Health and Safety and Risk Assessment Policy

For use by [Provider Organisation Name] Ltd, a CQC-registered adult social care service.

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Scope: This policy applies to all CQC-registered adult social care services provided by [Provider Organisation Name] Ltd, across all regulated settings and for all individuals supported by the organisation.
Not in scope: Services or activities not regulated by the Care Quality Commission (CQC).

1. Purpose

The purpose of this policy is to ensure the health, safety, and welfare of all persons we support, staff, and others who may be affected by the organisation’s activities. This includes creating and maintaining a safe environment, minimising risks, and fostering a culture of safety across all regulated activities. By implementing this policy, the organisation demonstrates its commitment to compliance with legal and regulatory requirements, as well as its dedication to upholding the dignity, rights, and wellbeing of individuals.

The Health and Safety at Work etc. Act 1974 places a legal duty on employers to ensure, so far as is reasonably practicable, the health, safety, and welfare of employees and others who may be affected by their operations. Similarly, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, particularly Regulations 12 and 15, require providers to assess and mitigate risks to service users and ensure that premises and equipment are safe and suitable for use. Failure to meet these obligations can result in harm to individuals, regulatory action, reputational damage, and potential legal consequences. This policy provides a structured approach to identifying, assessing, and managing risks, ensuring that all activities are carried out safely and responsibly.

The organisation recognises that a proactive approach to health and safety is essential to prevent accidents, incidents, and near-misses. This policy underpins the organisation’s commitment to continuous improvement in health and safety practices, ensuring that risks are not only identified but also effectively controlled. It also ensures that all staff are equipped with the knowledge, training, and resources necessary to fulfil their responsibilities in maintaining a safe environment.

To achieve these aims, the policy is designed to:

• Protect the health, safety, and welfare of persons we support, staff, visitors, contractors, and others who may be affected by the organisation’s activities.
• Ensure compliance with all relevant health and safety legislation, regulations, and guidance, including the Health and Safety at Work etc. Act 1974, the Management of Health and Safety at Work Regulations 1999, and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
• Promote a culture of safety and risk awareness throughout the organisation, encouraging staff to identify and report hazards and to take an active role in maintaining a safe environment.
• Provide a framework for the systematic identification, assessment, and management of risks, ensuring that appropriate controls are implemented and reviewed regularly.
• Ensure that all premises, equipment, and activities are safe, suitable, and properly maintained, in line with Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

By adhering to this policy, the organisation aims to create a safe and supportive environment where persons we support can live with dignity and independence, staff can work without fear of harm, and visitors and contractors can engage with the service confidently. This policy is a cornerstone of the organisation’s commitment to delivering high-quality, person-centred care in a safe and compliant manner.

2. Scope & Applicability

This policy applies universally across all regulated activities and settings operated by the organisation, ensuring a consistent approach to health and safety and risk assessment. It is designed to protect the health, safety, and welfare of all individuals who interact with the organisation, including staff, contractors, visitors, and the persons we support. By clearly defining the scope and applicability, the organisation ensures that all parties understand their responsibilities and the measures in place to mitigate risks. This is essential to meet the requirements of the Health and Safety at Work etc. Act 1974 and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, particularly Regulations 12 (Safe care and treatment) and 15 (Premises and equipment).

The policy is relevant to all CQC-registered adult social care services provided by the organisation, regardless of the specific setting. This includes, but is not limited to, care delivered in residential care homes, supported living environments, day centres, and individuals’ own homes. Where specific health and safety measures differ by setting, these are addressed within the relevant sections of the policy to ensure compliance and operational clarity. The risks associated with each setting are proactively managed through tailored risk assessments and safeguards, ensuring that the organisation maintains a safe environment for all.

