Health and Safety Procedurces
Counselling Hub Wales: Health and Safety Procedurces. Reviewed. 20th January 2024
The Managing Director of Counselling Hub Wales wish to make clear their intention to provide a safe and healthy environment for all employees, contractors, volunteers and visitors.
To this end the Managing Director undertakes:
· To provide and maintain safe machinery, equipment and systems of work, so far as is reasonably practicable.
· To provide such information, instruction, training and supervision as is necessary to ensure the health, safety and welfare at work of employees, contractors, volunteers and visitors.
· To provide, as far as is reasonable and practicable, an environment for employees, contractors, volunteers and visitors. that is safe without health risks and adequate as regards facilities and arrangements for their welfare at work.
· To ensure, as far as is reasonably practicable, that all other people coming onto the site (visitors, outside contractors, children, etc.) are not exposed to risks to their health and safety.
The Managing Director needs the help, support and co-operation of ALL employees, contractors, volunteers and visitors in working toward these goals. This policy statement and its arrangements will be brought to the attention of all employees, contractors, volunteers and visitors.. It is subject to revision as necessary to ensure that it is relevant to all operations being carried out. Contractors and volunteers will be consulted and notified of any such revision.
Health and Safety Manual
4.1 General Requirements
Counselling Hub Wales has implemented and maintains a health and safety management system using the framework of HS(G)65.
The Health and Safety Management system consists of a Health and Safety Policy Statement, this manual, management procedures, and work instructions (where deemed necessary). Forms are produced where necessary and records of completed forms are kept to prove adherence to the aforementioned procedures and other standards.
4.2 Health and Safety Policy
A Health and Safety Policy Statement has been developed for Counselling Hub Wales. This is communicated to all persons working under the control of the organisation by displaying at the company’s premises and website. It is also provided as part of the induction process.
Controlled copies of this document are held in the Health and Safety Management System and Computer Folders.
The policy is reviewed to ensure it still meets the requirements of their respective standard, and the requirements and risks of the company.
4.3 Planning
4.3.1 Management system planning
The following sections identify the processes that have been established and maintained with respect to system planning. This information is documented and maintained up to date, and is considered when setting health and safety objectives for the organisation.
Changes to any part of the management system, or other changes which might affect it, are generally announced at a Management Meeting, in order that planning can take place to deliver the change. If deemed necessary, documentation is maintained showing that the effects of the change were considered, and any necessary actions noted and implemented.
4.3.2 Legal and other requirements
Counselling Hub Wales are responsible for identifying and accessing applicable primary and secondary legal requirements to which the company must subscribe. Identification of industry standards and protocols are the responsibility of senior management at Counselling Hub Wales. Contractors providing services are responsible for legal requirements within their sphere of control or influence.
All this information will be developed into legal and other requirements to which everyone must subscribe which will be detailed in the risk assessments.
4.3.3 Planning for hazard identification, risk assessment and risk control
A documented procedure is maintained to ensure that the integrity of the management system is not compromised whenever changes are planned to the organisation or its activities. This procedure is maintained for the on-going identification of hazards, the assessment of risks, and the implementation of appropriate control measures.
See the associated procedure for further information.
4.3.4 Objectives, targets and management programme
Senior Management are responsible for ensuring the health and safety objectives are established for relevant functions and levels within the company. Objectives will be measurable and consistent with the Business Plan, relevant legal and other requirements, and the need for continual improvement. These might be developed into Key Performance Indicators to measure performance.
Management Programmes for achievement of objectives can be suggested by any member of the organisation but will be approved by senior management. These objectives and management programmes are documented in meetings and communicated via induction training, toolbox talks and noticeMDs.
Progress is reported back via the above mechanisms.
4.4. Implementation and Operation
4.4.1 Resources, roles, responsibility and authority
Roles responsibilities and authority are communicated at induction, and through management procedures.
The Staffing Structure document provides information on specific responsibilities and authorities.
