Health and safety policy

The Online NHS Trust considers effective health and safety risk management to be an integral part of its daily operations. This policy sets out our arrangements for health and safety management and the responsibilities of staff at all levels.

Policy details

Version number: 1
Approved by: Trust Board
Responsible Director: Chair
Policy author: Tania Openshaw
Review body: Organisational Build Steering Group
Review by date: 31 December 2026

1. Summary

The Trust considers effective health and safety risk management as an integral part of its daily operations. It is committed to carrying out its work in a way that ensures the safety and health of its staff, patients, and any others who might be affected by its undertaking.

This policy sets out the arrangements for health and safety management, determines the levels of responsibility at all levels and the channels of communication for health and safety. Whilst the Trust accepts the main responsibilities for the implementation of the policy, staff have a very important and legal role in co-operating with the Trust to ensure a healthy and safe working environment. Non-compliance by any member of staff with any of the statutory regulations or the safety policies and procedures laid down by the Trust, may result in disciplinary action being taken, and possible legal action.

2. Equality Impact Statement

The author of this policy has undertaken an equality impact assessment (EIA) and has concluded that there is no negative impact on any of the protected equalities groups. A summary of the completed EIA can be found in the equality impact assessment section of this page.

3. Introduction

The Trust recognises that the Health and Safety at Work etc. Act 1974 places a duty of care upon both employer and employee to identify and control risk.
The Trust accepts fully its responsibilities under the Health and Safety at Work etc. Act 1974 and under the Management of Health and Safety at Work Regulations 1999.
This policy helps the Trust comply with the above legal requirements and the policy acts as a general Statement of Intent. The Trust recognises the importance of ensuring that this policy is implemented, monitored and revised as necessary, in the light of legislative or organisational changes.

4. Objectives

The Trust Board recognises that all matters of health, safety and welfare are essential factors and must be integrated within all corporate and management decisions. Patient care, health, safety, environmental considerations and business objectives are mutually dependent.
The purpose of this policy is to support the core business of the Trust, through a robust and accountable health and safety framework that allows development and promotion of a positive and effective health and safety culture throughout the Trust. Although responsibilities are delegated throughout the Trust, overall responsibility rests with the Programme Director (or assigned deputy).
The objective of this policy is to provide a health and safety management framework that:

always complies with the Health and Safety at Work etc. Act 1974, the Management of Health and Safety at Work Regulations 1999 and all other relevant statutory provisions
provides a safe and healthy environment for all stakeholders
identifies all significant hazards arising from Trust activities and prevents adverse incidents across the Trust
assesses all resultant risk to the health, safety and welfare of our staff, patients, and other persons affected by our business
develops appropriate preventative and protective measures and ensures that there is an effective health and safety management programme in place
encourages involvement and participation of staff in all aspects of matters affecting their health and safety, and provides adequate information, instruction and supervision for employees
ensures that all employees are competent to do their tasks, and provides them with adequate training
monitors and applies appropriate control over the health and safety performance of contractors
integrates the management of health and safety across all management frameworks and ensures incidents are reported and are dealt with competently
establishes, and implements, appropriate emergency procedures and contingency plans, as outlined in the Emergency preparedness, resilience and response policy, to be followed in the event of situations of serious or imminent danger

5. Scope

This Health and Safety Policy applies to all staff at the Trust (that is, all those who perform work for, or on behalf of, the Trust), as defined in section 6. It is recognised that people are the most important resource in the organisation, and therefore it is important to equip all staff with appropriate health and safety resources and training.
The Trust will ensure suitable and sufficient resources are available to meet the requirements of this policy.

6. Definitions and abbreviations

6.1 Definitions

Risk assessment: A careful examination of what, in the course of the Trust's work, could cause harm to people, so that the Trust can weigh up whether it has taken enough precautions or should do more to prevent harm.
Staff: The Trust uses the skills of many different people, all of whom are vital to our work. This includes people on differing employment terms, who for the purposes of this policy we refer to as 'staff':

all salaried employees, including those seconded into the Trust

all workers

all office holders

all prospective employees and workers who are part-way through recruitment

contractors and sub-contractors

committee, sub-committee, and advisory group members (who may not be directly employed or engaged by the organisation)

all agency workers
Office holders: Refers to the Chair and Non-Executive Directors.
Senior staff members: The Workstream Leads, until such time as the Executive Directors and Specialty Directors are in post.
Supervisors: Those who supervise 'workers', for example Specialty Directors and Pathway leads.
Line managers: Those who supervise or line manage substantive staff.