Applicability

This policy applies to the following groups and contexts:

• Staff: All employees, whether permanent, temporary, bank, or agency, as well as volunteers. This includes those working on-site, remotely, or in community-based roles.
• Persons we support: All individuals receiving care and support from the organisation, irrespective of the setting in which the service is delivered.
• Contractors and visiting professionals: Any external individuals or organisations providing services, maintenance, or professional input on the organisation’s premises or within the scope of its regulated activities.
• Visitors: Family members, friends, advocates, and other individuals visiting persons we support or the organisation’s premises.
• Premises and equipment: All locations and equipment registered under the organisation’s CQC registration, including residential care homes, supported living properties, office spaces, and vehicles used for service delivery.

Coverage

The policy encompasses all aspects of health and safety and risk management relevant to the organisation’s regulated activities, including but not limited to:

• Risk assessment processes for identifying and mitigating hazards.
• Workplace safety, including fire safety, manual handling, and infection prevention and control.
• Safe use and maintenance of equipment, including compliance with the Lifting Operations and Lifting Equipment Regulations (LOLER) 1998.
• Management of hazardous substances under the Control of Substances Hazardous to Health (COSHH) Regulations 2002.
• Lone working protocols to protect staff operating in isolated or high-risk environments.
• Reporting and investigation of incidents, accidents, and near-misses, including compliance with the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 2013.

Universal Application Across Settings

This policy is designed to be universally applicable across all settings where the organisation operates. For example:

• In residential care homes: The policy ensures that premises are safe, fire safety measures are in place, and risks to residents are continuously assessed and mitigated.
• In supported living environments: The policy addresses the unique risks of shared living spaces while respecting the autonomy of individuals.
• In persons’ own homes: The policy ensures that staff are equipped to assess and manage risks in environments not directly controlled by the organisation, such as private residences.
• In community-based services: The policy includes provisions for lone working, safe travel, and dynamic risk assessment in unpredictable environments.

By applying this policy consistently across all regulated activities and settings, the organisation ensures compliance with legal and regulatory requirements while fostering a culture of safety. This approach not only protects individuals but also supports the organisation’s commitment to delivering high-quality, person-centred care.

3. Legal & Regulatory Framework

The legal and regulatory framework governing health and safety and risk assessment in CQC-registered adult social care services is extensive and designed to ensure the safety, welfare, and dignity of the people we support, as well as staff, visitors, and contractors. Compliance with these requirements is not optional; it is a legal duty and a fundamental expectation of the Care Quality Commission (CQC) under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Failure to adhere to these laws and regulations can result in enforcement action, including fines, suspension of services, or even criminal prosecution. More importantly, non-compliance puts people at risk of harm, undermines trust, and damages the organisation’s reputation.

The framework is underpinned by a combination of statutory legislation, regulatory requirements, and recognised good practice guidance. It requires providers to adopt a proactive approach to identifying, assessing, and managing risks, ensuring that all reasonable steps are taken to prevent harm. This includes maintaining safe environments, implementing robust risk assessment processes, and fostering a culture of safety. Providers must also ensure that staff are adequately trained, competent, and supported to fulfil their health and safety responsibilities. The following laws, regulations, and standards form the foundation of this framework and must be embedded into all aspects of service delivery.

Key Legislation and Regulations

1. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014:

   • Regulation 12: Safe Care and Treatment (In force): Requires providers to assess risks to the health and safety of service users and take all reasonably practicable steps to mitigate them. This includes ensuring that care and treatment are provided in a safe way.
   • Regulation 15: Premises and Equipment (In force): Mandates that premises and equipment are clean, secure, suitable for their purpose, properly maintained, and used in a safe way.

2. Health and Safety at Work etc. Act 1974 (In force):

   • Places a general duty on employers to ensure, so far as is reasonably practicable, the health, safety, and welfare of employees and others affected by their activities. This includes providing safe systems of work, adequate training, and appropriate supervision.

3. Management of Health and Safety at Work Regulations 1999 (In force):

   • Requires employers to conduct suitable and sufficient risk assessments for all work activities, implement control measures, and appoint a competent person to assist with health and safety compliance.

