North Eastern Health Board - Nurse On Call Jobs Safety Statement.d… · Web viewSafety...

Safety StatementFor

Our Lady of Lourdes HospitalDublin North EastHospital Network

1

Table of Contents Page No.Section 1 Safety Policy 6

Section 2 Declaration of intent 8

2.1 General Statement of Policy 9

Section 3 Organisational Responsibilities 11

3.1 General Duties of Employer 11

3.2 Safety Management Structure and Organisational Chart 12

3.3 Safety Management Responsibilities 13

3.3.1 Interim Network Manager 13

3.3.2 General Manager 14

3.3.3 Operational Services Manager 16

3.3.4 Director of Nursing 18

3.3.5 Heads of Department 20

3.3.6 Employees 24

3.3.7 Health and Safety Coordinator 25

3.3.8 Local Risk Advisor 26

3.3.9 Consultant Occupational Health Physician 27

3.3.10 Regional Fire Prevention Officer 28

Section 4 Service Arrangements 30

4.1 Accident / Incident Reporting

4.2 Policies & Guidelines & Safe Work Practice Sheets

4.3 Training & Instruction

4.4 Violence / Assault

4.5 Stress

4.6 Infection Control

2

4.7 OBE (Occupational Blood Exposure)

4.8 PPE (Personal Protective Equipment)

4.9 Latex

4.10 VDU’s (Visual Display Unit)

4.11 Eye & Eyesight

4.12 Pregnant Employees

4.13 Dignity at Work

4.14 Fire Safety

4.15 Waste Management

4.16 Manual Handling

4.17 Chemicals

4.18 Medical Gases

4.19 Electrical Safety

4.20 Slips / Trips / Falls

4.21 Maintenance

4.22 Contractors

4.23 Visitors

4.24 Transport

4.25 Emergency Situations

4.26 Shared Workplace

4.27 Information

4.28 Lone working

4.29 Welfare

3

Section 5 Risk Management Process 50

Risk Matrix 53

Impact Table 54

Principles of Prevention 55

Section 6 Consultation Arrangements 57

6.1 Safety Rep 57

6.2 Safety Committee 59

Section 7 Resources 62

Section 8 Distribution / Access to Safety Statement 64

Section 9 Review / Revision Safety Management Programme 65

9.1 Safety Statement

9.2 Safety Management System

Section 10 Dept. /Unit Safety Statement 66

Introduction

Hazard Identification and Control Measures

(Hazard Relevant to Service Area)

Appendices

Appendix 1 Range of Services 67

Appendix 2 Quality Assurance Programme 70

Appendix 3 Communication Plan 71

4

Document Control

Document Name: Health Services ExecutiveHospital Safety StatementOctober 2010

Document Owner: Margaret Swords

Document Type: Microsoft Word

Last Updated: October 2010

Version: 1

Status: Compliance with Safety, Health & Welfare Legislation

Revision HistoryVersion Date Revised by Revision Details

1 04/10/2010 Denise MeliaOrganisational Responsibilities-Local Risk Advisor Page 26

Distribution List

Name Department DirectorateExecutive Management Board

Senior Management Team

Signature from Group General Manager, Louth/Meath Hospital Group

___________________________________________Group General Manager, Louth/Meath Hospital Group

5

Section 1.0 Safety Policy

1.0 Safety Policy

Since the publication of the Corporate Safety Statement in October 2006, it is

undoubtedly a fact that the HSE has undergone many changes and faced many

challenges.

We would like to take this opportunity to reaffirm our commitment to placing

people at the centre of the organisation. In line with this commitment we consider

that the management of safety, health and welfare is of fundamental importance

in continually improving the quality of the services that we provide, as quality of

service is intrinsically linked to the provision of a safe work environment and the

operation of safe systems.

In striving to continually improve quality and safety, we recognise and accept our

responsibilities for safety, health and welfare. We believe that workplace injuries

and illnesses are preventable, and as a consequence we are committed to ensuring

the safety, health and welfare of our staff and those affected by the work activities

of the HSE.

In order to support the Corporate Plan, we will empower staff to promote and

provide leadership in relation to the management of safety, health and welfare in

the workplace.

We are committed to ensuring the implementation of a safety management system

in the HSE that is consistent with legislative requirements and best practice

standards. An integral component of the plan will be the clear allocation of

responsibility and accountability to managers and employees that will be

supported by the provision of appropriate resources.

6

We will ensure that appropriate channels of communication are in place to

facilitate effective consultation and communication with staff and those who are

affected by the activities of the HSE. The aim of consultation and

communication will be to promote a positive safety culture through enabling staff

to contribute to the decision making process as it relates to safety, health and

welfare at work.

We are further committed to ensuring that the safety management system will be

subject to continual monitoring and review so that we can ensure that the work

environment and systems of work continue to be safe and that they contribute to

quality improvement.

(Ref: HSE Corporate Safety Statement 2009)

7

Section 2.0 Declaration of Intent

2.0 Declaration of Intent

The Safety Statement has been prepared in accordance with the provisions of the Safety

Health and Welfare at Work Act, 2005. The basic intent of the document is to formally

declare the means by which the management of Our Lady of Lourdes Hospital, within

the HSE NE ensures, in so far as is reasonably practicable, the safety, health and welfare

of staff, clients and others such as visitors, and contractors who may be affected by our

activities.

The Safety Statement contains details of Our Lady of Lourdes Hospital, HSE NE, Safety

Management Programme and of the general arrangements for occupational safety, health

and welfare within the service.

Safety is everybody’s business and the success of our safety policy will depend on staff

co-operation. It is important that staff are familiar with the arrangements for health and

safety in the service and incorporate these as an integral part of the tasks performed while

at work.

Members of staff and others are invited to contribute to the improvement of safety in the

service by making suggestions for the improvement of this Statement through their line

manager or Safety Representative.

Signed (General Manager)

Date 10th September 2010

General Statement of Policy

8

2.1 General Statement of Policy

Louth/Meath Hospitals is one hospital on three sites (Our Lady of Lourdes, Louth

County Hospital and Our Lady’s Hospital Navan) and provides an acute hospital range

of services including Medical, Surgical, Paediatrics and maternity to the catchment

area of Louth, Meath and surrounding areas. There are 340 beds and 30 day beds in

Our Lady of Lourdes Hospital. There is 1441 staff employed in this hospital.

It is our policy to do all that is reasonably practicable to prevent injury or ill health to

Staff, Service Users and others who come in contact with our activities. In

recognition of our responsibilities under the Safety, Health and Welfare at Work Act,

2005 and other legislation relevant to our operations, the Service, is committed to

providing and maintaining safe and healthy working conditions by the following

measures:

1. Promote standards of safety, health and welfare that comply with the provisions

and requirements of the Safety, Health and Welfare at Work Act 2005 and other

statutory provisions and codes of practice.

2. Provide and maintain safe, healthy working environments, safe systems of work

and to protect staff, service users and others such as visitors and contractors, in so

far as they come into contact with foreseeable hazards.

3. Information, training and supervision will be provided to all staff to develop

safety awareness, enabling them to work safely and effectively.

4. Identify and define all individuals responsible for Health and Safety

arrangements.

5. Encourage full and effective joint consultation on all health and safety matters.

6. Provide financial and / or staff resources required in so far as is reasonably

practicable.

7. Review this safety statement and its contents or in the event of new development

s or experiences.

9

Review Safety Statement when:

(a) there has been significant change in the matters to which it relates, or

(b) there is another reason to believe that it is no longer valid, e.g. new

legislation, following an accident, introduction of a new process, etc.

This Safety Statement will be brought to the attention of all Staff and Contractors who

come in contact with our service.

The safety and health of our staff is an important service objective.

All staff are responsible for taking reasonable care of their own health, safety and welfare

and that of their service users and others affected by their acts or omissions at work.

Adherence to safety procedures is a condition of employment and wilful negligence will

result in disciplinary action.

10

3.0 Organisational Responsibilities

3.1 General Duties of the Employer

o Managing and conducting all work activities so as to ensure the safety, health and

welfare of people at work (including the prevention of improper conduct or

behavior likely to put employees at risk).

o Designing, providing and maintaining a safe place of work that has safe access

and egress, and uses plant and equipment that is safe and without risk to health.

o Prevention of risks from the use of any article or substance, or from exposure to

physical agents, noise, vibration and ionising or other radiations.

o Planning, organising, performing, maintaining and, where appropriate, revising

systems of work that are safe and without risk to health.

o Providing and maintaining welfare facilities for employees at the workplace.

o Providing information, instruction, training and supervision regarding safety and

health to employees, this must be in a form, manner, and language that they are

likely to understand.

o Cooperating with other employers who share the workplace so as to ensure that

safety and health measures apply to all employees (including fixed-term and

temporary workers) and providing employees with all relevant safety and health

information.

o Providing appropriate protective equipment and clothing to the employees (and at

no cost to the employees).

o Appointing one or more competent persons to specifically advise the employer on

compliance with the safety and health laws.

o Preventing risks to other people at the place of work.

o Ensuring that reportable accidents and dangerous occurrences are reported to the

Health and Safety Authority.

11

Every employer shall manage and conduct his or her undertaking in such a way as to

ensure, so far as is reasonably practicable, that in the course of the work being carried

on, individuals at the place of work (not being his or her employees) are not exposed

to risks to their safety, health or welfare.

3.2 Safety Management Structure and Organisational Chart

The following is the Safety Management Structure within Our Lady of Lourdes Hospital. Each person in the service must ensure the effective implementation of the Safety Statement in their area of responsibility.

12

Interim Network ManagerWillie Rattigan

Group ManagerMargaret Swords

Group Human Resources Manager

Colm Kinch

Operational Services Manager

Yvonne Gregory

Group Finance ManagerNiall Kelly

Director of Nursing & MidwiferyEileen Whelan

Asst Director of Nursing

See page 17

Clinical Nurse/Midwife Managers 3’sSee page 21

Clinical Nurse/Midwife Managers 2’s/CN/MSI/CPC’S

See page 21

CNMM1’s

Employees

Heads of DepartmentSee page 20

EmployeesSafety RepsMary Hewitt

Laura MuckianMartin Smith

Regional Director of OperationsStephen Mulvaney

Risk ManagerIrene O’Hanlon

Organisational Responsibilities

3.3 Safety Management Responsibilities

3.3.1 Interim Network Manager

Mr Willie Rattigan, Interim Network Manager will be responsible for the:

Within their area of responsibility that accountability for safety health and welfare

has been defined and a clear line of accountability has been described to include

roles and responsibilities.

