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Health and safety policy

1 Document summary

The health and safety policy is an overarching document detailing the organisation and arrangements for managing health and safety in the trust. This includes defining roles and responsibilities to ensure that the trust meets it legal obligations regarding the requirements of the Health and Safety at Work Act (1974) and associated regulations.
The first part of the policy is a health and safety statement, or statement of intent that summarises the trust’s commitment to health and safety and is signed by the trust’s most senior person, the chief executive.

Information about individuals with specific responsibilities for health and safety are detailed in section 4, whilst section 3 details the practical arrangements for ensuring effective health and safety management. These include consultation processes, risk assessments, safety equipment and employee training.

2 Introduction and aim

The trust owes a duty of care to employees, patients and others who use its services. The Health and Safety at Work Act requires employers to prepare and maintain a statement showing the policy on safety and the organisation and arrangements put in place to ensure the general policy is carried out. The Management of Health and Safety at Work Regulations extend this requirement and the need to ensure that the arrangements are documented where there are five or more employees. This policy provides details of the health and safety arrangements in place in the trust.

As part of the legal requirements the policy must contain the following:

  • a general statement of intent which summarises how the trust will manage health and safety (specifying objectives) (see section 2.1)
  • organisation of health and safety (people and their duties)
  • arrangements (systems and procedures), this part of the policy deals with how the policy will be implemented

The policy applies to all trust employees, patients, visitors and others to whom the trust owes a duty of care. It specifically relates to non-clinical risks and whilst there is an overlap in many areas with clinical risks, these are supported by a suite of patient safety policies and procedures which are not within the scope of this policy.

2.1 Health and safety policy statement

It is the trust’s policy to ensure, as far as reasonably practicable, the health, safety and welfare of all employees whilst at work and to have due regard for the health and safety of patients, visitors and others.

Every employee has a statutory duty to take reasonable care of their own health and safety and that of others who may be affected by their acts or omissions at work and to co-operate with the trust to meet its duties. To enable these duties to be carried out it is the intent of the trust to ensure that responsibilities for health and safety are effectively assigned, accepted and managed at all levels within the organisational structure, consistent with good practice throughout the trust.

The trust will, so far as reasonably practicable:

  • provide and maintain safe and healthy work environment conditions, safe equipment and safe systems of work
  • provide and maintain a safe workplace with safe access and egress
  • ensure the storage, handling, usage and transport of articles and substances is safe and without risk to health
  • provide all employees with information, instruction, training and supervision as necessary to secure their safety and health at work
  • ensure risk assessments are carried out where necessary
  • ensure monitoring activities are undertaken to maintain safety standards

The health and safety lead is the competent person as required by the Management of Health and Safety at Work Regulations (1999) who will assist the trust in undertaking the measures needed to comply with relevant statutory provisions. The trust will provide the health and safety lead with sufficient authority and resources to implement the health and safety policy.

The Health, Safety and Security Forum will provide and maintain effective measures for consultation and communication between all levels of management and employees on any matter regarding the trust’s health and safety arrangements. The trust expects the full co­operation of all employees to ensure continuous improvement of standards in all aspects of Health and Safety.

Toby Lewis, Chief Executive.

3 Procedure

The requirements of this policy will be met by:

  • the development of other subject-specific policies, procedures and guidance that meet the requirements of applicable health and safety law; refer to section 9
  • ensuring that suitable and sufficient risk assessments are carried out by managers and controls are put into place to reduce the level of risk in their areas of responsibility
  • the provision of appropriate health and safety training
  • carrying out effective consultation with recognised trade unions, employee and employee safety representatives

To summarise the key elements of health and safety management are:

  • carrying out a risk assessment to identify work hazards (anything with the potential to cause harm), such as manual handling, use of chemicals or unsafe work environments
  • identifying and implementing controls to reduce the risks; these include considering whether the hazard can be avoided and if not controlling it by redesigning the job, introducing procedures for working safely with the hazard or using personal protective equipment (PPE) where there are no other suitable controls available
  • consulting employees about proposed changes to their work and involving them in carrying out risk assessments
  • communicating relevant information about health and safety, such as the findings from risk assessments
  • providing relevant information, training and supervision to ensure safe working practices
  • reporting accidents and near misses
  • monitoring health and safety arrangements

3.1 Risk assessment

Risk assessment is a core element of an effective health and safety management system. It enables the identification, quantification and control of work-related hazards that may pose a risk of personal injury, damage or loss of equipment or premises. It is a legal requirement under the Management of Health and Safety at Work Regulations (1999) to carry out risk assessments and to establish controls to reduce the level of risk identified. Risk assessments should be carried out before work is undertaken that gives rise to the risk, when tasks or processes change, if new technology is introduced or if there is a change in legislation.

Assessments should be reviewed on an annual basis or if there is an incident that indicates that existing controls are inadequate. Guidance on carrying out risk assessments and templates is available to employees on the trust’s intranet site and within subject-specific health and safety policies.

A “suitable and sufficient” assessment is one that:

  • correctly identifies all reasonably foreseeable significant hazards and risks
  • identifies all of the existing control measures and from this evaluates the level of risk
  • enables the assessor to decide what action needs to be taken, and what the priorities should be
  • is appropriate for the type of activity
  • will remain valid for a reasonable time
  • reflects what employers may reasonably practicably be expected to know about the risks associated with their undertaking

Managers are responsible for ensuring that all significant risks within areas of their control are identified and recorded on a relevant trust risk assessment form. Advice on the completion of these forms may be obtained from the Health and Safety team on the intranet (staff access only).