4.4.1.1 Management representative
The Directorship is the nominated management representative for Health and Safety Management. This person has the authority and responsibility for:
· Ensuring the requirements of the respective systems defined in this manual are satisfied;
· Designing a management system which provides a framework that is capable of assessing and controlling the risks that the company face, and complying with customer, legal and other requirements to which the company must subscribe.
· Reporting to senior management (when requested) the performance of the management system and any need for improvement
· Assisting in the promotion and awareness of health and safety issues throughout the company
· They will provide leadership to the business on all health and safety issues and be a good example
The Health and Safety Consultant is also available to assist in this task.
4.4.1.2 Responsibility and authority
Current versions of the organisation charts are maintained in other business documentation. Roles, responsibilities and authorities are defined in job descriptions (when necessary), as well as the appropriate procedures.
In addition:
4.4.1.2.1 Managing Director
Ultimate responsibility for the Company’s H&S Policy rests with the MD. This includes ensuring that the necessary resources are made available for compliance with the requirements of the Policy.
The contractors are responsible for implementing Counselling Hub Wales Policy, and for ensuring the health, safety and welfare of all contractors and service users throughout their areas of control.
The MD will ensure that appropriate resources are provided so that health and safety commitments can be met and that appropriate standards and performance targets are achieved. This will include appointing named people to be responsible for maintaining and managing the emergency procedures when necessary. They will ensure that health and safety matters are given equal prominence with all other strategic and service decisions and that business risk implications are assessed before entering into any new activities.
In practice they must make sure that:
· They lead by personal example and set high standards of application in health and safety matters and the requirements of the health and safety management system.
· All relevant operational procedures, codes of practice, instructions and legislation are communicated to, implemented by and adhered to by personnel such as Contractors.
· All hazards are formally identified, assessed for risk and recorded in your areas.
· All possible actions are taken to either eliminate or reduce identified hazards and risks to as low as is reasonably practicable (Woodland and Instructors)
· Contractors are only allocated work according to their capability, and that they are given appropriate instruction, training and supervision to enable them to carry out that work in a safe manner. They will be responsible for identifying and mitigating risks from their services.
· Measures required by any new relevant legislation, approved codes of practice or Counselling Hub Wales policies and procedures are introduced and recorded.
· Safety equipment and personal protective equipment is provided or readily available when required and that it is used / worn appropriately. (Specific PPE to be provided as detailed in agreements between Instructors and Penygraig).
· Safety inspections and audits are conducted by delegates to monitor and review the effectiveness of safety management by directly employed or contractors’ contractors.
· All accidents and hazards are recorded on the accident and incident report form / book and promptly reported. These accidents will be investigated and, where possible, appropriate remedial actions to prevent reoccurrence implemented. In the event of a more serious issue, this investigation may be followed by an investigation by a Health and Safety Competent person or a consultant.
· Prompt corrective action is taken whenever unsafe acts are reported.
· Safety activities arranged by the organisation are fully supported.
· You and your staff co-operate and consult, as appropriate, with the Health and Safety Management Representative on all matters concerning safety, health and welfare.
You and your managers have the authority to make and implement decisions on the behalf of the organisation in order to ensure the elimination of that danger.
4.4.1.2.2 Contractors / Instructors
This level of the organisation is measured on the health and safety related outcomes for the areas of the business that they manage. In order to do this they must:
· Provide visible leadership on health and safety issues
· Carry out proactive monitoring and resolve issues
· Provide risk assessment related to their activity and complying with legal requirements and other relevant standards
· Ensure their staff are competent and have the tools to carry out the tasks that they set them
· Ensure necessary improvements are managed to completion
· Bring and provide required PPE
4.4.1.2.3 Service Users Responsibilities
You must always ensure that you work in a manner that will ensure the safety of yourself and others who may be affected by what you do (or do not do). Therefore you should co-operate at all times and:
· Follow safety procedures.
· Use and never intentionally or recklessly interfere with or misuse specific equipment that is provided in the interests of your own, other employee’s, or our customers’ safety.
