Residential Care Health and Safety Management Audit

Health and Safety System

Audit report

Policies and Procedures

Policies and procedures are reviewed on regular basis and updated to reflect best practice, standards and legislation. Policies are in placed and documented rationally to determine skill mix and staffing levels. Roster is provided for appropriate coverage for effective delivery of services to the client at all times.

The trust uses a combination of computer based planning for cares and documentation based information. The long term care plan is computer based and a printed out summary placed in front of the clients file. There is a lifestyle questionnaire for residents which provides information regarding the resident’s past and present likes and dislikes. Intervention are planned round those hobbies with set timeframe. Certain activities are planned out as well. Food, culture, religious beliefs are also considered.

Accident records

Interview with the Team leader it was found that the trust has no incident and accident record file onsite. All accident and incident reports are documentation, investigated within 24 hours of occurrence. Reported to and reviewed by the clinical coordinator. Corrective measures initiated immediately and data compiled on the data base and the paper work sent to the main office where it is kept in file.

Standards

NZS8134:2008 Health and Disability Services Standards are followed in policies ensuring appropriate standard comply with clients rights and services provided in a manner that clients are respected, minimises harm, facilitate choice and acknowledges persons culture, value and beliefs. Also services are effectively communicated to the residents and their whanau.

ISO standard is also followed in policies where there is food handling involved and to ensure services are reliable and of quality for residents, whanau and staff.

Job Description

Each and every person at Agape Trust is responsible to comply with current occupational Health and Safety (OSH) legislation and safety at work. Everyone works safely at all times; uses safety equipment provided; identify hazards and report instantly; encourage others to work safely; monitoring of own health and measures to improve when necessary. Also safe evacuation of residents and others during emergency; maintain safe environment for self, staff and residents. The General Manager is to be reported of any concern regarding security or any other issues.

Training Records

Was unable to site the training records as it kept in the office at all times. Interview with the team leader the following information was gathered. When required or requested by team leader, be involved in on the job training and service orientation of staff and volunteers. In house health and safety training in form of induction provided to new workers and volunteers. All staff to possess a valid First Aid Certificate, participate in refresher course, external training and qualification based on certified training.

Manuals

Manuals on how to use equipments available and kept in files. No written safety rules developed and posted around the equipment. Little attempt is made to control hazardous points on equipment. For example the treadmill is located near the door way to the laundry. Manuals on working with equipment and hazardous substances can easily be obtained at anytime.

Hazard Register

Hazard Register updated and accessed easily for handling common issues, hazards, causes with controls and options to assist control. It also has tools, resources and case studies. The register consist of hazard such as slips,trips,falls, manual handling, hitting stationery objects, challenging behaviours, exposure to trauma, stress, workplace violence, workplace bullying, security, shift work and hazardous substances. The hazards recorded were minimised, eliminated or isolated. It has been updated by the General Manager and initials of each worker after reading and understanding it.

Inventories

All inventories are hand written in books and updated bi monthly basis by the team leader and the clinical coordinator. Inventories expiry is checked and damaged equipment replaced or fixed. The data is then transferred to the computer for records.

Health and Safety System

Organisational Requirement

Have they been met? (No, partly, mostly, fully)

Policies and Procedures

Fully met

Policies and procedures are checked and updated. The safety procedures are in formats that are easily understood and special communication needs of people using the building taken into consideration as well. The staffs is familiar with the health and safety arrangements at the work place. There are policies and procedures around waste management, cleaning, laundry. Emergency management and the staff are fully aware of them. Policies and procedures also in placed for safe practice and staffs are closely monitored all times.

Organisational Management

Mostly met

There is enough qualified staff on duty at the Trust all times. The trust provides cares for highly needy clients with intellectual disability so experienced and qualified staff should be available at all time. The staff rooster is updated weekly. So the staffs have received adequate orientation and training before starting work.

Accident Records

Not met

There are no records of previous accident records at the Trust. All accident records are sent to the main office where data is transferred to the computer and the paper stored in file.

Organisational requirement.

The trust should have an accident record file with previous accident records present at the premises as this may help for future references.

Standards

Fully Met

Checking with residents, interview with team leader, staff ensured that policies support consumer rights under this standard. Resident’s well informed of their rights; personal privacy is protected and suffers no discrimination.