3.2 Information, instruction and training

The trust will ensure that all employees are provided with the information, instruction, training and supervision necessary to ensure, so far as it is reasonably practicable, their health and safety at work. This includes:

  • local and corporate inductions, job specific and refresher training. Information provided to employees as part of the training will include: health and safety responsibilities, how to report an accident and the trust’s arrangements for managing health and safety risks
  • copies of the poster “Health and Safety Law: What you need to know” are displayed in employee areas around the trust
  • appropriate safety signs are displayed in premises to warn of specific hazards

3.3 Consultation with employees

The trust recognises that an effective safety culture requires a partnership between management and employees working together to identify risks and to improve safety standards and working practices.

In accordance with the Safety Representatives and Safety Committees Regulations (1977), trade unions may appoint safety representatives from amongst employees of the trust, who are members of a recognised trade union. Where employees are not members of one of these trade unions the trust must consult employees directly or via nominated employee representatives in accordance with the Health and Safety (Consultation with Employees) Regulations (1996).

Employees are formally consulted about health and safety at the trust’s Health, Safety and Security Forum that meets every 2 months. The group includes trade union and employee representatives from across the trust. Information from the group is disseminated to care groups for discussion. This includes requesting feedback about health and safety policies and addressing any trust wide or local issues raised by forum members on behalf of the employees they represent.

3.4 Accident and incident reporting

All employees are encouraged to report accidents or near misses as these can be indicative of inadequately controlled risks. All incidents must be reported as per the trust’s incident management policy using the Radar electronic incident reporting system available via the intranet site.

The trust is required to report certain serious events to the Health and Safety Executive (HSE) under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR). Reports are either made by the manager in the area where the injury occurs or by the health and safety lead and recorded on the trust’s incident reporting system.

4 Responsibilities

4.1 All employees

All employees are responsible for acting in a safe manner that does not put themselves or others at risk. This includes:

  • being aware of local safety arrangements such as what action to take in the event of a fire and the actions set out in emergency plans
  • cooperating with health and safety arrangements including attending relevant training
  • using any equipment, dangerous substance, or safety device provided by the trust in accordance with any guidance, information, instruction and training which is provided
  • reporting all accidents or near misses that occur
  • informing their line manager of any circumstances that may affect their ability to work safely, for example, becoming pregnant or suffering from an injury or illness

4.2 Managers

Managers should ensure that employees are aware of the risks and controls relevant to their work and have attended relevant training. Any health and safety issues and incidents should be investigated by the manager and rectified where they have the authority to do so. Where they do not have the authority to deal with such matters they should be brought to the attention of more senior management.

4.3 Health and safety lead

The health and safety lead is the trust’s “competent person” for health and safety as required under the Management of Health and Safety at Work Regulations (1999.)

They will provide information, guidance and training to enable the trust to comply with relevant statutory provisions.

4.4 Other specialist advisors

The trust has a number of other employees and external providers who are able to provide a source of competent advice within their particular specialism and experience. These include:

  • fire safety advisor: the role includes but is not limited to providing advice and assistance to trust employees on all fire related matters, carrying out fire risk assessments and ensuring that there is suitable fire equipment and means of escape in place
  • local security management specialist (security advisor): duties include, but are not limited to, carrying out security inspections, providing security and personal safety advice, carrying out incident investigations and liaising with the police
  • Health and Safety team: duties include but are not limited to providing advice and assistance on health and safety and security matters
  • Manual Handling team: duties include but are not limited to providing training and advice relating to the manual handling of objects and patients and the use of display screen equipment (DSE), assisting managers with manual handling and display screen equipment assessments
  • occupational health: the trust has appointed an external company to provide occupational health information and services to support employee wellbeing

5 Training

5.1 Training course: health, safety and security

  • Employee groups requiring training: all employees.
  • Frequency: at induction, then every three years.
  • Length of the training:
    • online: 20 minutes
    • face to face: 3 hours (including safe use of sharps and waste management)
  • Delivery method: available online and face to face.
  • Deliver by: electronic staff record (ESR) and Health and Safety team.

There is also subject specific training available, dependent on role. This includes moving and handling and safe use of oxygen. Information can be found in role training matrices.

6 Monitoring arrangements

Regular monitoring and review of the safety arrangements is important to ensure that they remain relevant and are working effectively.

Annual health and safety inspections, including review of the physical environment and documentation are carried out by the Health and Safety team on an annual basis.  Ward and building managers should ensure that regular checks of the workplace are undertaken and recorded locally, escalating any risks as necessary.

Employee incidents are monitored on a daily basis and incident trends reported to relevant committees and groups, including the Health, Safety and Security Forum.

This section is about how we will know that the policy is working effectively.

6.1 Health and safety compliance

  • Area for monitoring: health and safety compliance.
  • How: workplace and premises inspections.
  • Who by: carried out by Health and Safety team and local manager.
  • Reported to: Health, Safety and Security Forum.
  • Frequency: annually.

6.2 Health and safety performance

  • How: annual health and safety report.
  • Who by: health and safety lead.
  • Reported to: board of directors.
  • Frequency: annually.

6.3 Ongoing health and safety issues

  • How: minutes of the Health, Safety and Security Forum.
  • Who by: forum chair.
  • Reported to: Risk Management Group.
  • Frequency: bi-monthly.

7 Related documents

The trust has numerous other policies which support the health and safety of staff, patients, visitors and others to whom owes a duty of care. These are available on the trust public website.

Document control

  • Version: 3.
  • Unique reference number: 501.
  • Approved by: Risk Management Group.
  • Date approved: 7 April 2026.
  • Document author: health and safety lead.
  • Title of accountable director: chief nurse.
  • Date issued: 17 April 2026.
  • Review date: April 2029.
  • Target audience: All trust staff, volunteers, agency and bank employees.

Page last reviewed: April 17, 2026
Next review due: April 17, 2027

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