6.2 Abbreviations

RIDDOR: Reporting of Injuries, Diseases and Dangerous Occurrences Regulations
H&S: Health and safety
HSE: Health and Safety Executive (national regulator for workplace health and safety in the UK)

7. Duties and responsibilities

Health and safety responsibilities by role
Role	Responsibility
Programme Director	Overall responsibility for health and safety within the Trust. Ensures the policy is implemented, resourced, monitored and reviewed. Oversees all health and safety matters, including ensuring suitable processes are in place for managing, monitoring and reviewing health and safety management arrangements. Reports findings from health and safety processes to the appropriate Trust committees with responsibility for overseeing health and safety. Ensures the Trust's health and safety management arrangements reflect best practice. Ensures the timely reporting of reportable RIDDOR incidents to the HSE and implements and maintains robust arrangements to ensure their responsive follow up including from any lessons learned.
Chair and Non-Executive Directors	Ensure the Programme Director and senior staff members fulfil their responsibilities for this policy.
Senior staff members	Implement the Trust Health and Safety Policy within their area of responsibility. Monitor health and safety performance through team meetings and ensure action plans are implemented. Ensure health and safety responsibilities are assigned to managers and supervisors or line managers within their structure. Establish measures for planning and setting priorities and objectives to address specific hazards to health and safety in line with Trust policies, objectives and risk profile. Allocate resources to health and safety improvement activities within the business planning of their area of responsibility. Ensure preventative and protective measures to reduce risk are developed and implemented within their area of responsibility. Ensure that all staff undertake and remain compliant with their mandatory training, where this has not been undertaken as part of a different NHS organisation, or similar. If the latter applies, senior staff members will check that these staff have undertaken the relevant training appropriately. Ensure systems to report, record and investigate incidents and near misses are implemented and responsively maintained.
Trust Secretary	Board level responsibility for raising awareness of and advising on the organisation's compliance with legal and statutory requirements and maintaining good corporate governance. Sources any professional advice and guidance required by the Trust on matters relating to health and safety or on specific risk assessments where a professional level of expertise is required, for example display screen equipment. Keeps the Trust aware of changes or updates to statutory requirements or guidance that impact upon the Trust and ensures this policy is kept up to date. Ensures the Trust develops and reviews policy, procedures, protocols, and safe working practices to meet statutory requirements and minimise risk.
Supervisors and line managers	Assist their staff in meeting their health and safety responsibilities. Ensure they are familiar with the Trust health and safety policy and supporting procedures and protocols. Responsible for the health, safety and welfare of the staff whom they supervise, and all users of the workplaces for which they are responsible. Ensure their staff are aware of and able to utilise the arrangements in place which protect their health and safety. Ensure risk assessments are completed and shared with team members and ensure that they are reviewed and updated on a regular basis. Ensure action plans are developed and implemented to enable preventative and protective measures identified from risk assessment. Ensure Trust incident reporting procedures are implemented and accidents, incidents, 'near misses' and complaints are reported as per Trust procedures. Ensure incident investigation is carried out at local level and that lessons are learnt and action is taken. Ensure timely reporting of incidents to the Programme Director to enable reporting under RIDDOR within the required time frame. Bring to the prompt attention of senior staff members any health and safety issues that require further action.
All staff	Take reasonable care of the health and safety of themselves and others who might be affected by any actions or omissions. Co-operate with their managers and comply with all relevant health and safety policies and procedures and risk control measures. Act in accordance with any health and safety information, instruction or training that has been provided or given to them. Familiarise themselves with Trust policy, procedures, protocols and guidance or preventative and protective measures relating to health and safety that have been brought to their attention by risk assessments. Report any hazards or defects in the equipment, arrangements or procedures and systems of work regarding health and safety to their immediate line managers as soon as possible. Report any incidents or dangerous occurrences occurring to them or brought to their attention (regardless of any injury or not) responsively by informing their immediate line manager and completing the Trust incident report form. Take responsibility for attending and participating in agreed training sessions about health and safety as requested by their manager or supervisor.
Contractors	Carry out their work in accordance with the requirements of this policy. Provide evidence to senior staff that they have suitable experience and have complied and worked safely on previous jobs. Act in accordance with any health and safety information (including any site-specific regulations within the contract requirement), instruction or training that has been provided or given to them.
Programme Management Office	Supports the development of and reporting from risk management and incident reporting systems. Ensures intelligence on health and safety themed risks and incidents is appropriately reported and arrangements are in place to track actions in response through the relevant management group or Board Committee.

8. Specific details to explain the policy

8.1 The process

Everyone is responsible for the health and safety of everyone else at work. All staff have a legal duty of care under the Health and Safety at Work etc. Act 1974, to ensure the safety of others, including colleagues, patients, contractors and others affected by the Trust's work.
In order to comply with this duty of care, all staff must be aware of the lines of communication and levels of responsibility, which exist to ensure that matters of health, safety and welfare can be dealt with adequately.

8.2 Risk assessment

Risk assessment is key to effective and sensible health and safety risk management. The findings from risk assessments must be used to identify, prioritise and control risks at all levels in the Trust. A range of different specific risk assessment tools are available to managers and staff.
Managers will ensure significant hazards in the workplaces and work activities under their control (where applicable) have been suitably risk assessed and, consequently, that risks are adequately controlled.
Under the Management of Health and Safety at Work Regulations 1999, senior staff, as well as supervisors and line managers, are expected to identify what could cause injury or illness in the business (hazard), decide how likely it is that someone could be harmed and how seriously (the risk), and take action to eliminate the hazard or, if this is not possible, control the risk.
The Trust's Risk Management Policy includes a risk assessment framework and risk scoring matrix. As necessary, in accordance with the Trust Risk Management Policy, unresolved significant health and safety concerns must be entered on the Trust's Risk Register.