4. Regulatory Reform (Fire Safety) Order 2005 (In force):

   • Imposes a duty to carry out fire risk assessments, implement fire safety measures, and ensure the safety of all relevant persons in the event of a fire.

5. Control of Substances Hazardous to Health (COSHH) Regulations 2002 (In force):

   • Requires the assessment and control of risks associated with hazardous substances, including safe storage, handling, and disposal.

6. Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 2013 (In force):

   • Mandates the reporting of specific work-related incidents, diseases, and dangerous occurrences to the Health and Safety Executive (HSE).

7. Lifting Operations and Lifting Equipment Regulations (LOLER) 1998 (In force):

   • Governs the safe use of lifting equipment, including regular inspections and maintenance.

8. Equality Act 2010 (In force):

   • Requires reasonable adjustments to be made to ensure that individuals with disabilities are not placed at a disadvantage in accessing services or employment.

Relevant Standards and Guidance

• CQC Quality Statements (Regulator guidance):

  • Safe — S1: Learning Culture of Safety: Providers must demonstrate a commitment to safety and learning from incidents.
  • Safe — S2: Assessing Risk: Providers must have robust systems for identifying, assessing, and managing risks.

• NICE Guidance NG211: Managing Medicines for Adults Receiving Social Care in the Community (Good practice):

  • Provides recommendations on safe and effective medicines management, which intersects with health and safety responsibilities.

• HSE Guidance (Good practice):

  • Includes sector-specific advice on managing risks, such as manual handling, lone working, and workplace stress.

Operational Requirements

To ensure compliance with the legal and regulatory framework, the organisation must:

• Maintain an up-to-date register of all applicable legislation and guidance, with clear links to internal policies and procedures.
• Conduct regular audits to assess compliance with health and safety laws and regulations, documenting findings and actions taken.
• Provide mandatory training to all staff on health and safety legislation, tailored to their roles and responsibilities.
• Ensure that risk assessments are conducted, documented, and reviewed in line with statutory requirements, using approved templates.
• Report all RIDDOR-notifiable incidents to the HSE within the required timescales and maintain records for at least three years.
• Appoint a competent person to oversee health and safety compliance and provide advice to the Registered Manager.

Common Pitfalls

• Failing to review risk assessments after incidents or changes in circumstances.
• Inadequate training or failure to evidence training records during inspections.
• Poor documentation of safety measures, making it difficult to demonstrate compliance.
• Overlooking the need for fire risk assessments or Personal Emergency Evacuation Plans (PEEPs).

By embedding these legal and regulatory requirements into everyday practice, the organisation can ensure a safe environment for all and maintain compliance with CQC standards.

4. Risk Assessment Process

The risk assessment process is a cornerstone of ensuring the health, safety, and wellbeing of the persons we support, staff, and others who may be affected by our activities. It is both a legal requirement under the Health and Safety at Work etc. Act 1974 and a regulatory expectation under Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. A robust risk assessment process enables the organisation to identify potential hazards, evaluate the likelihood and severity of harm, and implement proportionate measures to mitigate risks. Failure to conduct thorough and timely risk assessments can lead to harm, regulatory breaches, enforcement action, reputational damage, and loss of trust from service users and stakeholders.

Effective risk assessment is a proactive process that requires input from staff, the persons we support, and other stakeholders. It must be dynamic, reflecting changes in circumstances, environments, and individual needs. Good practice involves not only identifying risks but also embedding a culture of safety where staff are empowered to report hazards and contribute to the development of risk management strategies. This section outlines the step-by-step process for identifying, assessing, managing, and reviewing risks, ensuring compliance with legal and regulatory standards while promoting a safe and supportive environment.

4.1 Step-by-Step Risk Assessment Process

1. Identify Hazards

   • Observe the environment, activities, and equipment to identify anything that could cause harm.
   • Engage with staff, the persons we support, and other stakeholders to gather insights on potential risks.
   • Review incident reports, complaints, and feedback to identify recurring or emerging hazards.

