Manual Handling Policy
Version
V3.0
Ratifying Committee
Risk Management Committee
Date Ratified
28 March 2012
Name of originator /
author / job title:
G. Priestner (Clinical Therapy Lead for Community Services)
Name of responsible
committee:
Risk Management Committee
Name of responsible
individual:
Louise Kitchener – Head of Learning & Development
Date published on
intranet:
March 2012
Review date:
March 2014
Target audience:
Organisation wide
F. Voyce
(Moving and Handling Advisor – Acute Service)
Dr Martin Vernon – Director of Complex Health & Social Care
EQUALITY IMPACT
The Trust strives to ensure equality of opportunity for all both as a major employer and as
a provider of health care. This Policy Document has therefore been equality impact
assessed by Risk Management Committee to ensure fairness and consistency for all
those covered by it regardless of their individual differences, and the results are shown in
Appendix 6.
1
University Hospital of South Manchester NHS Foundation Trust
VERSION CONTROL SCHEDULE
Version
Number
Issue
Date
Revisions from previous
issue
V1.00
September
2006
V2.00
August
2010
Full review following
NHSLA Assessment 2008
V2.1
December
Minor adjustment to clarify
organisational overview for
NHSLA purposes
2010
V3.0
April 2012
Full Review
Date of approval by Committee
21 July 2010
28 March 2012
DOCUMENT CONTROL
Summary of consultation
process
Consultation with Safety Committee, all Clinical Directors,
Directorate Managers and Matrons, through web page
before submitting to Risk Management Committee for
ratification.
Control Arrangements
The policy will be audited for effectiveness, through
internal audit plan, Safety Committee and Risk
Management Committee
Regular reports and updates, as per the Safety
Committee work plan.
Chief Risk Officer and Corporate Health and Safety Risk
Advisor, responsible for developing the policy over the
next 2 years.
Associated documentation and
references
See References: page 11 and Appendices 1 - 8.
2
CONTENTS
SECTION
PAGE
1.
Introduction
4
2.
Purpose
4
3.
Definitions
4
4.
Duties and Responsibilities within the Organisation
4
5.
Arrangements for Access to Specialist Advisors
6
6.
Manual Handling Training
7
7.
Process for Undertaking Manual Handling Procedures
8
8.
Process For Monitoring Compliance Of This Policy
10
9.
Dissemination, Implementation and Access to this Policy
11
10.
References
11
11.
Review
11
APPENDICES
1
Moving & Handling/falls/bed rails combined documentation
for patients in the hospital
12
2
Patient Handling Plan for Patients in the Community
20
3
Generic Risk Assessment for Non-Patient Manual Handling Activities 22
4
Hospital Moving and Handling Link Workers
24
5
Further Related Information and Policies
25
6
Equality Impact Assessment Tool
26
7
Plan for Dissemination
27
8
The Principles of Manual Handling
‘The One Minute Essential Guide to Manual Handling
28
3
1.
Introduction
University Hospitals of South Manchester NHS Foundation Trust acknowledges its duty to
make suitable provisions to control manual handling activities, and to reduce the risk from
such activities to the lowest level, in so far as is reasonably practicable.
2.
Purpose
The purpose of this policy is to describe the arrangements of the Trust to safeguard the well
being of staff and patients by compliance with current legislation and promotion of best
practice with manual handling tasks by their elimination or control. The policy will outline the
measures that must be taken by managers and staff to reduce the risk of injuries by setting
guidance for manual handling of patients and loads. The aim is to eliminate hazardous
handling in all but the most exceptional of life threatening situations.
This policy has been developed in accordance with relevant legislation, in particular:Health and Safety at Work etc Act (1974)
Management of Health and Safety at Work (amendment) Regulations (1999)
Manual Handling Operations (amendment) Regulations (2002)
Lifting Operations and Lifting Equipment Regulations (1998)
This policy applies to all staff employed by the Trust, all contractors, volunteers, patients,
visitors, students and others.
3.
Manual Handling Definition
Manual handling is defined as “transporting or supporting of a load (including lifting,
lowering, pushing, pulling, supporting, carrying, or moving thereof), by hand, or bodily
force”.
The Manual Handling Operations Regulations, (M.H.O.R.) 1992.
4.
4.1
Duties and Responsibilities within the Organisation
The Chief Executive and Trust Board are responsible for:
Overseeing the implementation of the Manual Handling Operations Regulations
throughout the Trust
4.2
Executive and Clinical Directors are responsible for:
Ensuring the provisions of this policy are implemented throughout their area of control.
4.3
Director of Human Resources is responsible for:
Ensuring staff competence via adequate training provision.
4.4
Director of Estates and Facilities is responsible for:
Ensuring a safe working environment at all times.
Working in collaboration with others on new builds.
4
4.5
Matrons and Clinical Leads are responsible for:
Ensuring that the manual handling policy is implemented within their area of
responsibility.
Ensuring that risk assessments are in place and updated regularly within patient’s notes.
4.6
Directorate Managers and Heads of Service are responsible for:
Ensuring that the manual handling policy is implemented within their area of
responsibility.
Ensuring all incident reports are reviewed within individual divisions.
Identifying trends via the Hospital Incident Reporting System and implement controls to
minimise handling risks.
Ensure departmental managers fulfil their responsibilities under this policy
Alerting managers when a significant incident may need further investigation.
Implementing audit recommendations within their Directorate.
4.7
Ward and Departmental Managers are responsible for:
Overseeing the application of this policy within their area of responsibility.