The systems, processes and resources necessary to manage safety health and

welfare are in place within all sites/services within their area of responsibility.

The systems and processes in place contribute to compliance with the HSE’s

Safety Management System and relevant legislation.

Safety, health and welfare is integrated into all activities within their area of

responsibility.

The Corporate Safety Statement and its related obligations are communicated

throughout their area of responsibility.

Safety, Health and Welfare legislation is reflected as part of the general

conditions of a contractor’s work specification at all stages of the procurement

process.

Performance indicators in relation to safety, health and welfare are included as

part of the team based performance management

13


3.3.2General Manager

Ms Margaret Swords, Group General Manager is responsible for the integration of safety, health and welfare into all activities within his area of responsibility.

Responsibilities include:

Have in place a Site/Service Specific Safety Statement which conforms to the

requirements of the Corporate Safety Statement and is supported by a

documented risk assessment procedure.

Ensure that the systems, processes and resources necessary to manage safety

health and welfare are in place within all sites/services within their area of

responsibility.

To ensure that appropriate systems are in place to communicate the Site/Service

Specific Safety Statement to all employees and other persons who may be

exposed to any specific risk to which the Safety Statement applies at least

annually and at other time following amendment.

To ensure that the Site/Service Specific Safety Statement is reviewed and updated

on a regular basis and in the event of any significant change in work practice.

Oversee the auditing of the safety, health and welfare management system, and

ensure results are acted on through the development of appropriate action plans

Promote the integration of safety, health and welfare into all activities of their

area of responsibility i.e. management team meetings.

Incorporate Safety, Health & Welfare legislation as part of the general conditions

of a contractor’s work specification at all stages of the procurement process

Integrate performance indicators in relation to safety, health and welfare as part

of team based performance management.

Seek advice from specialist health and safety and risk advisors as necessary.


14

Ensure that employees have access to safety health and welfare training

appropriate to their role and that a record of each employee’s training is

maintained.

Provide reports from the safety committee to the Network Manager on an annual

basis or more frequently if requested

Report safety, health and welfare risks identified that are not within their ability

to control to the relevant Network Manager

Provide arrangements for the election of safety representatives

Put in place suitable arrangements for an effective and inclusive approach for

safety representatives in the consultation process

15


3.3.3 Operational Services Manager

Ms Yvonne Gregory, Operational Services Manager is responsible for the management and integration of safety, health and welfare within her area of responsibility.


The availability of the Site/Service Specific Safety Statement in their area of responsibility. This must be supported by a risk assessment that clearly reflects the risks within their Service.

That the systems, processes and resources necessary to manage safety health and

welfare are in place within their area of responsibility

Report safety, health and welfare risks identified that are not within their ability

to control to the relevant General Manager.

The systems and processes in place contribute to compliance with the Site/Service

Specific Safety Statement and relevant legislation.

Undertake “walk about safety audits” in their area of responsibility, and document

the findings while following up on corrective action to manage identified deficits

Promote the integration of safety, health and welfare into all activities of their

area of responsibility i.e. departmental/service team meetings.

Ensure that the Site Specific Safety Statement and its related obligations are

communicated throughout their area of responsibility.

Empower employees within their area of responsibility to take ownership of

safety, health and welfare risks and promote best practice in the management of

these risks

Distributing documented safe systems of work to nominated responsible people

for action

Integrate performance indicators in relation to safety, health and welfare as part

of team based performance management.

16


Monitor the performance of the safety, health and welfare system through

performance indicators and audit and ensure the outcomes of the monitoring

process are acted on through the development of appropriate action plans

Seek advice from specialist health and safety / risk advisors as and when required

Ensure that employees have access to and facilitate their attendance at safety

health and welfare training appropriate to their role.

Maintain a record of each employee’s training.

Ensure that a comprehensive incident management process is in place for all

incidents occurring within the department/service.

Ensure that all safety related records are maintained appropriately.

In addition to the above, the Operational Services Manager is responsible for coordinating the health and safety management programme throughout the Hospital.

17


3.3.4 Director of Nursing

Ms. Eileen Whelan, Director of Nursing is responsible for the management and integration of safety, health and welfare within her area of responsibility.

Assistant Directors of Nursing

Mr. Adrian Cleary General Areas

Ms. Marina O’Connor Nurse Prac Dev Co

Ms. Colette McCann Manager for Women & Children’s Health

Ms. Barbara O’Flynn Theatre/CSSD/Endo/Dayward

Ms. Miriam Kelly Midwife Prac Dev Co-ordinator

Ms. Mary Yau Out of Hours

Ms. Mary O’Connor Out of Hours

Ms. Mary McGrane Out of Hours

Ms. Kay Anderson Out of Hours

Ms. Roisin Collier Out of Hours

Ms. Caitriona Crowley, Project Manager - Transformation

Assume the following responsibilities on a day to day basis.

The availability of the Site Specific Safety Statement in their area of responsibility. This must be supported by a risk assessment that clearly reflects the risks within their Service.

That the systems, processes and resources necessary to manage safety health and welfare

are in place within their area of responsibility

Report safety, health and welfare risks identified that are not within their ability to

control to the relevant Local Senior Manager.



Undertake “walk about safety audits” in their area of responsibility, and document the

findings while following up on corrective action to manage identified deficits

Promote the integration of safety, health and welfare into all activities of their area of

responsibility i.e. departmental/service team meetings. 18



Empower employees within their area of responsibility to take ownership of safety,

health and welfare risks and promote best practice in the management of these risks

Distributing documented safe systems of work to nominated responsible people for

action

Integrate performance indicators in relation to safety, health and welfare as part of team

based performance management.

Monitor the performance of the safety, health and welfare system through performance

indicators and audit and ensure the outcomes of the monitoring process are acted on

through the development of appropriate action plans


Ensure that employees have access to and facilitate their attendance at safety health and

welfare training appropriate to their role.


Ensure that a comprehensive incident management process is in place for all incidents

occurring within the department/service.


Organisational Responsibilities19

3.3.5 Heads of Department

The following Heads of Department are responsible for the management and integration

of safety, health and welfare within his / her area of responsibility.

Admissions / Bed Management – Mari Gavin

Catering Dept – Vacant

Central Stores – Nicholas McCabe

Clinical Engineering – Brian Sharpe

Dietetics – Grainne Bogue

Finance / HIPE Dept – Niall Kelly

Human Resource Dept – Colm Kinch

Information Technology Dept – Frances McNamara

Infection Control Dept – Mairead Twohig

Laboratory Dept – Eamon Delahunt

Laundry Dept – Donal Leddy

Library – Jean Harrison

Medical Manpower – Deirdre Dineen

Medical Records / Appointments – Fiona Floyd

Maintenance Dept – Vacant

Occupational Health – Dr Peter Noone

Operational Services Manager – Yvonne Gregory

Pharmacy Dept – Elaine Conyard

Physiotherapy Dept – Karen Gunn/Kay Morris/Valerie Reddan

Risk Advisor – Irene O’Hanlon

Social Work – Anne Lennon

Speech & Language – Maura Reynolds

Support Services Dept – A/Roisin McMahon

X-Ray Dept – Jane Richardson

20

Clinical Nurse/Midwife Manager 3’sMs. Edel Kirwan General AreasMs. Mary Lenehan Maternity

Ms. Trish Donnelly General Areas

Ms. Anne Keating Maternity

Ms. Elizabeth Summersby Oncology

Sr. Catherine Mulligan St Therese Building

Ms. Ciara Finnerty A&E Dept

Ms. Grainne Milne Maternity

Ms. Maureen Kennedy A/Clinical Nurse Manager 3 CCU

Ms. Fiona Monaghan Tyer A/Clinical Nurse Manager 3 General Areas

Ms. Ejiro O’Hare Healthcare Assistants

Clinical Nurse Manager 2’s

Ms. Irene Hoey Ground Floor East

Ms. Mary Costello Theatre

Ms. Geraldine Horgan Theatre

Ms. Debbie McDaniel Theatre

Ms. Andrea McCabe Clinical Facilitator Theatre

Ms. Ailsling Moynihan Theatre

Ms. Sharon Fenelon A/Clinical Nurse Manager 2 First Fl East & West

Ms. Eithne Dunhill A/Clinical Nurse Manager 2 Short Stay Unit

Ms. Anne McIlwee Endoscopy/Dayward

Ms. Denise Flynn Walsh 3rd Fl Orthopaedics

Ms. Linda Rickard 3rd Floor Surgical

Ms. Marie Murphy ICU/CCU/HDU

Ms. Debra Taaffe 5th Fl Inf & Tods

Ms. Catherine Connolly A/Clinical Nurse Manager 2 6th Floor East

Ms. Adeline Milne A/Clinical Nurse Manager 2 6th Floor West

Ms. Kathleen Murray Outpatients Dept

Ms. Nicola McShane 1st Floor New Build

Ms. Nuala Rafferty 2nd Floor New Build

Ms. Mary Faulkner King E Dept

Ms. Paula McKenna E Dept

21

Ms. Adrienne Sharkey E Dept

Ms. Cathy Breen E Dept

Ms. Lynn O’Sullivan E Dept

Ms. Sinead Gardiner E Dept

Ms. Lorraine Clerkin A/Clinical Nurse Manager 2 E Dept

Ms. Rosemary Hodgins A/Clinical Nurse Manager 2 E Dept

Ms. Geraldine McCabe GP/Community Liaison E Dept

Ms. Lorraine Reynolds Clinical Facilitator E Dept

Ms. Irene Griffin MAU

Ms Mary Ita Niall Labour Ward

Ms Kathleen O’Brien Labour Ward

Catherine Smith Labour Ward

Siobhan Weldon Labour Ward

Leone Baillie CMM2 Labour Ward

Miriam Maguire Labour Ward

Leone Campbell Labour Ward

Christine McGeough Labour Ward

Tracey Cotter, CMM2 Labour Ward

Mary Sweeney Gynae

Ger Pigott CMM2 Antenatal Ward

Caroline Keegan MLU

Ms Siobhan Hackett NICU

Laurraine Crinion Postnatal Ward

Mary Gorman Antenatal OPD


The availability of the Site Specific Safety Statement in their area of responsibility. This must be supported by a risk assessment that clearly reflects the risks within their department.

