServicesHealth and Safety CommitteeHeads of Depts
Feedback from team members from participation on various committees of increased staff awareness
Information Sessions
Induction Presentation on OLOL Safety Management System.
Health and Safety information/education sessions will be provided to staff as required to raise profile of Health and Safety in OLOLH.
Health and Safety ‘Awareness Days’
As required
Number of sessions will be provided.
Periodically
Denise MeliaOperational Services
Karen McKiernan Health and Safety Coordinator - Hospital NetworkHSE DNE Area
Health and Safety Committee
Staff attendance records
Staff attendance records
Evaluation Form to be developed
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