Ensuring that an assessment of manual handling risks is undertaken for their
department, entered on their risk register, and reviewed as appropriate. This must
include all the controls that are in place to manage the risks, and identify any gaps and
further actions required
Ensuring that employees are fully aware of the manual handling policy.
Maintaining a safe environment for staff and patients
Ensuring there are suitable and sufficient manual handling aids
Liaising with the Manual Handling Advisors, prior to the purchase of suitable and
sufficient equipment to reduce handling risks.
Monitoring their employees’ attendance at manual handling training to ensure it is current
and effective according to the Trust’s induction and mandatory training policy.
Ensuring there are safe systems in place to identify the risk of manual handling to health
within the work place, taking into account the findings of an ergonomic risk assessment.
Example of risk assessment tools for both patient and non patient manual handling
activities see Appendix 1, 2 and 3.
Ensuring special arrangements are made for individuals with health concerns in
conjunction with Occupational Health.
4.8
Employees.
All employees have a duty under the Health and Safety at Work Act 1974 to take
reasonable care of their own and others safety whilst undertaking manual handling
operations and to cooperate with management in meeting its health and safety
responsibilities.
Employees are responsible for:
Following the manual handling policy
Making full and proper use of equipment and any safe systems of work in accordance
with training and instructions received.
Attending mandatory training as specified by the induction and mandatory training policy
and ensure they keep abreast of developments in professional knowledge and practice.
Adopting the safe principles of handling, when undertaking any manual handling
activities.
5
Reporting risks, either near miss or actual, on the Hospital Incident Reporting System.
Reporting any handling difficulties, hazards and defective equipment to their line
manager or specialist advisors if necessary.
Reporting any changes in health or medical conditions which may affect their ability to
handle loads safely
Informing their manager of any shortfalls in their training. This may include the use of
equipment or the practical application handling techniques.
Undertaking an appropriate ergonomic risk assessment prior to moving any load
4.9
Partners and service providers are responsible for:
Complying with the policy
4.10
Union Health and Safety Representatives’ are responsible for:
Co-operating with the implementation of the policy
5.
Arrangements for access to Specialist Advisors
The Trust has specialist Manual Handling Advisors who are available 8.30 to 4.30pm most
week days. Full contact details, advice and support is available via the Trust Training web
page on the intranet. In addition hospital based Moving and Handling Link Workers are
available on the wards and departments. See appendix 4
5.1
Manual Handling Advisors (Hospital and Community) are responsible for:
Overseeing the application of this policy within their area of responsibility.
Providing a source of expert advice appropriate to the needs of all employee groups.
Reviewing risk assessments and other relevant data, eg from HIRS, and reporting
identified ad hoc issues, to the bi-monthly Safety Committee for discussion / action as
required.
Advising with highly complex clinical risk assessments
Ensuring that appropriate and sufficient training is developed, delivered and evaluated to
all employee groups as identified in the Trust’s induction and mandatory training policy.
Providing advice on the purchasing of new equipment to reduce handling risks.
Providing expert ergonomic advice with the aim of reducing risk and preventing musculoskeletal injuries.
Ensuring own training needs are met.
Assisting with the investigation of incidents related to manual handling, and provide
expert advice and information to the investigation in conjunction with local management,
risk management and the occupational health department.
Ensuring that medical device alerts that involve manual handling equipment and tools are
reviewed, where appropriate actioned and guidance provided to health and safety, risk
management and line managers.
Providing return to work advice and assessments for staff off work with manual handlingrelated injury, in conjunction with occupational health team and occupational
physiotherapist.
Providing advice on handling issues or concerns with new builds, or refurbishments
within the Trust.
Acting as Trust leads for the NHSLA risk management standard ‘Moving and Handling’,
which includes:
6
 auditing the effectiveness of the policy, to include risk assessments and numbers of
incidents and injuries.
 produce an annual report and action plan to Trust Safety Committee and Risk
Management Committee. This action plan will be monitored six monthly by the
Committees.
Providing current up to date advice via intranet web site for manual handling issues.
In addition:
The Hospital Moving and Handling Advisor is responsible for
Training the Hospital Moving and Handling Link Workers see Appendix 4.
The Community Manual Handling Team are responsible for:
Developing strategic plans for Community Services, across UHSM and partner
organisations to meet contractual needs
Advising on strategic developments in Community Services to meet the requirements of
legislation, best practice and negotiate appropriate contracts with external partner
organisations as required to reduce musculo-skeletal disorders.
Developing, delivering and evaluating bespoke classroom based manual handling
training courses for Community staff and external partnership organisations.
Developing, delivering and evaluating e-learning training for Community staff.
5.2
Occupational Health Team are responsible for:
When necessary, conducting work health assessments to advise on functional capability
of new staff in relation to their future roles.
Providing advice, in conjunction with other healthcare specialist e.g. physiotherapists
regarding functional capability of staff within their normal role or during temporary or
permanent redeployment.
Working with managers, health and safety team and the hospital moving and handling
advisor to carry out workplace assessments to evaluate and advice on any manual
handling risks.
Assist the investigation of staff incidents related to manual handling incidents and
providing expert advice and information to support the process.
Provide Occupational Health advice to employees and managers on all aspects of work
related health issues.
Provide employee health data to the Trust in relation manual handling issues and
musculoskeletal conditions.
5.3
Corporate Health and Safety Risk Advisor
Providing health and safety advice and support to management and staff.