Organisational Requirements

The standards have been approved by Ministry of Health under the Act and set the standards for health and disability services. Standards have been reviewed yearly which includes general standards, core standards, infection prevention and control standards, restraint minimisation standards, organisational management and providing of safe environment.

Job Description

Fully Met

All staff at the Trust has clear roles and responsibilities and their use their knowledge and skills to promote a positive health and safety culture in the workplace. As organisational and legislative requirement, each worker has to comply with safety policies and practices and their help in planning, implementing and monitoring of protective and preventative safety measures at workplace.

All staff has written job descriptions and written copy of their terms and conditions of employment before commencing with the job.

Training Records

Not met

Staff files not updated. Document such as training undertaken and completed not found.

Organisational requirement

Long standing staff needs their competency and skills assessed to determine the need for further training. The trust needs staff training and development programmes to maintain skills, meet the changing needs of the residents, fulfil the aims of the Trust and understanding the policies and procedures of the organisation and suitable competent to carry out their roles.

The Manager should ensure that minimum mandatory training requirements for all his staff are met and updated on regular basis and records are maintained

Manuals

Fully Met

Manual of every equipment present for safety reasons. The manuals are updated by the management on regular basis. Copies of manual printed out and placed in areas where it can be easily accessed.

Hazard Register

Partially Met.

The Hazard Register is not updated, certain risk was identified but corrective measures still needs to be in place. The register has written confirmation of all statutory relating to fire safety and standards complied during fire drill.

Organisational requirement

The manager has to ensure that the risk assessment is carried out for all areas of work. To manage the identified risk that have been recorded, corrective action has to be implemented and all staff to be aware of any hazards identified and a control put in place. The Manager has to review the risk management records on regular basis. He also has to see to the events including accidents injuries and incidents of fire records and fire drills. Staff uses appropriate protective clothing and equipment suitable for the work to reduce the risk of harm and injuries to others and also to themselves.

Inventories

Partially Met.

All inventories are recorded and later data transferred to the computer for future reference. The organisation keeps all the required inventories for safety reasons.

The broken and old equipment should be discarded and replaced with the new equipment.

Organisational requirement

To reduce the risk of harm and safety old, broken equipment should to be replaced.

Health and Safety Systems

Legislative Requirement

Organisational Requirements

Policies and Procedures

Fully Met

Policies and procedures comply with health and safety legislation for maintaining and providing safety and healthy work place, minimise risk in work practise for welfare of everyone and environment

The safety procedures are in formats that are easily understood and special communication needs of people using the building taken into consideration as well. The staffs are familiar with the health and safety arrangements at the work place.

Emergency management and the staff are fully aware of them. Policies and procedures also in placed for safe practice and staff are closely monitored all times.

Accident Records

Partially Met

All organisations should have an accident record put in placed at all times. Staffs are to fill any form of accident or incident occurring at the work place.

An accident record file with previous accident records should be present at the premises as this may help for future references.

All accident and incident reports are documentation, investigated within 24 hours of occurrence. Reported to and reviewed by the clinical coordinator. Corrective measures initiated immediately and data compiled on the data base and the paper work sent to the main office where it is kept in file.

Standards

Fully Met

The standards are aimed to ensure respect, protection of the rights of people at the Trust and that the standards are qualitative which provides meaning to the residents life

Standards have been reviewed yearly which includes general standards, core standards, infection prevention and control standards, restraint minimisation standards, organisational management and providing of safe environment.

Job Description

Fully Met

Staffs are qualified, competent and experienced to manage needs of intellectual disabled clients and also meet the purpose, aims and objectives of the organisation. Job description enables an individual to have authority and take up responsibilities for duties assigned.

The staffs have to ensure that all legally required certificate and licences are updated and displayed when required. The organisation ensures that each staff gets proper orientation before commencing of his or her duties.

Manuals

Almost Met.

Manuals should be in place for all staff to refer to for procedures on health and safety and corrective measures of using certain equipment.

Manuals on how to use equipments available and kept in files. No written safety rules developed and posted around the equipment. Copies of manual printed out and placed in areas where it can be easily accessed.