22

That the systems, processes and resources necessary to manage safety health and welfare

are in place within their area of responsibility.

Report safety, health and welfare risks identified that are not within their ability to

control to the relevant Local Senior Manager.



Undertake “walk about safety audits” in their area of responsibility, and document the

findings while following up on corrective action to manage identified deficits.

Promote the integration of safety, health and welfare into all activities of their area of

responsibility i.e. departmental/service team meetings.



Empower employees within their area of responsibility to take ownership of safety,

health and welfare risks and promote best practice in the management of these risks.

Distributing documented safe systems of work to nominated responsible people for

action.

Integrate performance indicators in relation to safety, health and welfare as part of team

based performance management.

Monitor the performance of the safety, health and welfare system through performance

indicators and audit and ensure the outcomes of the monitoring process are acted on

through the development of appropriate action plans.


Ensure that employees have access to and facilitate their attendance at safety health and

welfare training appropriate to their role.


Ensure that a comprehensive incident management process is in place for all incidents

occurring within the department/service.



3.3.6 Employees

23

Employees have the following legal duties under section 13 and 14 of the Safety, Health and Welfare at Work Act 2005:

1. Take reasonable care of their own safety, health and welfare and that of others.

2. Ensure they are not under the influence of an intoxicant to the extent that they may endanger themselves or others.

3. Co-operate with their employer or any other person as appropriate.

4. They must not engage in improper conduct or behaviour (including bullying / harassment).

5. Attend all necessary training.

6. Use safety equipment or PPE provided, or other items provided for their safety, health and welfare at work.

7. Report to your line manger as soon as is practicable:

(i) Any work which may endanger the health and safety of themselves or others.

(ii) Any defect in the place of work, systems of work, articles or substance

(iii) Any breach of health and safety legislation of which he or she is aware.

Employees must not:(i) Interfere with, misuse or damage anything provided for securing the health, safety and

welfare of those at work.(ii) Place anyone at risk in connection with work activities.

Employees must not: Intentionally or recklessly interfere with or misuse any appliance, or safety equipment

provided to secure the safety health or welfare of persons at work.

The Health Service Executive, North East Area has expended considerable time and resources in the preparation of a Safety Management Programme designed to protect the interests of its employees. The programme will not succeed unless each employee co-operates fully.

Failure to comply with the terms of the Safety Statement may result in disciplinary action.


3.3.7 Health & Safety Co-ordinator Hospital Network

24

Ms Karen McKiernan

Role of the Health & Safety Co-Ordinator

Co-ordinate the HSE North Eastern Area’s health and safety management programme within Hospital Network and establish structures to ensure it is disseminated, understood and implemented and that managers are familiar with their roles.

Advise on legislation and technical developments relating to the health and safety of staff, patients, clients and visitors.

Monitor health & safety performance in the Hospital Network.

Assist in the co-ordination of the development of health & safety standards, policies and safe work practice sheets and put in place mechanisms to monitor their effectiveness in application.

Ensure health & safety training programmes are devised, presented and evaluated in line with the HSE North Eastern Area’s statutory obligations.

Receive reports on accident trends and target high-risk areas for priority attention.

Provide assistance in ensuring mechanisms are in place for monitoring the implementation of the Hospital consultation process.

Liaise with statutory bodies, including the HSA, in relation to matters of health and safety at work on behalf of the HSE North Eastern Area.

Work closely with the Occupational Health Department in furtherance of the overall objectives of the HSE North Eastern Area’s Safety Management Programme.

Contact Details:

Karen McKiernan,

Health & Safety Co-ordinator,

Dublin Rd,

Kells,

Co. Meath.

Tel: (046) 9280534/536 E-mail: [email protected]


3.3.8 Local Risk Advisor Risk Advisor: Ms Irene O’HanlonContact Details: St Theresa’s Building

25

mailto:[email protected]

Our Lady of Lourdes HospitalDroghedaTel: 041 – 9875220 E-mail: [email protected]

Dep Risk Advisor: Ms Nora HouriganContact Details: St Theresa’s Building

Our Lady of Lourdes HospitalDroghedaTel: 041 – 9875220 E-mail: [email protected]

Purpose of the job:The role of the Risk Advisor is to advise and support on the management of safety issues in the

hospital towards minimising the risk of harm and achieving the safest and highest standard of

care.

The Risk Advisor supports the development and implementation of Quality Safety & Risk

Management standards through supporting the development of governance structures and

processes as outlined in the Q&R Framework, within Louth/Meath Hospitals.

The Risk Advisor leads on core programmes of work in quality, safety and risk management,

including: development of governance structures with the hospital, clinical effectiveness, service

user & community involvement; risk management & patient safety and service improvement.

The Risk Advisor provides training and education on healthcare risk management issues to staff

including staff safety issues.

The Risk Advisor facilities the development of Risk Registers within specialties & departments

to create a comprehensive, working risk register within the hospital.

The Risk Advisor facilities the data management aspect of the incident reporting system by

ensuring that all adverse incidents & near misses reported are logged on to the STARSWeb

system.

The Risk Advisor monitors incidents reported supports and facilitates incident review towards

ensuring that appropriate measures to reduce or mitigate against reoccurrence of similar

incidents are identified and put in place.

The Risk Advisor works with Health & Safety Personnel and the Hospital Management as

required ensuring that statutory obligations in regard to Health & Safety are complied with.

Organisation and Responsibilities

3.3.9 Consultant Occupational Health Physician

Dr. Peter Noone26



Role of the Consultant Occupational Physician

1. Contribute to the effective strategic management of all staff health, safety and welfare

issues;

2. Assist management in providing a safer, healthier environment for staff, patients and

visitors by recognising, assessing and suggesting ways for managing risks;

3. Be responsible for the process of assessing staff health prior to appointment and in the

ongoing monitoring of staff health for those already in employment.

4. Advise on the medical suitability of an applicant or employee to perform all or any part

of the job description/person specification and assist the personnel department in making

any reasonable adjustment that may be required under the Employment Equality Act

2000;

5. Assist in identifying where sickness absence is a concern and make suggestions for

eliminating identified causes, consequently assisting in its management and reduction;

6. Be aware of the of the organisational and individual causes of work related stress and

advise management on the drawing up, implementation and monitoring of strategies for

dealing with the causes and effects of these;

7. Work with health and safety colleagues to produce strategies for the reduction of

violence to staff as well as providing or arranging for initial assessment of the

counselling needs of those who have been abused;

8. Advise on health risks in the workplace and support employer and employees in

reaching the most appropriate OH strategy or solution to their problem.

Contact Details:

Dr. Peter Noone, Tel: (041) 6857811

Consultant Occupational Physician E.mail: [email protected]

Occupational Health Department,

St Brigids Complex, Ardee, Co. Louth

Organisation and Responsibilities

3.3.10 Regional Fire Prevention Officer

Ms Selina Kavanagh

27


Role of the Regional Fire Prevention Officer

Under the general direction and control of the Technical Services Officer, the Fire Prevention Officer will be responsible, within the HSE North East.

1. Regular inspections of the buildings, means of escape and all fire-fighting equipment and ensuring that all such equipment is properly located, well marked, in good repair and in good working order.

2. Reviewing and, as necessary, drawing up of fire orders, including evacuation schemes for the various types of building and institutions, including schemes for evacuation of all persons with particular regard to mentally ill and non-ambulant patients.

3. Instruction of staff in each institution in:

a. Avoidance of fire hazards.b. Summoning of the fire brigade.c. Operation of the fire alarm and fire equipment, and means of escape.d. Curtailment of an outbreak of fire, pending the arrival of the fire brigade,

prevention of smoke spread and evacuation of danger areas.

4. Arranging regular fire drills in each institution and ensuring that they are properly carried out.

5. Advising as appropriate regarding interpretation of Fire Protection Standards and Building Regulations issued by the Government Departments and ensuring their implementation.

6. Monitoring all means of escape to ensure that they are both safe and adequate and at all times, kept operative and clearly indicated.

7. Keeping proper records of all inspections, fires, evacuation drills, fire-fighting equipment and such other matters relating to his/her office as Fire Prevention Officer.

8. Reporting in writing, to the Technical Services Officer or other delegated Officer, at three-monthly intervals on the state of the fire prevention services in the Board’s buildings and institutions assigned to her. Also, report immediately all outbreaks of fire, breach of the fire prevention orders and failure to perform fire drill at the Board’s buildings and institutions. If so directed, the Fire Prevention Officer will make out an annual report on all aspects of fire and safety pertaining to the Board’s property.

9. To arrange to have the fire prevention work programmes implemented under the direction of the Technical Services Officer.

10. To help in the setting up and alterations to Emergency Plans in all of the boards buildings.

Contact Details:28

Selina Kavanagh Tel: (046) 9280410

Regional Fire Prevention Officer E-mail: [email protected]

Technical Services

Oldcastle Rd

Kells

Co. Meath

Nicola McKenna Tel: (046) 9280410

Asst Regional Fire Prevention Officer Email: [email protected]

Technical Services

Oldcastle Rd

Kells

Co Meath

Section 4.0 Hazard Control Service Arrangements

4.1 Accident / Incident Reporting

All Accidents/Incidents/near misses must be reported immediately to your Line Manager and

recorded in accordance with the HSE Dublin North East Incident Reporting Policy.

29



The following process is undertaken in respect of incident reporting. An incident report form is

completed in triplicate.

White copy: The first copy is forwarded to the Risk Management department.

Yellow copy: In the case of non clinical related incidents, these are submitted to the Operational

Services department for review and action if necessary. . The clinical incidents are reviewed by

the Nursing Management/Head of Department and assessed by the Risk Manager.