Providing staff with non-patient related manual handling advice and risk assessment,
seeking support from the Manual handling Advisor where necessary.
6
Manual Handling Training
All staff receive manual handling training on Induction. This is updated every 2 years for
clinical staff and every 3 years for non-clinical staff. The manual handling and risk
assessment training will be relevant to the individuals’ role. For identified staff this will
include practical sessions. Having completed training, staff are expected to undertake
appropriate risk assessments for the manual handling of patients and of objects. Example
of risk assessment tools for patient and non patient manual handling activities see
Appendices 1, 2 and 3.
7
For details of training required of individual staff, refer to the Induction and Mandatory
Training Policy, which can be accessed via the following link http://uhsmintranet/policies/Pages/default.aspx sub category Human Resources. A training booklet is
also available which details basic information relating to the manual handling of patients.
7
Process for Undertaking Manual Handling Procedures
Manual handling of loads – patients and inanimate loads – is to be AVOIDED as far as
reasonably practicable. When it cannot be avoided, an ASSESSMENT is made of the
operation and where there is a risk of injury, appropriate steps taken to REDUCE THE
RISK to the lowest level reasonably practicable by the use of CONTROLS - safe working
practices and mechanical aids where appropriate. Staff operating such aids will receive
appropriate training, instruction and supervision prior to use.
Staff must report any incidents / near misses experienced whilst undertaking manual
handling procedures in order that they can be investigated appropriately and any
modifications can be made.
7.1
.
7.2
Principles of Safe Handling:
The one-minute essential guide to manual handling principles
Avoid all unnecessary load handling
Wear appropriate clothing that does not restrict movement
(e.g. trousers and short sleeved tunics)
Wear appropriate footwear
(e.g. low heeled, enclosed toe and heel, securely attached to the foot)
Check that the method to be used reflects the assessment guidelines and
remains applicable
Prepare the environment prior to the manoeuvre
Ensure that necessary training in the use of the equipment / technique has
been undertaken
Check equipment is in safe working order and if necessary has been
inspected by a competent person
Apply brakes on wheelchairs / beds
Be aware of your own handling capacity and limitations and do not attempt
procedures if unhappy to do so – report to management
Identify a leader when team handling
Agree and give clear unambiguous verbal instructions
(e.g. “ready, steady, lift /roll / slide” etc)
Where appropriate, use rhythm and gentle movement prior to the procedure
Ensure any physical contact with a patient is safe and comfortable and avoid
pressure from the fingertips (use palmar holds)
Ensure that you have a good stable base of support
Keep the patient or object as close to your body as possible
Maintain a lazy “S” shaped spine (avoid twisting and stooping)
Do not rush
Appropriate Risk Assessments must be undertaken for all manual handling activities,
and formally documented where appropriate. Risk assessments are undertaken at three
levels:
an overarching risk assessment for the ward or department;
8
8
an individual risk assessment for manual handling each patient or
specific (and probably frequently-occurring) manual handling task; and
an informal and dynamic assessment of the unique situation, immediately
prior to undertaking the procedure, by the person[s] involved.
7.2.1.
Risk assessment for each department / service.
(See duties of ward and departmental managers)
Ward, department and service managers must ensure that overarching risk assessments
are undertaken for their area for the manual handling of patients and loads as appropriate,
taking account of the specific factors relevant to their area. These must be entered onto
their risk register with appropriate generic control measures and assurances documented,
and reviewed in accordance with the Trust Risk Management strategy. Any gaps in control
must be addressed / escalated as appropriate.
7.2.2
Risk assessment for manual handling individual patients
A risk assessment of each patient’s manual handling needs will be undertaken. The patient
/ carer should be involved in the risk assessment whenever possible. The risk assessment
will follow a balanced decision making approach which considers the person’s human
rights, mental capacity, and privacy and dignity.
For in-patients, a formal documented assessment must be completed on admission, and
reviewed every 7days, or sooner if indicated: on transfer to a new ward; or if the patient’s
condition changes e.g. if patient falls, post op. The assessment is incorporated in the
patient’s admission document in the notes.
For all other patients, including community patients, an informal assessment of the
patient’s requirements must be undertaken by the attending clinician, and any problems
identified documented in the notes and communicated to other members of the team as
appropriate. This will be reviewed on each and every occasion a clinician makes contact
with a patient.
A formal individualised risk management care plan will be completed for patients where a
manual handling risk has been identified. See appendices 1 & 2
7.2.3
Risk assessment for manual handling specific inanimate loads
Where the overarching departmental general risk assessment has identified risks
associated with manual handling of specific difficult loads, or with frequently-undertaken
tasks, it will be necessary to complete an individual risk assessment. Assessment of all
inanimate load handling operations must be carried out in line with the T.I.L.E. principals
taught on training. Example of non patient handling risk assessment documentation see
appendix 3
Task to be undertaken
Individual carrying out the task
Load to be handled
Environment in which the activity occurs
9
7.2.4
Informal dynamic risk assessment immediately prior to undertaking any manual
handling manoeuvre.
Any staff preparing to undertake any manual handling manoeuvre must assess the
individual situation immediately prior to doing so in order to identify any modifications that
may be required to the formal documented plan as indicated by the unique circumstances
(T.I.L.E). Advice must be sought from a supervisor, or specialist advisor when necessary
Appropriate Action must be taken in respect of manual handling risk assessments.
7.3
Risk management plans will be formulated when necessary as a result of Moving &
Handling risk assessments. Each ward / department / service must have an overarching
plan detailing the general controls that are in place for all activities within the area.