8.3 Accident and incident reporting and investigation

Accident and incident investigations provide an opportunity for the reactive assessment of effective control of health and safety risks. They also provide an opportunity for learning and the development of new risk controls. All accidents and incidents must be recorded, reported and investigated in accordance with the Trust's Incident Reporting Policy.
Managers must ensure their staff are aware of and follow the Trust's Incident Reporting Policy. Managers will review all reported incidents (including accidents) which occur in their service area and investigate certain incidents further, for example those incidents which either are serious or are frequent. The main purpose of the investigation is to identify and implement suitable measures which reduce the likelihood of a similar accident occurring.
Managers will review periodically (for example every quarter) all reported incidents (including accidents) in their service area to identify any trends, for example the frequent occurrence of the same type of incident, or increasing numbers of accidents overall. Suitable action should be taken where the review reveals a worsening health and safety performance, for example a review of risk assessments.
Senior staff members should, with support from supervisors and line managers, have oversight of all reports of hazards or defects from any member of staff, alongside any actions (or the rationale for no action) being taken to address these.
All incidents reportable under RIDDOR (2013) will be subject to an investigation, the level of which will be commensurate with the severity of the incident. Any incidents that are notifiable under RIDDOR will be reported to the HSE.

8.4 Internal audits

It is best practice for annual safety audits to be undertaken, therefore the Trust's Internal Audit service is likely to audit the Trust's health and safety management arrangements. The audit findings, and any actions required to be completed, will be cascaded to the relevant staff for action and reported at the appropriate Trust Committees.

9. Training requirements

Health and safety information and training will be provided for staff as part of their induction and, subsequently, as part of the Trust's statutory and mandatory training arrangements, where this has not been undertaken as part of another role in a different organisation or similar. Any other specific or specialist health and safety training necessary for the staff in their relevant area of work will be identified through the risk assessment process and staff appraisals.
Refresher training will be provided to staff at intervals specified by the Trust statutory and mandatory training arrangements.

10. Implementation and dissemination

The requirements of this policy will be implemented by all staff.
This policy will be published on the intranet (via Teams) for access by all staff.

11. Monitoring and audit

Monitoring criteria and methods
Monitoring criterion (what is being monitored to ensure the policy is effective)	Monitoring method (evidence of compliance, regularity of reporting, lead staff, where reported)
Ensure risk assessments have been undertaken by all teams; these will be carried out utilising standard templates found on the intranet.	Managers to ensure all staff in their team are aware of where to find and undertake risk assessments using standard templates.
Compliance by all staff and departments with all health and safety policies and procedures, as outlined in the health and safety policy.	Managers to ensure all staff comply with health and safety policies and procedures.
Where risks are highlighted from reviews, ensure there is an action plan in place (with a named lead) to mitigate or reduce the risk, with dates in place to follow up on actions. Any significant risks requiring urgent actions to be reported to senior staff members for immediate attention.	Report findings to the relevant Board committee or management group and follow up on any anomalies with the relevant team. Significant risks with urgent actions to be addressed in a timely manner and reported to the relevant Board committee or management group at the time. Lessons learnt from non-compliance will be documented and fed back to all relevant staff, and incorporated, where relevant, into refresher training.
All staff have completed the health and safety induction and training relevant to their area of work. Staff are aware of mandatory refresher health and safety training requirements.	Corporate governance team to maintain a log of all staff and compliance with health and safety training. They will use this to ensure that all mandatory and refresher training is up to date and to issue reminders to staff when relevant.

Equality impact assessment

The author of this policy has undertaken an equality impact assessment and concluded that there is no negative impact on any of the protected characteristics. The policy applies to all Trust activities and to all staff working for or on behalf of the Trust. Following consultation with key groups, no negative impact has been identified for any protected characteristic.

Equality impact assessment by protected characteristic
Protected characteristic	Negative impact?	Rationale
Age	No	No negative impact identified. The policy applies equally to all age groups.
Sex	No	No negative impact identified. The policy applies equally to all genders.
Gender reassignment	No	No provisions in the policy differentiate on the basis of gender identity or reassignment.
Race	No	No negative impact identified. The policy does not introduce race-based criteria.
Disability	No	No negative impact. The policy supports reasonable adjustments.
Religion or belief	No	The policy is neutral regarding religion or belief and does not affect religious practices.
Marriage and civil partnership	No	No provisions relate to marital or partnership status.
Pregnancy and maternity	No	No negative impact on these staff members. The policy does not highlight anything specific in this area.
Sexual orientation	No	The policy is neutral regarding sexual orientation.