Pink copy: The third copy is retained by the department in which the incident occurred. The

review of the accident/incident investigations will be carried out in a timely manner by the line

manager. The purpose of review is to determine the immediate and root cause of the

accident/incident and to prevent recurrence.

All employees are required to co-operate with such reviews and to provide any information,

which may be useful in establishing the circumstances surrounding the accident/incident.

Corrective action will be taken where necessary and recorded.

Accident data will be periodically analysed by line manager with a view to improving safety

performance. Where appropriate, the Safety Statement (including risk assessments) will be

reviewed in light of any accident/incident.

Part X Safety, Health and Welfare at Work (General Application) Regulations 1993

(Notification of Accidents and Dangerous Occurrences) requires that certain accidents and

dangerous occurrences are reported to the Health and Safety Authority. These include the

following categories:

- An accident resulting in the death of an employee;

- An accident resulting in the absence of an employee for more than 3 working days (not

including the day of the accident);

- An accident to any person not at work caused by a work activity which causes loss of

life or requires medical treatment (e.g. member of the public); and

- Certain dangerous occurrences, which have the potential to cause serious injury, whether

or not they did cause serious injury.

The Operational Services Department is responsible for reporting any such accidents/

dangerous occurrences to the Health and Safety Authority.

30

It is the responsibility of the Office of The Director of Nursing to forward details of any

such incidents/occurrences into the Operational Services Manager.

Reporting will be done on the prescribed forms IR1 (accidents) or IR3 (dangerous

occurrences) and forwarded to the Health & Safety Authority.

H.S.A contact details:

The Health & Safety Authority

The Metropolitan Building

James Joyce Street,

Dublin 1 (Tel. No. (01) 6147000)

4.2 Policies & Guidelines & Safe Work Practice Sheets

A number of policies, guidelines have been developed and detail the appropriate methods and

practices to reduce risks associated with unsafe behaviour. A number of safe work practice

sheets are been developed.

List of Policies and Guidelines are as Follows:

1. Guidelines for the Management of Chemical Waste 2004

2. Guidelines for Biological Substances Category B UN3373, 2007

3. Guidelines for the Transport of Infectious Specimens Category A, UN 2814, 2007.

4. Guidelines for the Management of Healthcare Risk Waste, 2004

5. Gloves Use Guidelines for practice – 2009

6. Moving & Handling Policy, 2008

7. Guidelines on the Management of Violence and Aggression in the Workplace –

2007

8. Occupational Blood and Body Fluid Exposure and Administration of Post

Exposure Prophylaxis Guidelines 2010

9. The Stress Management Policy - 2002

It is imperative that each Line Manager ensures that they have copies of all relevant Policies,

Guidelines and Safe Work Practice Sheets relevant to their department. If Line Manager’s

require copies of any such documents, please liaise with Yvonne Gregory, Operational Services

31

Manager. It is essential that all employees carefully read, understand and work in accordance

with these documents.

4.3 Training & Instruction

Heads of Service are required to undertake a training needs analysis for all staff and hold

training records for all their staff. A central repository of attendance names of training

delivered in Fire Safety, Manual Handling, Risk Assessment Technique and Health and Safety

Awareness Training are held in the Operational Services Management department for all staff.

Training shall be provided to employees at Our Lady of Lourdes Hospital a) on recruitment b)

in the event of the transfer of an employee or change of task assigned to an employee c) on the

introduction of new work equipment, systems of work or changes in existing work equipment or

systems of work and d) on the introduction of new technology.

The following training is provided based on legislative requirements and the risk assessment

process

• Fire Safety Training

• Infection Control to include hygiene and decontamination Training

• Professional Management of aggression and violence (is currently being organised)

• Risk Assessment Technique training for Heads of Service

• Biological Agents Risk Assessment Technique training for Heads of Service

• Safety Representative training

• Health & Safety Awareness training

• Manual Handling Training

• Dangerous Goods Safety Training

• Safe Pass Training

• Additional Health and Safety training is provided through the H.S.E. course prospectus

which can be obtained from the REC in Ardee.

4.4 Violence / Aggression

The hospital recognises that violence and aggression is on the increase in the health care sector.

Our Lady of Lourdes Hospital does not tolerate any form of violence and aggression to any staff

member. It is the responsibility of each Head of Service to carry out a physical environment

32

risk assessment which includes identifying the hazards associated with violence in the

department in consultation with staff to ensure appropriate controls are in place.

On completion, these risk assessments are required to be sent to the Operational Services

Manager in order for an action plan to be developed.

Based on risk assessments the following controls are in place throughout the hospital.

These are as follows:

Security

Our Lady of Lourdes Hospital provides a 24/7 security service to maintain a secure working

environment for both staff and all service users. Security can be contacted on Bleep 285.

Equipment

There are 24 C.C.T.V. cameras placed in strategic positions around the hospital.

Some locations in the hospital have an intercom system, these areas include Area 4 OPD,

Cardiac Rehabilitation, Social Work, Palliative Care, Dermatology, The Bungalow, ICT Dept.,

Maternity, Oncology and St. Therese’s Building. There is a swipe system in some areas of the

Hospital i.e. Utility Rooms, ICU/CCU, Laboratory.

Training

On a regional basis, the Hospital has access to trained Professional Management of Aggression

& Violence (PMAV) instructors, which provide specific training sessions, based on risk

assessment on violence and aggression to Hospital staff (this is currently in the process of being

organised). Staff are encouraged to report all incidents of violence and aggression to ensure

appropriate and effective control measures are put in place. Line Managers should be aware of

the whereabouts and proposed itinerary of staff if working away from their base.

In the case of an incident of violence and aggression, staff may contact the Staff Care Line on

1800 409388. Further information on the above may be obtained from the Occupational Health

Department (OHD) on 041 6857811.

4.5 Stress

The Health Service Executive recognises its greatest asset is its employees. Some staff

experience stress which can be the result of pressures within personal life or within the

workplace. Such stress needs to be managed in order for staff to avoid “burnout” or becoming

ill as a result of exposure to such stress

The Occupational Health Service offers a confidential service to employees who maybe

suffering from the effects of stress, whatever the cause. The Occupational Health Department 33

can be contacted on 041 -6857811. The Confidential Counselling Service can be accessed

through the Occupational Health Service also or by using the freephone number which is on the

back of the Staff ID badges (1800409388). The Human Resources Department and can also

provide support.

Further information in relation to the management of stress can be sought from the Health

Service Executive’s Stress Management Policy 2002, which is available in each department.

4.6 Infection Control

The prevention and control of infection is achieved by utilizing standard precautions. See RICG

L/M 0002 (2006).

All staff should be aware of and have access to relevant policies and guidelines pertaining to

infection control. Staff are obliged to inform line managers if they have been exposed to any

infectious disease that may be a risk to themselves colleagues or patients. First aid management

of occupational blood and body fluid exposure is outlined in RICG L/M 00003 (2006) and this

should be followed in the event of occupational blood / body fluid exposure. Relevant

vaccinations are offered by the Occupational Health Department.

Staff should attend the mandatory annual hand washing up-dates.

Transmission based precautions is utilised for all patients requiring isolation. Colour coded

signage is in place and all HCWs should make themselves aware of this.

For further guidance on infection control, please refer to the following:

HSE North East Louth Meath Hospital’s Infection Control Guidelines 2006 (currently

being updated due out in Dec 2010)

Immunisation for Healthcare Employees 2002

Glove Use Guidelines for Practice 2009

Waste Management Guidelines 2004 (Currently being updated)

WHO Hand Hygiene Guidelines 2009

Prevention of blood borne diseases in Health Care setting 2005

Norovirus Guidelines 2003

National Aspergillus Guidelines 2002

SARI MRSA Guidelines 2006 (Currently being updated nationally)

HPSC Clostridium Difficile Guidelines 2008

34

TB Guidelines 2010

Prevention of Intravascular Catheter Related Infection in Ireland 2009

Guidelines for Antimicrobial Stewardship in Hospitals 2009

Legionella Guidelines 2009For further support and information please contact the infection prevention & control department ext

2514. Bleep 113.145.

4.7 OBE (Occupational Blood Exposure)

Due to the nature of work within our service, staff may be at risk to exposure to blood,

bodily fluids and sharps injuries.

Healthcare workers should be familiar with the first aid procedures in the event of such

injuries/exposures.

Encourage bleeding by gentle squeezing, but do not suck the area

Wash with soap and running water

Treat mucosal surfaces such as the mouth or conjunctive of the eye by rinsing with

warm water or saline

Following first aid all injured employees should immediately seek further advice from the local

Accident & Emergency Department regarding further treatment or prophylaxis. The

Occupational Health Service provides advice to Accident & Emergency who provide follow-up

for employees with significant injuries. All Needlestick and occupational blood/body fluid

exposures must be reported to the Department Head/Line Manager and an incident report form

completed. For further guidance, please refer to the H.S.E.Policy on Occupational Blood and

Body Fluid Exposure and Administration of Post Exposure Prophylaxis Guidelines 2010.

The Occupational Health Dept will provide the Health and Safety Committee with 6 monthly

OBE incident reports.

4.8 PPE (Personal Protective Equipment)

Where it is not practicable to eliminate certain risks, the Hospital will provide adequate and

suitable personal protective equipment based on risk assessment to reduce the risk to an

acceptable level. Instruction and practical training in use of P.P.E. will be given prior to issue

of such equipment.

35

Employees are obliged to wear personal protective equipment during the applicable activity.

Failure to do so can result in disciplinary action and prosecution under Safety, Health and

Welfare at Work Act 2005.

Details of specific personal protective equipment provided in each department are contained in

the department safety statement.

Further advice on appropriate personal protective equipment or medical suitability to use such

equipment can be obtained from the Health and Safety Department and/or Occupational Health

Service.

4.9 Latex

Latex gloves are still the most effective barrier against viral penetration. Staff who have

concerns in relation to developing sensitivity to latex should immediately advise their direct

Head of Service, and be referred or self refer to the Occupational Health Service on ph: 041

6857811 or Speed dial 7271. The use of latex gloves is only recommended for contact with

potentially infected materials or body fluids.