Hazard Register

Partially Met

Hazard register is updated and kept to carry out risk assessment of the work area. Action taken around the identified risk. Clear procedure in placed setting out the action to be taken together with reporting requirements. Significant events such as accidents, injuries, dangerous occurrence and incidents of fire are recorded and updated. Staff wears appropriate protective clothing and equipment in times of emergencies.

The manager has to ensure that the risk assessment is carried out for all areas of work. To manage the identified risk that have been recorded, corrective action has to be implemented and all staff to be aware of any hazards identified and a control put in place. The Manager has to review the risk management records on regular basis. He also has to see to the events including accidents injuries and incidents of fire records and fire drills. Staff uses appropriate protective clothing and equipment suitable for the work to reduce the risk of harm and injuries to others and also to themselves.

Training Records

Partially Met.

Promotion of safe working practice through acknowledging provision of information, training, monitoring, supervision of staff under safe working environment, fire safety, infection control, manual handling, first Aid, food safety, maintaining of equipment, personal safety at work.

The Manager should ensure that minimum mandatory training requirements for all his staff are met and updated on regular basis and records are maintained. Staff needs their competency and skills assessed to determine the need for further training.

Inventories

Partially Met.

Organisation should be up to date equipped with necessary resources at the facility to maintain health and safety. An inventories record should available at all times with expiry dates for equipment.

The organisation keeps all the required inventories for safety reasons.

The broken and old equipment should be discarded and replaced with the new equipment. To reduce the risk of harm and safety old, broken equipment should to be replaced.

Health and Safety

System

Degree of Compliance

Assessment of the significance of

Hazards

Cost Benefit

Analysis

Policies and Procedures

Compliance

No risk – organisation meets the requirements

Nil

Accident Records

Non Compliance

properly completed accident forms and records should be kept

High risk of hazard

No accident records present, staff may not know how to handle on similar types of accidents as no references available.

Low cost – printing of materials, buying a file and filing of documents.

Standards

Compliance

No risk – organisation meets with all requirement

Nil

Job Description

Compliance

No risk – organisation meets with all requirements.

Nil

Manuals

Non Compliance

High risk of hazard. Most manuals are old, torn and out dated.

Low cost – reprinting of manuals.

Benefit would be for safeguard.

Hazard Register

Non Compliance

no records of eliminating, isolating or minimising on file.

High risk of hazard – no proper records available for future references. Proper and corrective action taken should be in place and recorded in file.

Low cost – buying a folder and filing of the documents.

Benefit – for safeguard

Training Records

Non Compliance

High risk of hazard – long serving staff not aware of new ideas and manage changing behaviours of clients. Staffs not up to date with training, staff personal information not complete.

Medium cost – in house training for staff. A yearly staff training calendar posted in staff room to ensure all staff receives proper training. Refresher course made available for long serving staff and that they are up to date with qualification.

Inventories Record

Non Compliance

High risk of hazard – staff may be use expired and broken equipment which may cause harm and injuries to themselves as well as to the residents. Also to reduce the risk of infection at the facility it is best for the organisation to maintain adequate resources at all times

Low cost – a proper exercise book bought and all data entered in the journal which later transferred to the computer.

medium cost – for the right equipment and resources such as gloves, hand wash, soaps and toilet paper and cleaning material

Overall Strategies

Corrective Action

Accident Records

• Ensuring that there are two people signing off all accidents.
• The team leader ensures all documents are properly filled
• The manager and clinical coordinator amends policies for accidents and incidents register

Monitoring of Hazards

• Modifying ways to monitor hazards and recording them. Assigning a person to be in charge of monitoring the register.
• Working with team leaders, clinical coordinator and manager to develop and implement ideas.

Training

• Conducting in house trainings for staff – infection control, fire control.
• External training – First Aid certification and CPR training.
• Refresher courses – handing washing, medication competency and manual handling.
• Professional development training – Diploma in healthcare, Mental health, Treaty of Waitangi, rights and ethics, leadership courses.
• Challenging behaviour management courses.
• Qualification based on certificates – Diploma, NZQA qualification and certification
• Modification of induction training – orientation at work, interviews and appraisal.

Manuals

• Working with team leaders and management to improve the manuals, communication styles suitable for everyone to understand. Printing out simple procedures and making attractive charts with diagram illustrations.

Inventories

• One of the staff is assigned to keep checks on supplies and resources.
• The team leader checks the inventory journal at all times.