2. Determine Who Might Be Harmed and How

   • Consider all individuals who may be affected, including the persons we support, staff, visitors, contractors, and the public.
   • Identify specific vulnerabilities, such as mobility issues, sensory impairments, or medical conditions.
   • Document how the identified hazards could impact these individuals.

3. Evaluate Risks and Implement Controls

   • Use a 5x5 risk matrix to assess the likelihood and severity of harm (see Section 3.2 for matrix details).
   • Categorise the risk level (Green, Amber, Orange, Red) and determine the urgency of action.
   • Identify and implement control measures to eliminate or reduce the risk to an acceptable level. Controls may include:
     • Engineering controls (e.g., installing safety barriers or alarms).
     • Administrative controls (e.g., updating procedures or providing training).
     • Personal protective equipment (PPE) as a last resort.

4. Record Findings

   • Complete the Risk Assessment Form (HS-RA-001), ensuring all sections are fully documented.
   • Include details of the hazard, who is at risk, the risk level, and the control measures implemented.
   • Ensure the assessment is signed and dated by the person completing it and the Registered Manager.

5. Communicate and Implement

   • Share the findings and control measures with relevant staff and stakeholders.
   • Provide training or guidance where necessary to ensure understanding and compliance.
   • Display or store the risk assessment in an accessible location for reference.

6. Monitor and Review

   • Review risk assessments at least annually or sooner if:
     • There is a significant change in circumstances (e.g., new equipment, processes, or environments).
     • An incident, near-miss, or complaint highlights a potential gap in the current assessment.
     • Feedback from staff or the persons we support indicates a need for reassessment.
   • Update the Risk Assessment Form (HS-RA-001) with any changes and ensure all relevant parties are informed.

4.2 Roles and Responsibilities

• Registered Manager: Ensures all risk assessments are completed, reviewed, and stored appropriately. Reviews high-risk assessments and escalates unresolved risks to senior management.
• Competent Person: Provides technical advice and support on health and safety matters, including risk assessments.
• Staff: Participate in identifying hazards, implementing control measures, and reporting changes or concerns.
• Persons We Support: Where appropriate, are involved in the risk assessment process to ensure their needs and preferences are considered.

4.3 Evidence and Records

• Completed Risk Assessment Forms (HS-RA-001) for all identified hazards.
• Training records demonstrating staff competency in risk assessment and control measures.
• Incident reports and investigation records linked to risk assessment reviews.
• Meeting minutes or communications evidencing the dissemination of risk assessment findings.

4.4 Worked Scenario

Scenario: A person we support has recently transitioned to using a wheelchair and requires assistance with transfers. Staff report concerns about manual handling risks.

Process:

1. Identify Hazards: The potential for injury during transfers due to inadequate equipment or training.
2. Determine Who Might Be Harmed: The person we support and staff assisting with transfers.
3. Evaluate Risks: Using the 5x5 matrix, assess the risk as "High" (Orange) due to the likelihood of injury and the severity of harm.
4. Implement Controls: Provide a hoist and train staff in its use. Develop a personalised manual handling plan for the individual.
5. Record Findings: Document the assessment on HS-RA-001, including the control measures and training provided.
6. Monitor and Review: Review the assessment after one month to ensure the controls are effective and adjust as needed.

Common Pitfall: Failing to involve the person we support in the assessment process, leading to a plan that does not fully address their preferences or needs.

By following this structured process, the organisation ensures a consistent, thorough approach to risk management that protects all stakeholders and meets regulatory expectations.