It is recommended that non-latex gloves be used for all other activities that are not likely to

involve contact with infectious materials (e.g. food preparation, routine house keeping and

maintenance). For further details please refer to the latex policy which is available from the

Head of Service or the Occupational Health Department. Also available is the Glove use

guidelines for practice

4.10 Visual Display Units

Under the Safety, Health & Welfare at Work (General Application) Regulations 2007, all

hazards associated with display screen equipment (VDU’s) must be identified and any risk to

the health and/or safety of the user must be assessed.

If an employee’s work situation changes e.g. change of work location, a VDU assessment

should be carried out. VDU assessments should be carried out for all new employees.

A copy of the VDU Risk Assessment template and guidance notes are available within each

department.

VDU Assessors

36

Name Location Extension

Emily Maguire Medical Records 2266

Linda Halton Library 4672

Francis McArdle Risk Management 4751/5220

Ian McGovern Physiotherapy Dept 4662

4.11 Eye & Eyesight

All staff who are regular and significant users of Visual Display Units (i.e. they use a VDU for

one continuous hour or more as part of an everyday work routine) are entitled to have an eye

test completed under the Safety, Health and Welfare at Work (General Application)

Regulations, 2007, as follows:

Before commencing VDU work

At three yearly intervals thereafter.

If an employee develops or experience visual difficulties that may be due to VDU work.

In this case, the employee must advise the Line Manager and a referral be made to

Occupational Health outlining the difficulties being experienced.

Eye sight testing may be carried out by the Occupational Health Department and if any

abnormality is found on screening, you will be referred to an Optometrist.

For additional information, please refer to the Staff Handbook.

4.12 Pregnant Employees

In accordance with the Safety, Health & Welfare at work (General Applications) Regulations

2007, Chapter 2 of part 6 Protection of Pregnant, Post-natal and Breast Feeding Employees, a

risk assessment requires to be completed as soon as reasonably practicable after notification of

the pregnancy to the Line Manager.

Notification can be made verbally and accompanied by written confirmation from the GP, the

latter being a legal requirement.

The Line Manager is responsible for completing this risk assessment with the pregnant

employee, advice may be sought if required from the Occupational Health Department.

37

Where there are complex issues requiring further assessment, the employee should be referred

to the Occupational Health Department as a standard management referral. Controls that are

identified are reviewed accordingly and kept in personnel file.

4.13 Dignity at Work

The anti-bullying policy was reviewed under a national partnership initiative and the revised

policy 'Dignity at Work' has formerly become the policy. The HSE Dublin North East

recognises the right of all employees to be treated with dignity and respect in an environment

which is free form all forms of bullying, sexual harassment and harassment. The Dignity at

Work Policy protects employees from bullying, sexual harassment and harassment regardless of

whether it is carried out by a work colleague, patient/client, member of the public, business

contact or any other person with whom employees might come into contact during the course of

their work.

There is a comprehensive complaints procedure in place for further guidance please refer to the

‘H.S.E. Employee Handbook’ or the 'Dignity at Work' Policy. The ‘Dignity at Work’ policy is

available from the Human Resources Department which may be contacted at extension 4655.

4.14 Fire Safety

Fire Detection and Alarm System

Our Lady of Lourdes Hospital has an Analogue Addressable Fire Alarm System. This is

installed in compliance with IS 3218, “Code of Practice for Fire Detection and Alarm Systems

for Buildings. – System Design, Installation and Servicing”

The main Fire Alarm panel is located in the telephone exchange room. Repeater Panels are

displayed at Nurses Stations and various other locations throughout the premises. Smoke

Detectors are located in all rooms except bathrooms and kitchens. Heat Detectors are located

within the Kitchen / Canteen areas. The Fire alarm and emergency lighting system is serviced

on a quarterly basis as per current Fire Regulations.

Emergency Lighting

38

The hospital has an adequate means of emergency lighting. These emergency lights are put in

place to:

Facilitate the means of escape from the building during any interruption or the general

lighting system.

Indicate clearly a route to a protected area.

Identify the location of portable fire fighting equipment.

Fire Fighting Equipment

The purpose of portable fire fighting equipment is as follows:

To extinguish incipient fires

The extinguishers that are provided are only to be used if it is safe to do so. They are installed

in accordance with the recommendations of B.S. 5306: Part 3:1985 code of Practice for the

installation and maintenance of portable fire extinguisher.

An external contractor (MasterFire Protection) maintains all fire response equipment. The

contractor carries out a check on all equipment, including hoses; extinguishers, etc and ensures

that they are in good working order.

The following fire fighting equipment is available throughout the premises

Fire Blankets

Multi Purpose Powder Fire Extinguishers

Water Fire Extinguishers

Water Hose Reels

CO2 Gas Fire Extinguishers

Fire Drills

Employees will be instructed, during their training, on the evacuation procedures within the

hospital. Demonstrations also take place on the use of Fire Fighting extinguishers during

training sessions. A fire drill should be undertaken at least twice a year and recorded in the fire

log book on site.

The Fire Log Book will be a record of:

Date of fire drill

39

Staff attendance

Type of Fire Lecture (Prevention, Control or Evacuation)

Issues arising from the drill

Fire Orders

Where Fire Orders are displayed throughout premises, the procedures shown on these Fire

Orders are to be followed in an emergency situation. All employees should read these Fire

Orders and make themselves familiar with the procedures.

The Regional Fire Prevention Officer Ms. Selina Kavanagh and Asst Regional Fire Prevention

Officer Ms. Nicola McKenna, Technical Services, Kells, can be contacted at 046-9280414.

4.15 Waste Management

All waste must be segregated and disposed of in a safe and responsible manner. Particular

care is needed in disposal of sharps and healthcare risk waste. Clinical Waste must be disposed

of in accordance with the H.S.E’s ‘Guidelines for the Handling and Storage of Healthcare

Waste’2004. Our Lady of Lourdes complies with guidelines for the Management of Chemical

Waste 2004 and in the disposal of Chemical Waste.

The Maintenance Department is responsible for arranging the collection of healthcare waste

from each Department and also responsible for the removal of chemical waste as required.

Collections of healthcare risk waste takes place on a daily basis at regular intervals. Dangerous

Goods Safety Audit is carried out by the Dangerous Goods Safety Advisor in consultation with

the Health & Safety Department. Reports are issued and recommendations addressed on an

ongoing basis.

4.16 Manual Handling

An operational plan is currently being developed with regard to manual handling for the

hospital. Training will be provided by qualified and competent Instructors as per the Moving

and Handling Policy. (Refer to page 16 of the Moving & Handling Feb 08 for arrangements for

the provision of training)

Manual Handling Instructors

Name Location

Ian McGovern, Co-Ordinator Physiotherapy

40

Grainne Vavasour Physiotherapy

Miriam Gamble Physiotherapy

Rosie Clarke Post-natal

Felicity Parkes 5th Floor

The Operational Services Manager is responsible for organising and coordinating the training

programme for the Hospital. The coordinating of this training programme is delegated to Ian

McGovern, Physiotherapy Department. Copies of all manual handling records are held in the

Operational Services Department. All Manual Handling tasks must be risk assessed and lifting

avoided where possible by provision of equipments e.g. hoists, sliding sheets trolleys etc, or

other mechanical devices e.g. (lifts, etc). Where manual handling cannot be avoided, the Head

of Department undertakes a risk assessment in consultation with employees to identify control

measures required to minimise the risks from manual handling.

For further information in relation to Manual Handling, please refer to HSE Dublin North East

Moving and Handling Policy 2008.

4.17 Chemicals

Under the Safety Health and Welfare at Work (Chemical Agents) Regulations 2001 it is the

duty of the employer (Line Managers) to complete a Chemical Risk Assessment for hazardous

products. In order to complete this assessment, a Safety Data Sheet with sixteen headings must

be obtained from the supplier. Details can also be obtained from the label of the product. On

completion of this Risk Assessment, the details must be communicated by the Line Manager to

all relevant staff in that area. Training in the completion of Chemical Risk Assessment will be

provided as appropriate to Heads of Departments.

All chemicals/cleaning agents are stored in accordance with manufacturer’s instructions in

appropriate locked storage cabinets.

For further information, please refer to Safe Work Practice on Chemical Safety – SWPS 1- Use

of Chemicals.

41

4.18 Medical Gases

Medical Gas Cylinders are stored in a locked storage area based at the lower ground floor in the

Maintenance yard. These gas cylinders are stored in accordance with manufacturer’s

instructions e.g. stored upright, chained etc. Safety data sheets for all BOC gases are provided

and located in the storage area. Any replacement cylinders required in clinical areas are carried

out by the hospital porter with the use of a purpose made trolley,

Boilerhouse staff attend training in the management of liquid oxygen and BOC gases.

All empty cylinders must be returned to this storage area by porter. Appropriate hazard warning

signs are displayed at the locked storage area and at the liquid bulk oxygen tank.

Relevant orientation is given to new employees by the Support Services Department in relation

to the transport and setting up of medical gas cylinders.

For further information please refer to Safe Work Practice on Gas Cylinders – ref no. SWPS

12-Gas Cylinders.

4.19 Electrical Safety

Electrical installations and portable electrical appliances must comply with current Health &

Safety and electrical installation regulations.

Faulty or defective leads, plugs, switches, sockets of electrical equipment must be taken out of

service, appropriately labelled and reported to Line Manager or supervisor.

Repairs to all electrical equipment and appliances are carried out by a competent person.

It is the responsibility of all employees to ensure that electrical leads and cables are distributed

in such a manner as not to cause an electrical risk or trip hazard.

All electrical sockets are protected by residual current devices and by fuses or MCBS to protect

against over current or short circuit. In the interest of safety, these devices must be reset by

authorised personnel only. The use of extension blocks are confined to computer equipment

and equipment approved by the Electrical Department.

All Electrical installations are carried out by approved contractors under supervision and

direction of consulting engineers.

42

All workshops within the Hospitals maintenance department are provided with battery operated

hand tools. All other portable tools, e.g. hand grinders, kango hammers, heavy duty drills etc are

110 volt. Contractors carrying out works on the hospital site must ensure that their workers are

provided with 110 volt or battery powered equipment.

The use of 110-volt supply for portable tools is mandatory, but the use of battery-operated tools

is encouraged where possible.