7.3.1
7.3.2
Individual manual handling care plans must be in place for patients where risks have been
identified. These may include the use of specific techniques and / or mechanical aids /
equipment for which staff must have had appropriate training prior to using. Advice is
available from the Specialist Manual Handling Advisors. For further information regarding
acceptable manual handling techniques and equipment available please see:[email protected]
[email protected]
[email protected]
http://uhsm-intranet/training/LearningDevelopment/Liss/Calendar.aspx, http://uhsmintranet/training/LearningDevelopment/Moving%20and%Handling/Pages/default.aspx
Individual manual handling procedures must be in place for tasks / activities that have been
identified in the generic departmental risk assessment as being particularly difficult [e.g.
heavy or unwieldy equipment] or frequently-occurring. This will describe the steps
necessary (general and specific controls) to manage the risk associated with the task and
will need to be available for staff to refer to at the point of work
Each ward and department will have a basic supply of equipment suitable for their own
general needs, as identified by the manager through generic risk assessment. If it is
necessary to access additional specialist equipment, contact the Manual Handling Advisor
or see Moving and Handling Equipment page on Trust intranet.
Manchester Equipment and Adaptation Partnership supply a range of standard manual
handling equipment for use in the community, although specialist individualised nonstandard pieces of equipment can be ordered for patients whose risk assessment, control
measures and action plan requires such.
If suitable equipment is not available immediately, patients will be managed in a way least
likely to cause harm to themselves and the clinician. In extreme circumstances this may
necessitate them being cared for in a less than optimum place / situation until such time as
the necessary equipment and suitably trained staff are available.
8
Process For Monitoring Compliance Of This Policy
The effectiveness of the policy will be monitored by monthly audit of key indicators. These
will be reported locally, and an annual report compiled for the Trust Safety Committee and
then presented to the Risk Management Committee. An action plan will be formulated to
address any deficiencies identified by the audits and kept under constant review by the
10
manual handling advisors. The progress against the action plan will be monitored by the
Trust Safety Committee after 6 months, or more frequently if deemed necessary. Any
significant risk arising from the reviews shall be escalated as required to the Risk
Management Committee in accordance with UHSM’s Risk Management Policy and
Strategy.
As a minimum, the audit will include analysis of the risk assessments of
A sample of 5 patients on each of 6 wards and 5 patients from community
Ward / departmental / area generic risk assessments
Monthly reports from Specialist Manual Handling Advisors
This is correlated with HIRS and claims data, and staff accident data to identify any
common/ recurring themes. Other indicators may be audited in addition, as and when
necessary – for example if indicated by increasing numbers of incident reports.
Attendance at Manual Handling Training and follow up of non-attendees is monitored and
reported as part of the monthly mandatory training Trigger report, by the Learning and
Development Dept.. Figures are reported bi-annually to the Safety Committee, and actions
will be included where appropriate in the overarching Trust Wide action plan, monitored by
the Safety Committee.
9
Dissemination, Implementation and Access To This Policy
Awareness of the existence of this policy will be made via the usual Trust communication
mechanisms. It will be featured in the daily bulletin and placed on the Trust’s intranet policy
web site. (See Appendix 7 for details).
10
References
Induction and mandatory training Policy v2.00
Resuscitation Policy v2.1
Risk Management Strategy and Policy v3.00
Health and Safety at Work etc Act 1974
Manual Handling Operation Regulations (Amendment) (2002)
Management of Health and Safety at Work (Amendment) Regulations (1999)
Mental capacity Act 2005
The Guide to the Handling of People – A Systems Approach (HOP) 6th Edition 2011
Health and Safety Policy v 2.00
Safety Inspection Procedure v3.0
11
Review
This policy will be formally reviewed 2 years after implementation, or earlier if indicated by
the results of monitoring, or changes in legislation or national guidance.
11
MOVING & HANDLING & FALLS RISK FACTOR ASSESSMENT / GENERAL INTERVENTIONS FOR ALL
PATIENT NAME:
COMPLETE: For ALL PATIENTS on ADMISSION
REVIEW WHEN:
 Condition change: eg Fall
 Ward transfer
 Post OP or Procedure
 Shift basis or within 7
days if no other change
Dependent on patient need
Document which
ward & for what
reason the review
was done
Shift review:
record in ‘ongoing
review ‘ section
NHS No:
Appendix 1
policy page12
PreAdmission /
Pre-Op Ax.
Date:
…/…./…..
Admission
Assessment
Date:
Review
Date:
Review
Date:
Review
Date:
…/…./…..
…/…/..
…/…/..
…/…/….
