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