4.20 Slips / Trips / Falls

Employees must take responsibility for their safety particularly in their own immediate working

environment. Defective equipment and hazards in the environment must be reported

immediately. Neat and tidy working is part of this responsibility. The facilities for storage of

files should be used effectively by employees. Files or other such items are not to be stored on

the ground or in positions where trips or collisions with them could occur.

All loose electrical and telephone leads are routed away from pedestrian areas and fed through

cable ports / cable tidies. The Maintenance Department should be contacted where more

permanent re-arrangement of leads and cables is required. The following Safe Work Practise

Sheets exist in relation to house-keeping:

- SWPS 1 (Safe use of Chemicals)

- SWPS 28 (good house-keeping/accident prevention)

- SWPS 53 (cleaning operations)

It is essential that all relevant employees read, understand and work in accordance with the

above SWPS.

All Line Managers undertake risk assessments of their working environment and are required to

put control measures in place to minimise the hazard of slips and trips.

4.21 Maintenance

Maintenance work is carried out in all the hospital’s buildings and grounds by the Hospital’s

Maintenance team and external contractors are used as necessary.

Fire alarm systems and fire extinguishment equipment are serviced annually by external

specialist contractors. Acceptance checks are carried out on all newly delivered medical devices 43

by the Clinical Engineering Department. The service and maintenance of medical equipment is

managed by the Clinical Engineering Department who determines as to whether the service and

maintenance of medical equipment is serviced in-house or by external specialists or on a shared

basis between the Clinical Engineering Department and relevant external specialists.

Statutory inspections of certain equipment such as steam boilers, calorifiers, pressure vessels,

elevators, hoists etc are carried out by qualified personnel as required by legislation.

Many of the hazards identified in the Risk Assessment are being eliminated in the course of

routine building maintenance work.

4.22 Contractors

Contractors will be provided at pre-contract stage with a copy of the Hospital safety statement,

in addition to the relevant Department Safety Statements as will visitors who may be affected by

our work activities e.g. inspectors, suppliers, etc.

They will sign the documents to indicate that they have read and understood them. They will

perform their work in accordance with H.S.E. requirements. It is implied in this condition that,

in its work activities, the contractor or visitors will adhere to recognised standards and

regulations relevant to their works.

Contractors will be required to submit relevant sections of their own safety statement and

method statements at pre-contract stage for examination. Those relating to buildings and their

services will be examined by the Operational Services Manager, Maintenance Manager as

appropriate and a representative of the Estates Department where necessary.

Persons can direct the contractor to amend the statement to ensure safe work conditions.

4.23 Visitors

Visitors are obliged to comply with the HSE NHO Visiting Policy. Visitors are obliged to

follow any instructions given by Hospital Personnel. Visitors should not enter “Restricted”

44

areas. Public fire safety notices are posted throughout the Hospital complex. The no smoking

policy must be adhered to by all members of staff, patients, visitors and service users

4.24 Transport

Based on risk assessment a Traffic Management policy is in place for the Service yard to ensure

the safety of staff and service users. The speed limit in the Service Yard is 5mph, 8km. A

Traffic Marshall is on duty from 8am to 4.30pm Monday to Friday, to manage traffic flow and

pedestrian safety. Appropriate training has been provided to all Traffic Marshals. Pedestrian

traffic in the yard area is managed by means of clearly defined and barrier protected walkways.

Interface between traffic and pedestrians are managed on the hospital campus by providing

walkways and pedestrian crossings. Appropriate signage is in place where necessary. Control

barriers and speed ramps are used to restrict vehicular traffic and control access and egress.

Five parking spaces are reserved for service personnel while on duty in the hospital. All

security staff outside the barrier protected area must wear hi-vis jackets.

A number of designated disabled parking bays are available on both the main hospital site and

also at Crosslanes Car Park. A dedicated shuttle bus service is available to transport patients

and visitors from Crosslanes car park to the main hospital site.

4.25 Emergency Situations

In the event of total electrical failure the hospital’s emergency generator will maintain supply to

all areas and systems. The generator will distribute power within twenty seconds, during this

brief situation; a plan is in place to mitigate against a number of potential occurrences. In the

event of electrical outages, the generator service will kick in at the hospital preventing any

undue risk to patients or staff. Presently an internal emergency plan is being developed in Our

Lady of Lourdes Hospital.

4.26 Shared Workplace

Where the Health Service Executive Dublin North East share a workplace with another

employer, employees can suffer accidents or ill health when they are not aware of the risks they

face which may be generated by one or other of the various employers sharing the workplace.

45

The arrangements at Our Lady of Lourdes Hospital has in place with Primary Community and

Continuing Care (PCCC) within the hospital include the following:

A copy of this safety statement is forwarded to PCCC managers who are located in this

hospital.

Fire Safety training is available to all occupants within the building including PCCC

staff.

4.27 Information

The HSE Dublin North East has acquired published safety material relevant to its work

activities. This material includes legislation, standards, guidance notes and codes of practice

together with some journals and publications from occupational safety and health organisations.

Sources of health and safety information are as follows:

Safety Data Sheets

Manufacturers/Suppliers Manuals

HSE DNE Policies and Procedures

Safe Work Practice Sheets

Standard Operating Procedures

Occupational Health Department

Health and Safety Department

Risk Management Department

4.28 Lone Worker/Lone Working

Lone Workers are staff who work by themselves without close or direct contact with colleagues i.e. staff working out of hours in Laboratory & X-ray Departments.

A Risk Assessment for Lone Working is completed by the Head of Department in consultation with staff and attached to Section 10 of this document.

4.29 Welfare

Our Lady of Lourdes hospital recognises that staff will experience ill health from time to time

and therefore support the staff in order to improve or maintain their health by

Keeping in regular contact with staff member who is on sick leave

Referral to Occupational Health Department where appropriate

46

Informal return to work meetings with staff who have been on long term sick leave.

Discuss additional training needs with staff if relevant(The above as per Management

Attendance Policy)

Other arrangements in place include:

Dining Room/Canteen provided for staff usage

Water coolers at strategic points throughout the hospital.

Rest Room available for staff to Breast Feed

Provide information leaflets on Staff Counselling. Staff Care provides counselling

services to HSE Dublin North East Employees. This service can be accessed directly by

phoning the free phone Careline, on 1800 409388. When contacted, the Staff Care

Counsellor will respond sensitively to the employees’ needs. All Staff Care Counsellors

are professionally qualified with relevant counselling experience. For further details

please refer to brochure on Staff Care which is available from your Head of Department

or from Occupational Health.

Our Lady of Lourdes hospital aims to promote and change the physical, mental and social well-

being of its employees, the following are available to staff in Our Lady of Lourdes hospital.

Smoke Free Policy & Provide Smoking Cessation Assistance, contact Martin Smith on

0857439448 .Staff are entitled to One month’s free nicotine Replacement Therapy if

seen by service

Health promotion days & initiatives, contact Health Promotion Corner at 4732/ 4790

Specific Staff health checks are carried out in conjunction with relevant National

campaigns (i.e. Irish Heart Foundation’s Blood Pressure Awareness Day)

Our Lady of Lourdes hospital has received Silver level status in the health Promoting

Hospital’s Breastfeeding Supportive Workplace Award.

Ongoing staff information and advice on healthy lifestyle is available at the Health

Promotion Corner

The HP department also facilitate ongoing programmes / training and awareness/

information initiatives for staff

Our Lady of Lourdes Initiatives:

47

Secure bicycle racks for staff are situated at the back entrance to the hospital ( Beside

laundry)

Special price reductions for staff members have also been negotiated with local leisure

centres.

Physical activity programmes for staff are held regularly in collaboration with the regional

physical activity coordinators i.e. ‘ Operation Transformation’

The hospital participates each year in the health promoting hospital network’s national

“Challenge Day” in May. Our Lady of Lourdes hospital has won its category in this

competition for the last three years.

The staff dining room has been audited externally and has obtained the Irish Heart

Foundation’s Happy Heart at Work Award and offer health options to all hospital staff.

Smoke-Free at Work – A policy for the Health Service Executive

Smoking is strictly prohibited within all buildings owned or occupied by the Health Service

Executive including offices, hallways, waiting rooms, restrooms, lunchrooms/canteens,

elevators, meeting rooms and all community work areas. This policy applies to all employees,

clients, contractors and visitors. It also should be noted that Health Service Executive vehicles

are regarded as a place of work under the Act, and so smoking is also prohibited in all vehicles

owned, or leased to the Health Service Executive. Smoking will be permitted at a reasonable

distance outside any enclosed area where smoking is prohibited to ensure that environmental

tobacco smoke does not enter the area through entrances, windows, ventilation systems or any

other means. Smoking will not be permitted in any circumstances during normal working time,

and employees wishing to smoke may only do so during their official break periods.

Our Lady of Lourdes hospital is a member of the European Smoke Free Hospital Network and

the local committee audits the smoke free status of the hospital each year. Our Lady of

Lourdes hospital has been awarded silver status for the past three years. The hospital’s smoke-

free multidisciplinary committee monitors the policy and related signage at all entrances. All

staff are reminded of the policy at induction and there is a smoking cessation counsellor

available free to any staff wanting to quit. Staff can also receive a free months’ supply of

Nicotine replacement therapy when attending the counsellor.

48

Section 5.0 Risk Management Process

5.1 Risk Assessment

A Risk Assessment is a systematic and critical examination of the workplace for the

purpose of identifying hazards, assessing the risk and recommending controls of the

hazard where appropriate. Where hazards cannot be eliminated, control measures will

be recommended to reduce the risk to an acceptable level

In accordance with Section 19 Safety Health and Welfare at Work Act 2005, Risk

Assessments have been completed for Our Lady of Lourdes Hospital.

Within the Risk Assessment persons responsible for ensuring that additional

recommended controls are implemented within agreed timeframes are named.

Employees will be made aware of the Risk Assessments relevant to their work

activities. A Risk Assessment will be reviewed where:

(a) there has been significant change in the matters to which it relates, or

(b) there is another reason to believe that it is no longer valid, e.g. new


Following the review, Risk Assessments will be amended as appropriate.