Ward:
Ward:
Ward:
Ward:
Ward:
Reason
Reason
Reason
Reason
Reason
SECTION 1
A. Eyesight
GENERAL INTERVENTIONS Initial in relevant admission or review boxes when completed
Requires glasses

Pt wearing glasses 
Documented communication plan
Needs no visual aids

Ask to be brought in 
if can’t hear normal speech 
When section A has been
Hearing
Requires hearing aid

Pt wearing aid

completed: Date……… .. Initial……
Can hear speech at bedside 
Ask to be brought in 
B. Orientated to bed, toilet, bathroom, dayroom & ward area
Admission
Review
Review
Review
C. Explained location of call bell & ability to use bell assessed: If
Unable to use: Documented alternative plan 
D. Checked for safe footwear and clothing worn that doesn’t
increase risk of falling: Ask to be brought in  Hospital provided 
E. Communicated with / agree & explain plan of care to:
Patient  Family  Main Carer 
F Documented any alternative plans/variances for above sections in
relevant Falls intervention tool (FIT) & Care Plans
 Drinks, food, walking aid & belongings within easy reach of patient whether in bed or sitting in chair
 Make sure bedside and ward environment safe: e.g. adequate lighting and chair, clutter removed,
REMINDER
cleared spills Leave bed in lowest position when patient unattended
comments page comcommentssection

Show or display Patients & Carer Advice leaflet for Falls Prevention whilst in hospital
SECTION 2:
MOVING, HANDLING & FALLS RISK FACTOR ASSESSMENT (All patients require)
Tick √ if YES to any that apply to patient in Q1-14
Pre op / Ax
Admission
Review
Review
Review
1. Safe & Independently Mobile +/- walking aids
2. Bed bound: Immobile  Limited bed mobility 
3. Needs hoist to move or transfer
4. Unlikely to move unless assisted
►Action: Any √ (Yes) in the risk factors below (Q5 to14) requires a tailored Falls Intervention Tool (FIT) Care Bundle
5. Tries to walk or transfer alone but unsteady / &
or unsafe.
6. Confused  Agitated  Disorientated 
7. Tends to wander.
8. History of falls /collapse before admission
9. Admitted with fall  Fall since admission 
10. Patient  Relatives  anxious about falls
11. Visual difficulties: e.g. Unable to differentiate
between pen and scissors from end of bed
12 Continence issues increase risk of falling
13. Medications causing sedative effect & or
postural BP drop
14 You consider patient is at risk of falls for any other
reason: eg alcohol, CVA, Blackouts, Pain, Fits etc
SIGNATURE (countersign if required):
Next: Complete or review M&H Care plan & Bed Rails assessment and check list (next 2 pages: Section 3&4 ) ►
12
Toileting
Bathing / showering
Turning on the bed/trolley
Moving on the bed/trolley
Chair-bed/trolley
transfers
Bed-trolley transfers
Standing and mobilising
Tick all boxes that apply or enter details
as required for All patients
To be completed on admission. Review
on transfer to a new ward , condition
change e.g. if patient falls , Post op,
within 7days (if none of the
Previous)
Toileting
…………………………………….
Bathing / showering
ID No:
Turning on the bed/trolley
…………………………………….
Moving on the bed/trolley
Date…….........Ward /Dept ………….
Patient Name:
Chair- bed/trolley
transfers
REVIEW assessment
Date……………Ward /Dept. …...........
Bed-trolley transfers
ADMISSION assessment
HANDLING CARE PLAN
Standing and mobilising
Section 3 UHSM MOVING &
Walking aid Type……………….……
Wheelchair (assisted push / self-propelled
/ powered)
Independent
Assistance of 1 (H = hands on
SB = standby)
Assistance of 2 (H = hands on SB = standby)
Pat slide + assistance of 3+
Slide sheet
Type……………………….…..
Sling type………….……… Size………..
Hoist
Banana board
Stand Aid Type………………………..
Sling type……….……….… Size………..
Patient handling pole
Walking aid Type……………….……
Wheelchair (assisted push / self-propelled
/ powered)
Independent
Assistance of 1 (H = hands on
SB = standby)
Assistance of 2 (H = hands on SB = standby)
Pat slide + assistance of 3+
Slide sheet
Type……………………….…..
Sling type………….……… Size………..
Hoist
Banana board
Stand Aid Type………………………..
Sling type……….……….… Size………..
Patient handling pole
Any other requirements or provision of
equipment :
SIGNATURE:
policy page 13
13
Bathing /
showering
Toileting
Turning on the
bed/trolley
Chairbed/trolley
transfers
Moving on the
bed/trolley
Bed-trolley
transfers
Standing and
mobilising
REVIEW assessment
Date……… Ward…………
Bathing /
showering
Toileting
Turning on the
bed/trolley
Chairbed/trolley
transfers
Moving on the
bed/trolley
Bed-trolley
transfers
as required
For All patients
To be completed on admission.
Review on transfer to a new ward,
condition change e.g. if patient falls ,
Post op, within 7days ( if
none of the previous)
Standing and
mobilising
Any other requirements or provision
of equipment :
SIGNATURE:
UHSM MOVING & HANDLING
REVIEW assessment
CARE PLAN
Date………….Ward…………
Tick all boxes that apply or enter details
Section 4:
UHSM BED RAILS ASSESSMENT & CHECKLIST For All Patients policy page 14
Patient name ……………………………………………… NHS No……………………………………
BED RAILS CAUTION!
 Do not use If there is a
greater risk of harm to
patient by using bedrails
than by not using. Bed
rails must not be used to
restrain
 If Patient is active,
disorientated & likely to
climb over rail Consider
alternatives eg hire low bed
/ crash mat/ sensor pad /
specialing
 Risk of entrapment of
head, limbs, lines or
drainage tubes. Consider
Using bed rail bumpers to
reduce risk (document)
Date
of
revie
w
Time
CONSIDER USE IF
CHECKLIST
 Episodes of falling or fear
of falling out of bed
 Poor sitting balance; leans
or rolls over in bed
 Not using bed rails :
Signature and date………………………………………..