· Observe safe standards of dress and wear personal protective equipment or protective clothing where provided.
· Keep the workplace clean and tidy.
· Never attempt to use equipment or carry out tasks unless trained and authorised to do so.
· Inform your manager immediately if you have an accident or discover anything which you feel could cause harm, or which you feel is hazardous or unsafe.
4.4.1.2.3 Emergency Personnel
First Aid Box – will be on each location to ensure adequate first aid equipment needed to cover for contractors, sub-contractors and visitors. Each business unit will be given a first aid box complying with HSE recommendations. Their main responsibilities will be to: Directors are responsable to:
· Ensure the first aid boxes are correctly stocked.
· Ensure that an accident form is completed for all accidents / incidents reported to them, however slight, as soon as possible. Upon completion, the form should be passed to your Manager to be stored securely. A copy of the form should be sent to the MD for review.
4.4.1.3 Provision of resources
The MD shall ensure the availability of resources essential to establish, maintain and improve the health and safety management system. Resources include human resources and specialised skills, organisational structure, technology and financial resources. These resources are considered as part of business planning and are documented in various meeting minutes where necessary.
In addition, contractors are responsible for providing certain resources for H&S. This will be communicated in tender documentation, SLA’s and emails.
4.4.1.4 Infrastructure and work environment
Senior management shall determine, provide and be accountable for the maintenance the infrastructure and work environment needed to achieve conformity to health & safety requirements.
4.4.2 Competence, training and awareness
All contractors / instructors undergo induction training, including site awareness. It is the responsibility of management and their supervisor to ensure that this training goes ahead.
Contractors are responsible for health and safety training in their subject area.
Service Users will be provided with general awareness training Counselling Hub Wales, as well as specific training from the Instructors.
Topics to be discussed as part of Health and Safety training include:
· Any applicable Risk Assessment(s) including actions to keep themselves and others safe
· The Fire Plan and what to do in a fire emergency
· First Aid arrangements
· Security arrangements
· Other items as specified by senior management or in health and safety documents
Competence to carry out work tasks with potential health and safety impacts is determined by Instructors. Instructors will be formally approved to carry out roles.
Similarly, learners will be pre-assessed by counselling hub wales, and supervised by persons leading activities. The degree of supervision will be determined by discussion amongst all parties.
A training log is kept of training whether that be formal training or mentoring.
4.4.3 Consultation and Communication
Internal communication regarding health and safety issues and the effectiveness of the health and safety management system is achieved via a number of means including meetings, toolbox talks / briefings, reports, notices.
These methods ensure that all pertinent information is communicated to and from interested parties.
The Counselling Hub Wales MD is responsible for receiving, documenting and responding to all external communications received from interested parties.
4.4.4 Documentation
The health and safety management system consists of ensure adequate control.
· Health and Safety Manual – This describes the scope of the health and safety management system and the company’s methods of complying to the clauses of ISO45001. Appropriate procedures are signposted from, or included in this document where necessary.
· Policy– this is a statement of commitment to comply with the requirements and continually improve the effectiveness of the management system.
· Procedures – these describe the actions required to achieve the policy and manual stated objectives. These specify who does what, when it is done, and what documentation is used to verify that the activity was executed in the specified manner
· Forms and Records – are defined and maintained in a way that provides objective evidence of the effective operation of the management system and allow practical auditing of the specific procedures.
4.4.5 Control of documents
Documents and data including any electronic information is controlled on the company computer system so that latest versions are consulted upon, approved and communicated.
Paper copies are maintained up to date on site.
4.4.6 Control of records
Records are maintained to provide evidence of conformity to the requirements and of the effective operation of the health and safety management system.
These records will contain sufficient information to ensure that it can be assured that the correct version only is available for use by all.
Section 4.4.7 Operational control
Operations are carried out under controlled conditions. This is generally through the appropriate risk assessment and any method statements. The risk assessment may also include information on the safe ways of working.
Notices and company emails may also be used to communicate this information.