The selection and implementation of the most appropriate method of risk or hazard

control is a crucial part of the risk assessment process.

Persons carrying out Risk Assessments will have regard to Schedule 3 of Safety

Health and Welfare at Work Act 2005

49

5.2 The Risk Management Process as outlined in Figure 1 below comprises of

the following four steps:

Step 1 Identification of the Hazard

Step 2 Identify the Risks associated with the hazard

Step 3 Assess (i.e. Rate) the risks

Step 4 Identify any additional control measures (if any) required (i.e.

Evaluate and Treat the Risks)

Communicate and Consult:

Describe the communication and consultation process in relation to risk

assessment.

Figure 1 below outlines the Risk Management Process.

Each of the 4 steps in the risks management process are described in detail below.

Com

mun

icat

e an

d C

onsu

lt

Monitor and R

eview

Assess (Rate) the Risks

Identify the Risks associated with the Hazard

Identify any additional control measures if required

(Evaluate and Treat the Risks)

Identify the Hazard

Figure 1 – Risk Management Process

50

Step 1 Identification of hazards

The first step in safeguarding safety, health and welfare is to identify hazards.

To help identify hazards it is useful to categorise hazards as the following

Physical

Chemical

Biological

Psychosocial

Step 2. Identification of risks associated with hazards

This step starts with describing the risks associated with and persons affected by each

of the hazards identified. It is important that the description of each risk provided,

accurately and comprehensively captures the nature and impact of the risk.

As the information from this process may be included in the relevant risk register the

risks should be described using the following process:

The ‘ICC approach’ to risk description

o Risk is inherently negative, implying the possibility of adverse

impacts. Describe the potential area of Impact if the risk were to

materialise.

o Describe the Causal Factors that could result in the risk materialising.

o Ensure that the Context of the risk is clear, e.g. is the risk ‘target’ well

defined (e.g. staff. Patient, department, hospital etc.)

51

Step 3. Assess (Rate) the Risks

The next step in the process is to rate the risk associated with the hazard (risk

analysis). Rating of risk is carried out taking account of existing control measures.

Two elements need to be determined when assessing the level of risk posed:

i.e.

1. The likelihood that a specified event may occur or reoccur.

and

2. The impact of harm to patients, staff, services, environment or the

organisation as a result of the undesired event occurring.

HSE Risk Matrix (Combining Impact and Likelihood)

Risk Matrix Negligible(1) Minor(2) Moderate(3) Major(4) Extreme(5)

Almost Certain

(5)

5 10 15 20 25

Likely (4) 4 8 12 16 20

Possible (3) 3 6 9 12 15

Unlikely (2) 2 4 6 8 10

Rare/Remote (1) 1 2 3 4 5

Example 1: Likelihood of 3 (Possible) x Impact of 2 (Minor) = 2 x 3 = 6 (Amber) M6

Example 2: Likelihood of 2 (Unlikely) x Impact of 3 (Moderate) = 3 x 2 = 6 (Amber) M6

52

Step 4 Identify any Additional Control Measures that are required

(Risk Evaluation and Treatment)

There is a requirement to do all that is reasonably practicable to minimise the risk of

harm to staff, service users and visitors. Therefore once a hazard is identified and the

risk assessed, the necessary control measures must be developed and implemented to

protect safety, health and welfare. Best practice is to remove the hazard, if it cannot be

removed, control measures must be put in place to reduce the risk.

An action plan should be devised for each risk where the assessment completed indicates

that further control measures are required. It is advised that when completing action

plans that high risk hazards are dealt with as a priority. Time frames must be compiled

for the actioning of each hazard identified. Actions must be realistic and timely.

Immediate actions and long term actions must be considered in order to eliminate the

hazard or reduce the risk to an acceptable level.

The General Principals of Risk Prevention are as follows:

o The avoidance or risks.

o The evaluation of unavoidable risks.

o The combating of risks at source.

o The adaptation of work to the individual, especially as regards the design of places

of work, the choice of work equipment and the choice of systems of work, with a

view, in particular, to alleviating monotonous work and work at a predetermined

work rate and to reducing their effect on health.

o The adaptation of the place of work to technical progress.

o The replacement of dangerous articles, substances or systems of work by non-

dangerous or less dangerous articles, substances or systems of work.

54

Recording your Risk Assessment:

The results of the risk assessment must be documented in accordance with legislative

requirements

Monitoring and Review

Once control measures have been developed and implemented a systematic and regular

review must be implemented to ensure that the control measures are working effectively.

Control measures must be monitored and evaluated on a regular basis. Sooner or later new

equipment, procedures or substances will be introduced that could lead to new hazards – if

there is any significant change the risk assessment should be amended to take account of

these new hazards and brought to the attention of the relevant personnel. All assessments

should be reviewed on an annual basis. It is the responsibility of the HOD to complete the

RA in consultation with staff. Once these risk assessments are completed a copy is

forwarded to Operational Services Dept and a meeting is organised with Line Manager to

discuss and develop an action plan.

55

Section 6.0 Consultation Arrangements

The Health Service Executive recognises that all staff has an integral role to play in the

adoption and management of health and safety and should have effective means for

consultation and representation on health & safety matters.

In accordance with S20 of the Safety, Health & Welfare at Work Act 2005 consultative

structures have therefore been established to facilitate participation by management, staff

delegates and Safety Representatives.

The effectiveness of the consultation arrangements will be reviewed at regular intervals.

Our Lady of Lourdes Hospital have the following consultation mechanisms in place:

Safety Representative

Safety Committee

Health & Safety is an agenda item at staff meetings

6.1 Safety Representatives:

Section 25 of the 2005 Act states that employees are entitled to select and appoint one of their

number to represent them in matters of health, safety & welfare.

Safety Representatives are nominated/elected on a three-year cycle. The Safety Representatives

for Our Lady of Lourdes Hospital are :

Martin Smith, Health PromotionTel: 041 9874732 Bleep 358Email; [email protected]

Laura Muckian, Labour Ward Tel: 041 9837601 ext 2122Email: [email protected]

Mary Hewitt, Support ServicesTel: 041 9874649Email: [email protected]

56




Training of Safety Representatives is ongoing. Time off as may be reasonable is given to Safety

Representatives to carry out their functions and to acquire training and information on matters of

safety, health and welfare.

Section 25 of the Safety, Health & Welfare at Work Act 2005 states that the Safety Representative

may:

Make representations to their employer on any aspects of safety, health and welfare at the

place of work.

Inspect the place of work after giving reasonable notice to their employer. The frequency

and schedule of inspections must be agreed between the Safety Representative and the

employer in advance

Inspect the place of work in the event of an accident, dangerous occurrence or a situation

of imminent danger or risk to health and safety.

Investigate accidents and dangerous occurrences provided they do not interfere with or

obstruct any person fulfilling their legal duty.

After giving reasonable notice to their employer, investigate complaints made by

employees whom they represent.

Accompany a HSA Inspector on a tour of inspection.

At the discretion of the HSA Inspector, accompany the Inspector while they are

investigating an incident or dangerous occurrence.

Make oral or written representations to the HSA Inspectors on matters relating to health,

safety and welfare at the place of work.

Receive advice and information from the HSA Inspectors on matters relating to health,

safety and welfare at the place of work.

Consult and liaise with other Safety Representatives appointed in the organisation.

57

Consultation Arrangements

6.2 Safety Committees:

There is a Safety Committee in place which meets at 2 monthly intervals. Members as follows:

Margaret Swords, Group General Manager (Chair) Tel: 041 9874693 Email: [email protected]

Yvonne Gregory, Operational Services ManagerTel: 041 9874773Email: [email protected]

Karen McKiernan, Health and Safety Advisor DNETel: 046 92 80554Email: [email protected]

Denise Melia, Occupational Health and SafetyTel: 041 9874701Email; [email protected]

Roisin McMahon A/Support Services Manager Tel: 041 [email protected]

Martin Smith, Safety Rep Health PromotionTel: 041 9874732 Bleep 358Email; [email protected]

Laura Muckian, Safety Rep, Labour Ward Tel: 041 9837601 ext 2122Email: [email protected]

Mary Hewitt, Safety Rep, Support ServicesTel: 041 9874649Email: [email protected]

Bernadette Boylan, Catering Officer II Tel: 041 9837601 ext [email protected]

Aoife Carroll, Occupational HealthTel: 041 6857811Email: [email protected]

58











Adrian Cleary, Assistant Director of NursingTel: 041 9874636Email: [email protected]

Mairead Twohig, CNS, Infection Control DeptTel: 041 9837601 Ext 2514 Email: [email protected]

Rose Byrne, Health PromotionTel: 041 9874732Email: [email protected]

Ian McGovern, PhysiotherapyTel: 041 9874662Email: [email protected]

Frances McNamara, ICTTel: 041 9874695Email; [email protected]

Elaine Conyard, PharmacyTel: 041 9837601 Ext 2604Email: [email protected]

Niall Kelly, FinanceTel: 041 9805721Email: [email protected]

Irene O’Hanlon, Risk AdvisorTel: 041 9837601 Ext 2226Email: [email protected]

All Safety Committee meetings will be minuted and the minutes circulated to Heads of Service with a request to discuss with staff for information and action as appropriate.

Terms of Reference as follows:

Make recommendation on the amendments to the Safety Statement when:

a) There has been significant change in the matters to which it relates, or.

b) There is another reason to believe that it is no longer valid, e.g. new legislation,

following an accident, introduction of a new process, etc.

59









To ensure that the risk assessment process meets the requirements of the Act in the terms of a

comprehensive assessment of all hazards and risks, existing and foreseeable, relating to

buildings, equipment, work practices and work systems.

Monitor the implementation of the remedy and controls recommended for hazards in each

location.

To carry out an on-going review of all relevant policies and practices.

Act as the forum for consultation with staff and for dealing with occupational health, safety &

welfare issues at the location within their control.

Review accident and incident trends and identify and advise on measures to reduce same.

Identify and advise on training needs.

Our Lady of Lourdes Hospital Health & Safety Committee are represented at the Quality

Assurance Programme Working Group which monitors the compliance with Health & Safety

Audit and Quality Improvement Plans. This Group report progress on compliance of the Seven

Standards Programme, which includes Health & Safety to the Louth / Meath Quality & Risk

Committee.