 Patient requests bed rails
and consents (provided not as
turning aid)
possible state action taken ……………....………………………
…………………………………………………………………………
 Air flow mattress in use
If using bed rails for any other
reason please
state:………………….……..……
……………………………………
……………………………………
OR if unable to consent:
Assess Mental Capacity 
In patient’s best interests 
Using
rails?
 Using rails: Patient can be easily observed. If not
 Ensure rails work correctly and match bed ……………
 Ensure mattress is appropriate size for bed ……………
 If mattress height increased have horizontal extension
rails in place ……………………………………………..
 Use both rails if bed against wall ……………………..
*If split rails, ensure both in place when patient unattended
*Use bed rails when transporting patient
 Patient/carer bedrail information sheet given………….
Signature……………………..….Date……………..
Reason if change
Yes /
No
UHSM Falls Intervention Tool (FIT) and Ongoing Review / Variation sections follow on next four pages
14
Signature
Patient Name …………………………….. ………….
policy page 15
Section 5
UHSM Falls Intervention Tool (FIT) Care Bundle
NHS as
no:……………………………………………………..
Update as soon
practical within 24hours if patient sustains any fall or if triggered by M&H & Falls Assessment
Review, on ward transfer, post op, condition change (deterioration or improvement) or planned timescale within 7days or sooner
Aim to reduce harm & incidence of falls whilst maintaining dignity & independence
Admission Review
Review
Review
FALLS RISK FACTOR CARE INTERVENTIONS:▼▼▼▼
TRIGGER
Tick any risk factor (s) below
▼▼ ▼▼▼
that apply to your patient
Consider and undertake
corresponding numbered
interventions, as triggered
►►►►►►►►►►
1 Any Fall during
current admission 
►►►►►►►►►►
Admission due to
a fall / Collapse 
Fallen /Collapse in the
past 12 months 
You consider that
Patient is at risk
of fall( s) 
Postural dizziness
or imbalance 
Interventions
INITIAL relevant intervention/ review
box if care undertaken ►►►►►
Mark N/A if not applicable or U if unable
to complete Document any care variation
& plan different care in ‘ongoing review &
variation section
2. Patient is confused,
drowsy, agitated
or unable to summon
help 
Suspect Delirium 
On sedating effect
Medication 
Wander some 
Suspect Dementia 
‘The Confusion
Assessment Method’
(CAM)* can be used to
help decide if patient is
confused
Continue to next page
…./…/..
Date
Date
…/…/...
…/…/...
Ward:
ward:
Ward:
Lying BP:
Lying BP:
Lying BP:
Lying BP:
Standing
BP:
Standing
BP:
Standing
BP:
Standing
BP:
Initial:
Initial:
Initial:
Initial:
YN
Y N 
Y N
Y N
Initial:
Initial:
Initial:
Initial:
Ward:
./…/..
Date
1a.Implement immediate ‘ Essential care
after an inpatient fall’ care / protocol*
Report all falls. Record HIRS no. in
‘Ongoing review section’ data bank
1b. Allocate to best available bed / chair
for needs i.e. Observation, toileting etc
State Bed No. in relevant dated review box
Consider use of ‘low profile’ bed
1c. Risk assess patient re: bedrails
Update “Bed Rails assessment / checklist”
1d. Refer for further falls & bone health
review including medications: by Medical
Team  &/ or Ward Pharmacist 
1e.Measure & record Lying & Standing
BP. If A drop of 20+mmHg in systolic
pressure or symptomatic:
Maintain / or improve hydration.
Advise patient to sit and stand up slowly 
Inform Doctor. Plan Re-test 
1f. Dipstick Urine  Negative test (N)
If Positive test (Y) refer to medical team 
► ►►►►►►►►►►
Recurrent faller 
Complex patient 
Remains at high risk
of falling despite
intervention? 
Date
1g. Consider / discuss escalation of extra
plan of care: with Senior Nurse  Named
Consultant  Falls Co-ordinator  Moving &
Handling Advisor  MDT  Relatives 
Review each shift & consider : increasing
frequency of monitoring  movement alert
sensor care system  Low profile bed  Any
other issues record in’ ongoing review’
section
2a. If new problem & / or medical team not
already addressing problem, refer for:
Medical assessment of delirium /dementia
Risk benefit / review of any sedatives &
medications used by patient 
2b. Complete bedrail risk / benefit
assessment and review each shift
2c. Communicate with patient’s relatives
& carers. Consider their input to care
Assess & record: Any extra patient
specific care needs and plans in
‘Ongoing review / variation Section’
Signature (Countersign if required)
15
UHSM Falls Intervention Tool (FIT) Care Bundle (continued)
PATIENT NAME:
FALL RISK FACTOR
TRIGGERS
ID NO
Admission
Intervention
CARE INTERVENTIONS:
▼▼▼▼▼
Tick below ▼▼▼▼▼
any risk factors that apply
to your patient &
Complete corresponding
numbered interventions as
appropriate ►►►►►►
3.
Unsteady walking 
Unsafe Transferring 
Reduced Confidence
Parkinson’s Disease
Stroke 
Any Gait disorder
Problems with feet 
Initial in the relevant assessment /review
box if care undertaken ►►►►►►
Mark N/A if not applicable or U if unable to
complete Document any variations to
care,& plans in ‘ongoing review & variation
section
4.