Outsourcing / Contractors
Suppliers, including contractors / instructors, are vetted for competence in the area of Health and Safety Management, and then communicated their responsibilities at induction training (where appropriate).
No contractor / instructor is allowed to work on site prior to approval of a suitable and sufficient risk assessment and method statement.
4.4.8 Emergency preparedness and response
Counselling Hub Wales has in place documented plans that enable effective planning and implementation for emergency situations that may arise which could impact on the health and safety of people.
Specific personnel are made known to service users / instructors / contractors. Plans are tested at regular intervals and the findings recorded after the occurrence of incidents or emergency situations.
4.5 Measurements, Analysis and Improvement
4.5.1 Monitoring and measurement
The company has implemented methods to monitor and measure on a regular basis:
· Operations that can have a significant health and safety impact
· Conformity to the company’s objectives and targets and management system
Records are maintained of all inspections and monitoring activities to demonstrate acceptability to defined parameters, e.g. compliance with applicable operational controls and legislative and regulatory requirements.
Recorded Inspections undertaken include:
· Instructor Inspections and Pre-use checks
· Penygraig Woodland inspections and pre-use checks
4.5.2 Evaluation of compliance
Compliance with applicable legal and other requirements to which the company subscribes is periodically evaluated. These are generally undertaken through Inspections.
4.5.3 Incidents, non-conformances, corrective action and preventative actions
Counselling Hub Wales has a formal procedure for the reporting and investigation of incidents that will be carried out by authorised personnel.
Managers are responsible for ensuring that all accidents and incidents are properly investigated and directed towards establishing the facts, determining the root causes, examining controls and implementing preventative and corrective actions.
All incidents are properly recorded and communicated in line with statutory requirements and Counselling Hub Wales policy. Counselling Hub Wales MD is responsible for completing RIDDOR Reports and submitting them via the HSE Website.
Preventative and corrective action is reviewed to ensure it is effective.
Please refer to the Accidents and Incidents Procedure for further information.
4.5.4 Internal audit
Internal audits are conducted to determine whether the health and safety management system is effectively implemented and maintained. They are also designed to be a tool to seek out continual improvement opportunities. The outcomes are documented, actions agreed and followed to completion. Audit findings are discussed at management reviews and business planning meetings.
4.6 Management Review
Regular reviews are held for ensuring the continuing suitability and effectiveness of the management system to determine if the management system is meeting stated objectives.
This will generally take place annually as part of business planning. The management review have a set agenda of inputs, are documented, and provide outputs by determining decisions and actions on opportunities for improvement, and the need for changes to the health and safety management system.
· Items to be discussed at the Management Review
· Internal Audits
· Suitability of System and Policy
· Non-Conformances (including Accidents and Incidents)
· Audits and Assessments
· Supplier Performance & Problems
· Customer Complaints / Feedback
· Training
· Effectiveness of Procedures (including risk assessments and method statements)
· Corrective and Preventative Actions
· Key Objectives
· Any Other Business
HAZARD ASSESSMENT, RISK ASSESSMENT, RISK CONTROL
Scope
This procedure applies to all operations and services of the Organisation, outsourced service providers or contractors. We recognise that risk assessments are the most essential element of effective health and safety management. Comprehensive risk assessments help us to prevent accidents and ill health by systematically considering the hazards that exist and how we need to manage them.
Purpose
This procedure outlines the steps involved in preparing and carrying out a risk assessment. From these assessments, we can develop safe systems and methods of work and ways to prevent problems occurring so that we are assured that the risks are reduced to a tolerable level.
Specific risk assessments are required by certain regulations and also potentially to take account of differences in people. These regulations may contain a reference to the requirement for risk assessment or may refer to the Management of Health and Safety at Work Regulations for this requirement.
Procedure
The risk assessment is completed using an appropriate form. Forms used by Outsourced Service Providers will be accepted providing they conform to the Health and Safety Executive, Five Steps to Risk Assessment methodology.