The Quality & Risk Committee in turn provides assurance to the Executive Management Board.

Health & Safety issues are also discussed at Senior Management Team Meetings. See Appendix 2

for Quality and Risk Programme.

60

Section 7.0 Resources

7.1 Resources

It is necessary to expend resources in order to achieve the implementation of the safety

management programme. This takes the form of personnel, time and finance.

Personnel

Considerable time resources have been expended by management in implementing the Safety

Management Programme, developing Safety Statements, monitoring and reviewing Risk

Assessments, Safe Work Practice Sheets and consulting with employees. Additional specialist

input is made by the Health and Safety Coordinator, Moving and Handling Instructors, VDU

Assessors, Safety Representatives, Occupational Health Department, Estates Department,

Infection Control Department and Fire Officer among others.

Maintenance

Dedicated efforts of the maintenance department in terms of time, materials and services are

directed to improving plant, equipment and facilities with consequent improvements in the

hospitals Health & Safety management programme.

Training

The training mentioned in Section 4.5 is provided to all relevant employees in Our Lady of

Lourdes Hospital. This consumes financial and direct resources (time, materials and equipment).

Personal Protective Equipment

Adequate and suitable personal protective equipment is provided to employees based on the risk

assessment requirements at considerable financial and time cost to Our Lady of Lourdes Hospital

Management are committed to the provision of such protective equipment as is deemed

necessary.

61

Direct Costs

There are direct costs involved in eliminating or reducing hazards, purchase of personal

protective equipment, warning signs, guards, on a needs basis etc. The Operational Services

Manager estimates these costs, which are submitted to the General Manager with other budgetary

requirements from Health and Safety Risk Assessment.

Direct costs may be estimated under the following headings:

Personal Protective Equipment

Warning Signs

Health and Safety related training courses

Implementation of Risk Assessments

Safety Representative Consultations

Information Workshops

Immunizations/prophylactic treatment

Health Surveillance

Occupational Hygiene Monitoring for Work Exposures

Others

62

Section 8.0 Distribution / Access to the Safety Statement

On completion of the Hospital Safety Statement, this will be forwarded to all departments

in hard copy format. Sections 1-9 will be completed and revised by Hospital

management. Section 10 must be completed by the Heads of Departments. It is

imperative that the Line Manager discusses all aspects of the Safety Statement during

their team meetings with their employees. The Safety Statement should be an agenda

item at team meetings. It must be located in the Health & Safety folder for all staff to

access. There is a responsibility on all employees to read, understand and work in

accordance with its contents. Communication Plan being devised which details how

documentation relating to Health and Safety is to be communicated to employees. (See

Appendix 3)

63

Section 9.0 Review/ Revision of the Safety Management Programme

9.1 Safety Statement

This Safety Statement and associated Risk Assessments are required to be reviewed when:

(a) There has been significant change in the matters to which it relates, or

(b) There is another reason to believe that it is no longer valid, e.g. new


(c) If there is direction from the Health & Safety Authority following

inspection to have the Safety Statement amended.

This Safety Statement will be reviewed by the responsible persons. Section 1-9 will be

reviewed by hospital management in consultation with the safety committee and section

10 will be reviewed in accordance with the above statements by the Line Managers.

9.2 Safety Management System

Safety and Health Audit Tool for the Health Care Sector (HSA) is carried out on an

annual basis and a quality improvement plan is developed from the findings. Progress is

reported on a quarterly timeframe basis as required by the National Hospitals Office.

Actions are continuously been implemented. The following Key Performance Indicators

were identified and agreed to monitor safety and health performance:

1. The organisation has completed the annual health and safety self-assessment and

identified areas for improvement.

2. The self-assessment results and associated list of quality improvement plans (QIPs) have

been reviewed and signed-off by the clinical governance (or appropriate) committee

3. The organisation has a documented safety and health policy

4. Organisation has in place up-to-date safety statement, in accordance with requirements

5. The content of the safety statement is brought to the attention of all employees at least

annually

6. Percentage of Managers trained in Risk Assessment process.

64

Section 10.0 Department / Unit Safety Statement

10.1 Introduction

This is the Department Safety Statement and associated risk assessments for Our Lady of Lourdes Hospital, Drogheda, Co. Louth

This section should contain all relevant department / unit risk assessments e.g.

Physical environment to include the management of violence Biological Agents Chemical Agents Lone Working VDU

This is not an exhaustive list.

Signed: ___________________

Date: ___________________

Appendix 1

65

The range of acute services is as follows

MEDICAL SERVICES:General MedicineEmergency MedicineCardiologyEndocrinology/Diabetes OncologyDermatologyGeriatric MedicineRespiratory Medicine Physical MedicinePalliative Care

SURGICAL SERVICES:General SurgeryOrthopaedics UrologyIntensive CareE.N.T

Anaesthetics

SPECIALIST SERVICES:OphthalmologyPaediatric & Neonatal Obstetric/Gynaecology Nursing & Midwifery ServicesHaematology Clinical Support PathologyRadiology

Bed Complement

The current bed complement is as follows

Our Lady of Lourdes, Drogheda Louth County Hospital, Dundalk

Inpatient Beds;o Medicine 90 71o Surgery 52 32o Orthopaedic 27o Paediatrics 40o Obstetrics 57o Gynaecology 18o ICU 4 2o CCU 3 4o HDU 3o NICU 16o Day Surgery 14o Five Day Ward 14

Total 310 (of which 99 are private) 137

There are also 30 day beds in Our Lady of Lourdes Hospital.The following is also located in the grounds of Louth County Hospital:

16 Bed High Support Mental Health Unit 150 Bed Geriatric nit Psychiatric Unit Alzheimer’s Unit

Current Configuration of Consultants and Services

66

All recent Consultant posts in Our Lady of Lourdes have cross site commitments to either Louth County Hospital or Our Lady’s Hospital, Navan.

Our Lady of Lourdes Louth County HospitalMedicine:

7 Consultant Physicians. 3 Consultant Physicians 1 Specialising in Geriatrics, 1 Specialising in Geriatrics, 1 Specialising in Respiratory, 1 Specialising in GIT 1 Specialising in Cardiology, 1 Specialising in Endocrinology, 1 Specialising in Dermatology, 1 Specialising in Palliative,

A second Consultant Cardiology post has been approved for the hospital group.

Surgery: A joint department of surgery was established in 2004 between Louth County, Dundalk

and Our Lady of Lourdes Hospital, Drogheda. There are 6 consultants with a special interest in Breast, paediatric and upper and lower

GIT. There is a one stop shop for breast services which caters for the North East Region.

Radiology: 9 Radiologists. 2 of whom have a sessional commitment to Louth County Hospital. In 2005 an MRI scanner was installed and house in portacabin on site at Our Lady of

Lourdes Hospital, Drogheda. CT for Louth County, Dundalk, Our Lady’s Hospital, Navan are all carried out in Our

Lady of Lourdes Hospital, Drogheda.

Our Lady of Lourdes Louth County HospitalAnaesthetics:

9 consultant anaesthetists. 3 consultant anaesthetists (one recently appointed)

One of which specialises in Intensive Care

Accident and Emergency: 3 Emergency Medicine Consultants. 2 of whom have sessional commitments to Dundalk and Navan.

Orthopaedics Surgery: 8 Consultant Surgeons. Regional Orthopaedics services are deliver across two sites Our Lady’s Hospital Navan

for elective operations and Our Lady of Lourdes Hospital Drogheda for Trauma operations

67

Obstetrics and Gynaecology: There are 7 consultant Obstetricians/Gynaecologists. One of which specialises in Maternal Foetal Medicine. In June 2004 a new midwifery led unit was launched.

Paediatrics/Neonatology: There are 6 paediatric consultants. 1 of whom specialises in community child health. 2 of whom are neonatologists who supply neonatology service to the entire North East

Region.

Pathology:There are 3 Histopathologists and 1 recently appointed Haematologist.

Sessional Consultants:

Sessional services are provided for the following areas, Occupational Health Urology ENT Surgery Oncology Ophthalmology Endocrinology and Diabetes Mellitus Rheumatology Infectious Diseases

Appendix 2 Quality Assurance Programme

68

Appendix 3 Communication PlanHealth and Safety

Communication Plan –Reviewed Sept 2010

Mode of Details of Use Frequency Responsible Evidence of

69

Communication

effectiveness

Email Periodically messages/updates will be sent out via ‘T’ Drive to disseminate key Health and Safety Documentation including OLOL Safety Statement and all new and revised Health and Safety Policies and Procedures.

As required Denise MeliaOperational Services

Random checks call to wards/departments

Safety Audit

Notice boards Notice boards identified and will be used to display Health and Safety updates namely back stairs, canteen area.

Monthly Denise MeliaOperational ServicesHealth and Safety Committee

Questionnaire on H & S knowledge to be developed

Team/Departmental

Meetings

Health and Safety is a standing agenda item at the Louth/Meath Senior Management Team Meetings

Health and Safety Committee meeting feedback to the Management Team on a bi monthly Basis.

Health and Safety is also an agenda item on all ward/ departmental meetings, CNM111, ADON’s /CNM 11 Multidisciplinary team meetings

Minutes of Health and Safety Committee Meetings will disseminated to all departments via T Drive

Bi Monthly Denise MeliaOperational ServicesHealth and Safety CommitteeHeads of Depts

Feedback from team members from participation on various committees of increased staff awareness

Information Sessions

Induction Presentation on OLOL Safety Management System.

Health and Safety information/education sessions will be provided to staff as required to raise profile of Health and Safety in OLOLH.

Health and Safety ‘Awareness Days’

As required

Number of sessions will be provided.

Periodically

Denise MeliaOperational Services

Karen McKiernan Health and Safety Coordinator - Hospital NetworkHSE DNE Area

Health and Safety Committee

Staff attendance records

Staff attendance records

Evaluation Form to be developed

70

North Eastern Health Board - Nurse On Call Jobs Safety Statement.d… · Web viewSafety...

Documents

Transcript of North Eastern Health Board - Nurse On Call Jobs Safety Statement.d… · Web viewSafety...