Risk of falls
Associated with:
Continence Issues 
On diuretics 
On laxatives 
4. Ask about / assess continence & make
plan i.e. Assistance / Access to toilet
facilities & commode 
Routine of toilet visits 
Night lighting if toileting independently 
Refer to specialist  Date……..Initial……
5. Impaired
vision 
Hearing
difficulties 
Affecting
Mobility &
Management 
6. Any other factors to
pose a falls risk?  e.g.
alcohol, stroke
pain
dementia, delirium ,
collapse, etc
7.Discharge planning:
Would benefit from
further interventions
for falls and bone
health after discharge
Ongoing review section
(found on next page)
policy page 16
Review
Date
Review
Date
Review
Date
./…/..
…/…/...
…/…/...
Ward:
Ward:
Date:
../…/….
Ward:
Ward:
3a. Explain need to wear footwear & ask
for help when mobilising
3b. Supervise & assist any mobilising
dependant on ‘up to date’ M & H & Falls
assessment and care plan
3c.Refer to physiotherapy for mobility &
balance assessment / treatment
3d. Unexplained impaired mobility Refer for
medical assessment  MDT  Podiatry 
5a. Review hearing & Vision & any aids
Consider induction loop 
Make communication plan  Unexplained
problem: Refer for medical review 
5b.Supervise & / or assist transfers &
walking as outlined in M&H & falls care
plan - Amend care plan as required
5c. Recommend patient has :
Eye test 
Hearing test  Post discharge
6a. Plan & document any other
specific needs & referrals in ‘Ongoing
Review & care’ record  or related
pathway State other
factor……………………………………………
7 At discharge:
Flag up any residual falls & bone health
issues needing attention after discharge; to
medical team for GP summary  Eg
Consider onward referral i.e. Rehabilitation
referral ( ICT  Day hospital ) or Falls
service referral  if appropriate
Signature (Countersign if required)
1. A Patient may need to be reviewed before a planned date i.e. if condition changes eg a further fall / post op or if moves ward
ensure all relevant M&H &Falls Bedrails assessments / guidance are reviewed & updated at the same time.
2. Please record written plan for frequency of review in ‘Ongoing Review Section’ eg shift review for recurrent/complex fallers
3. Shift review can be done in ongoing review section unless change effects main risk assessment/ interventions .Continue to
sign off’ ongoing review as no change until discharge or until patient triggers full review sign off or doesn’t need FIT
16
UHSM FT ONGOING REVIEW SECTION:
policy page 17
FALLS,MOVING & HANDLING
PATIENT NAME:
ID NO
Plan frequency of review and document below. Document on a shift basis or review frequency determined by clinical need
If any change refer back and review relevant M&H& Falls assessments , Falls care bundle (FIT) and Bedrails guidance plan
Any
Signature
Date, Time
Document any review comments & additional care related to Falls and
Change Moving & Handling below:
Designation
& Shift
Y/N
More space for review on next page. Additional review pages should be available on the ward or downloadable from intranet
Document every ST&F incident report no here
Date
HIRS No.
Sign
Date
HIRS No.
17
Sign
Date
HIRS N0.
Sign
UHSM FT ONGOING REVIEW SECTION (CONTINUED)
policy page 18
FALLS,MOVING & HANDLING
PATIENT NAME:
ID NO
Plan frequency of review and document below. Document on a shift basis or review frequency determined by clinical need
If any change refer back and review relevant M&H& Falls assessments , Falls care bundle (FIT) and Bedrails guidance plan
Any
Signature
Date, Time
Document any review comments & additional care related to Falls and
Change Moving &Handling below:
Designation
& Shift
Y/N
Additional review pages and associated documentation should be available on the ward or downloadable from intranet
18
UHSM FT ONGOING REVIEW SECTION (CONTINUED)
policy page 19
FALLS,MOVING & HANDLING
PATIENT NAME:
ID NO
Plan frequency of review and document below. Document on a shift basis or review frequency determined by clinical need
If any change refer back and review relevant M&H& Falls assessments , Falls care bundle (FIT) and Bedrails guidance plan
Any
Signature
Date, Time
Document any review comments & additional care related to Falls and
Change Moving &Handling below:
Designation
& Shift
Y/N
Additional review pages and associated documentation should be available on the ward or downloadable from intranet
19
Appendix 2
20
.
21
Appendix 3
Generic Risk Assessment for Non-Patient Manual Handling Activities
Description of manual handling task to be assessed:
Date of assessment:
Personnel involved:
Location of assessment:
Assessor(s) name:
Base:
Designation:
Tel No:
There may be manual handling hazards involving the task being carried out, the individual
capability of the handlers, the load or the working environment. Please complete the next
page to identify specific hazards within each area. Rate the risk in the appropriate category,
then decide on the action required to reduce the risk to an acceptable level. Then return to this
page to decide on your priorities of action.
Level of risk is defined as follows:
Low (L):
Acceptable risk but monitor for increase.
Medium (M):
May be considered acceptable or unacceptable depending on individual
situation. Attempts should be made to reduce risk where practicable.
Unacceptable risk. The activity must be discontinued / suspended
immediately. Corrective action is required to reduce the risk to an
acceptable level.
High (H):
What remedial steps should be taken in order of priority?
Level of risk following remedial action:
Date by which action to be taken:
Date for review:
Signature:
22
Hazards to consider (The following are
examples only. You do not have to respond
to each point.)