Necessary controls are agreed with immediate management and implemented to ensure the risks are at a tolerable level. Where further precautions are necessary, responsibility and timeframes are allocated so that they are implemented. Where necessary a method statement / safe system of work is developed in sufficient detail so that the task is carried out as planned. This information can be included in the risk assessment if appropriate.
All records are to be held in the Health and Safety Management System and must be approved by management.
Risk assessments will be made available on site at the point of work for inspection and so that they can be communicated to anyone who could be affected by them.
Hierarchy of Control
Decisions about the reliability of controls can be guided by reference to thepreferred hierarchy of control that has now been incorporated into regulations such as the Management of Health and Safety at Work Regulations. The following is a summary of the preferred hierarchy of risk control principles. Examples are:
Eliminate risks by substituting the dangerous by the inherently less dangerous, eg:
· Use less hazardous substances;
· Substitute a type of machine which is better guarded for the same task;
Combat risks at source by engineering controls and giving collective protective measures priority, e.g.:
· Separate the operator from the risk of exposure to a known hazardous substance by enclosing the process;
· Protect the dangerous parts of a machine by guarding;
· Design process machinery and work activities to minimise the release, or to suppress or contain airborne hazards;
· Design machinery that is remotely operated and to which materials are fed automatically, thus separating the operator from danger areas.
Minimise risk by:
· Designing suitable systems of working;
· Using personal protective clothing and equipment; this should only be used as a last resort.
Risk Control and Risk Management
The development of risk controls is a management responsibility, with consultation from others where necessary including the persons who supervise and have undertaken the task.
Review
A risk assessment should be reviewed:
· At the date set for review (annually from the last change made)
· When an accident or incident occurs
· When any circumstances change that may lead you to believe that the risk assessment is no longer valid (e.g. change of job).
The general risk assessment may need to be adapted to the needs and risks of the individual.
Types of Risk Assessment
There are various risk assessment types used within The Organisation. These can be categorised as follows:
· General Risk Assessments (with associated method statements)
· Specific Risk Assessments (e.g. COSHH, Fire, New and Expectant Mothers, Manual Handling, DSE)
· Care / Support Plans
Responsibilities
Risk Assessments are generally developed by the person in charge of the task (including outsourced services). They will require approval by senior management prior to the task being able to be carried out.
Senior Management of each organisation are accountable for allocating resources for the risk assessment process, and for ensuring preventative measures as necessary and agreed from the risk assessment are implemented.
Supervisors of the tasks are responsible for ensuring that all persons are made aware of all pertinent risk assessments before they start work. It should be ensured that they are competent to carry out the task. All personnel should be made aware of any changes to risk assessments. Records should be kept for all training received.
INCIDENTS AND ACCIDENTS PROCEDURE
Scope
This procedure applies to all incidents and accidents raised under the Health and Safety Management System of the company. It also details the process used to develop corrective and preventative actions.
Purpose
This procedure outlines The Company’ process for identifying issues, and recording and managing actions to ensure lessons are learned and improvements are made. It is intended that this process will ensure issues do not occur, or if they have occurred, will not re-occur. Management tools used to identify these issues include accident and incident investigations, near misses, hazards, incidents etc.
As part of the process actions will need to be raised to improve practices and these will need to be managed to completion.
Procedure
Any incidents, accidents, or other issue of a significant health and safety nature should be recorded using the appropriate form.
The person in charge of the service should complete this form with as much information as possible so as to allow a full and thorough investigation.
The person raising the issue for investigation will assign a lead investigator, generally a senior manager within the organisation responsible for the task.
The investigation process is documented using the investigation form. Actions raised as a result of investigations will be assigned with responsibility and a timescale for implementation. Senior management will monitor completion of these actions.
RIDDOR Reports
Reporting accidents and ill health at work is a legal requirement. The information enables the Health and Safety Executive (HSE) and local authorities, to identify where and how risks arise, and to investigate serious accidents.
As an employer, and someone in control of work premises, we all have legal duties under RIDDOR that require us to report to the HSE some work-related accidents by the quickest means possible.