The
Level of risk
Identified hazards
Low
Tasks – do they involve:
Stooping or twisting
Reaching forward away from the body or
above shoulder height
Large vertical movements
Long carrying distances
Strenuous pushing, pulling or lifting
Frequent or prolonged physical effort
Insufficient time
Repetitive handling
Specialised clothing
Individual capability (of handler)
Training
Injury or medical condition
Hazard to pregnant staff
Specific physical attributes
More than 1 person required
Clothing hindering posture or movement
The
Load
Is it heavy
Is the weight evenly distributed
Is the item bulky or awkward to handle
Are the contents liable to spill
Is it unstable or unpredictable
Is it potentially harmful (e.g. sharp or hot)
The Working
Environment
Space / constraints on posture
Temperature / ventilation
Floor surface – slippery or uneven
Variations in levels
Lighting
23
Med
High
Action required
Appendix 4
The Role of Hospital based Moving and Handling Link Workers
Hospital Moving and Handling Link Workers will ensure that the aims of this policy
are achieved by:-
Ensuring their own training needs are met in terms of keeping up to
date with new developments/national guidelines in relation to manual
handling by attending yearly updates with the Moving and Handling
adviser.
Facilitating training sessions for new or existing employees on how to
use the manual handling equipment on the area of employment and
where the equipment is located. Providing support to employees in
their area and to the handling adviser.
Acting as a resource in patient care, promoting and improving
standards of quality in relation to manual handling.
Reinforcing manual handling training and safe practice within the work
place by working alongside colleagues
Notifying the relevant manager and where necessary the Moving and
Handling Adviser of manual handling issues which they are unable to
resolve.
Ensuring manual handling equipment is clean, in good working order
and appropriate checks have been made reporting any faults.
Ensuring suitable and sufficient records will be maintained of local training
and submission of registers to be forwarded moving and handling adviser for
recording purposes.
24
Appendix 5
Further Information and Related Policies
Community Staff Manual Handling Advisors
Lindsey Murray – [email protected]
Steve Whitehall – [email protected]
0161 274 1677/1678
Hospital Staff Moving and Handling Advisor
Frances Voyce – [email protected]
0161 291 5925
Click http://uhsm-intranet/training/LearningDevelopment/Liss/Calendar.aspx,
http://uhsmintranet/training/LearningDevelopment/Moving%20and%Handling/Pages/default.aspx for
further Manual Handling information on the UHSM Intranet Training Web
25
Appendix 6
Equality Impact Assessment Tool
.
Yes/No
1.
Comments
Does the policy/guidance affect one
group less or more favourably than
another on the basis of:
Race
No
Ethnic origins (including gypsies and
travellers)
No
Nationality
No
Gender
No
Culture
No
Religion or belief
No
Sexual orientation including lesbian,
gay and bisexual people
No
Disability
No
Age
No
2.
Is there any evidence that some
groups are affected differently?
No
3.
If you have identified potential
discrimination, are any exceptions
valid, legal and/or justifiable?
N/A
4.
Is the impact of the policy/guidance
likely to be negative?
No
5.
If so can the impact be avoided?
N/A
6.
What alternatives are there to
achieving the policy/guidance
without the impact?
N/A
7.
Can we reduce the impact by taking
different action?
N/A
26
This will form part of the
monitoring of the policy
Appendix 7
Plan for Dissemination of Policy or procedural documents
Title of document:
Manual Handling Policy V3.00
Date finalised:
Jan 2012
Previous document
already being
used?
Dissemination
leads:
Print name and
contact details
Yes
Gill Priestner
Clinical Therapy Lead
0161 946 8201
Frances Voyce
Moving and Handling
Advisor
0161-291-5925
If yes, in what
format and where?
Version 2.1 available on the intranet
Proposed action to
retrieve out-of-date
copies of the
document:
Document to be archived and replaced with new version
To be disseminated
to:
How will it be
disseminated, who
will do it and when?
Paper
or
Electronic
Comments
Members of safety
committee
Christine Garratt
E
For consultation
Members of RMC
Christine Garratt
E
Consultation prior to approval
Published policy on
intranet
Notified through daily
bulletin
E
Subject to approval at RMC
Referred to at
induction and update
manual handling
training
All staff
N/A
Referred to during teaching
Dissemination Record - to be used once document is approved.
Date put on register /
library of policy or
procedural documents
Disseminated to:
(either directly or via
meetings, etc)
Date due to be reviewed
Format (i.e.
paper or
electronic)
Date
Disseminated
27
No. of
Copies
Sent
March 2014
Contact Details /
Comments
Appendix 8
Principles of Safe Handling
‘The One Minute Essential Guide to Manual Handling’
Avoid all unnecessary load handling
Wear appropriate clothing that does not restrict movement (e.g.
trousers and short sleeved tunics)
Wear appropriate footwear (e.g. low heeled, enclosed toe and
heel, securely attached to the foot).
Check that the method to be used reflects the assessment
guidelines and remains applicable
Prepare the environment prior to the manoeuvre
Ensure that necessary training in the use of the
equipment/technique has been undertaken
Check equipment is in safe working order and if necessary has
been inspected by a competent person
Apply brakes on wheelchairs / beds
Be aware of your own handling capacity and limitations and do
not attempt procedures if unhappy to do so – report to
management
Identify a leader when team handling
Agree and give clear unambiguous verbal instructions (e.g.
“ready, steady, lift /roll / slide” etc)
Where appropriate, use rhythm and gentle movement prior to the
procedure
Ensure any physical contact with a patient is safe and
comfortable and avoid pressure from the fingertips (use palmer
holds)
Ensure that you have a good stable base of support
Keep the patient or object as close to your body as possible
Maintain a lazy “S” shaped spine (avoid twisting and stooping)
Do not rush
28