· For information on what we must report can be located on the Health and Safety Executive website (http://www.hse.gov.uk/riddor/).
RIDDOR applies to all work activities but not all incidents are reportable.
Reporting
Accident and incident information is reported to senior management as they occur so that they can review issues and assess progress against preventative and corrective actions. At least annually, all accidents and incidents, along with corrective actions are reviewed.
Guidance on completing the investigation form:
This form is used in determining the Root Cause through an analysis process. Identifying immediate causes will not prevent re-occurrence. Identifying Root, or Underlying Causes will address the issues that can combine to make it happen again and again.
Root Cause Analysis has five identifiable steps that are contained within the Form
Investigation Summary Section
Step One: Define the Problem
· What do you see happening?
· What are the specific symptoms?
Details of what was done and what was uncovered as part of the investigation
Step Two: Collect Data
· What proof do you have that the problem exists?
· How long has the problem existed?
· What is the impact of the problem?
You need to analyse a situation fully before you can move on to look at factors that contributed to the problem. To maximise the effectiveness of your Root Cause Analysis, get together everyone – experts and front line staff – who understands the situation. A decision on how many people should be included and how long and detailed this process is, needs to be made based on the potential severity of the issue which has led to the analysis. People who are most familiar with the problem will help lead you to a better understanding of the issues.
Step Three: Identify Possible Causal Factors
· What sequence of events leads to the problem?
· What conditions allow the problem to occur?
· What other problems surround the occurrence of the central problem?
During this stage, identify as many causal factors as possible. Too often, people identify one or two factors and then stop, but that’s not sufficient. With Root Cause Analysis, you don’t want to simply treat the most obvious causes – you want to dig deeper.
Conclusions Section
Step Four: Identify the Root Cause(s)
· Why does the causal factor exist?
· What is the real reason the problem occurred?
· Recommendations
Step Five: Recommend and Implement Solutions
· What can you do to prevent the problem from happening again?
· How will the solution be implemented?
· Who will be responsible for it? By when?
Be sure to think about any undesirable impacts which could occur as a result of the recommendation being implemented.
Investigation Team – All persons involved in the investigation are recorded here. A single member may be all that is required to investigate the majority of accidents.
Management may review each action for its effectiveness after it has been implemented.
Responsibilities
All employees have a responsibility to detail incidents and accidents as soon as possible using the appropriate form. It is only by being made aware of these issues that management can implement actions to prevent them re-occurring, potentially preventing further injury.
It is the responsibility of everyone to ensure all accidents are reported, and that line management are informed. Persons responsible for tasks (including Outsourced Service Providers) are responsible for investigating all incidents and accidents and for devising and implementing preventative / corrective actions, so as to attempt to prevent re-occurrence.
It is also their responsibility to provide information to Senior Management so that they can determine if the accident is reportable to the Health and Safety Executive.
It is furthermore the responsibility of line management to inform Senior Management of any work time lost as a result, whether immediately after the accident or in the future. This is to allow tracking of the time lost to allow reporting of the issue if and when required.
Where further advice is required, the Health and Safety Consultant is available to assist in the investigation process.
Each person with responsibility for an action must complete it in a timely manner.
Outsourced Services Procedure
Scope
This procedure applies to all contractors and outsourced service providers who undertake work on or on behalf of the Pen-y-graig Woodland.
Purpose
The purpose of this procedure is to ensure that all contractors and outsourced service providers who carry out work are approved, competent and have carried out the necessary health and safety related tasks.
Procedure
Responsibilities
All Contractors and Outsourced Service Providers are responsible for ensuring adequate information and insurances are in place for the tasks that they undertake.
This information will include public (and potentially employers) liability insurances, RAMS (Risk Assessments Method Statements), and copies of pertinent training / competence certification.
It is the responsibility of the organisation management to ensure that this information is reviewed and accepted as adequate.
The organisation is also responsible for monitoring the work of the outsourced services / contractor, to the degree deemed necessary.