5. Health and Safety Procedures

Ensuring a safe environment is a fundamental responsibility of any CQC-registered adult social care service. This section outlines the specific procedures required to maintain health and safety across all settings, including infection prevention, fire safety, equipment safety, and emergency preparedness. These procedures are designed to protect the people we support, staff, visitors, and contractors from harm, while also ensuring compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and the Health and Safety at Work etc. Act 1974. Failure to implement robust health and safety procedures can result in harm to individuals, regulatory breaches, enforcement actions, and reputational damage.

Good practice in health and safety involves proactive risk management, clear communication, and regular training. All staff must understand their roles in maintaining a safe environment, and the organisation must provide the necessary resources, training, and oversight. This includes ensuring that all equipment is safe to use, infection prevention measures are strictly adhered to, fire safety systems are maintained, and emergency plans are in place and regularly tested. The procedures below provide a structured approach to achieving these outcomes.

5.1 Infection Prevention and Control (IPC)

• Hand Hygiene: All staff must adhere to the "5 Moments for Hand Hygiene" as defined by the World Health Organization (WHO). Alcohol-based hand rub or soap and water must be available at all points of care.
• Personal Protective Equipment (PPE): PPE must be provided and used in accordance with risk assessments and UK Health Security Agency (UKHSA) guidance (In force). This includes gloves, aprons, and masks where appropriate.
• Cleaning Protocols: Cleaning schedules must be in place for all areas, with high-touch surfaces (e.g., door handles, light switches) cleaned at least twice daily. Cleaning products must comply with BS EN 14476 standards for virucidal activity.
• Waste Management: Clinical waste must be segregated and disposed of in line with the Department of Health and Social Care (DHSC) guidance (Statutory guidance). Sharps bins must be used for all needles and disposed of when two-thirds full.
• Outbreak Management: In the event of an infectious disease outbreak, the Registered Manager must implement the organisation’s outbreak management plan and notify the local Health Protection Team within 24 hours.

5.2 Fire Safety

• Fire Risk Assessments: A fire risk assessment must be completed for each location and reviewed annually or after any significant change. This must include identification of fire hazards, people at risk, and control measures.
• Fire Drills: Fire drills must be conducted at least every six months, with outcomes recorded and lessons learned shared with staff.
• Fire Equipment Maintenance: Fire alarms must be tested weekly, emergency lighting monthly, and fire extinguishers serviced annually. Records must be maintained for all tests and servicing.
• Evacuation Plans: Personal Emergency Evacuation Plans (PEEPs) must be in place for all individuals requiring assistance during an evacuation. These must be reviewed every six months or after any change in the person’s needs.
• Training: All staff must complete fire safety training at induction and annually thereafter.

5.3 Equipment Safety

• Maintenance and Servicing: All equipment used in the provision of care (e.g., hoists, wheelchairs, medical devices) must be maintained and serviced in line with manufacturer guidelines. Records of servicing must be kept for inspection.
• LOLER Compliance: Lifting equipment must undergo a thorough examination every six months by a competent person, as required by the Lifting Operations and Lifting Equipment Regulations (LOLER) 1998.
• Pre-Use Checks: Staff must complete pre-use safety checks on all equipment before each use. Any faults must be reported immediately, and the equipment must be taken out of service until repaired.
• Training: Staff must be trained in the safe use of all equipment relevant to their role, with refresher training provided annually.

5.4 Emergency Preparedness

• Emergency Plans: Each location must have an up-to-date emergency plan covering scenarios such as fire, flood, power failure, and medical emergencies. Plans must be accessible to all staff and tested annually through drills.
• First Aid: Adequate first aid provision must be available at all times. This includes maintaining a fully stocked first aid kit and ensuring that at least one trained first aider is on-site during operational hours.
• Business Continuity: A business continuity plan must be in place to ensure the continuation of critical services during emergencies. This must include contact details for key personnel and suppliers.
• Communication: Emergency contact numbers, including [Local Authority Safeguarding Team telephone] and emergency services, must be prominently displayed in all settings.

5.5 Records and Evidence

The following records must be maintained and made available for inspection:

• Infection control audits and cleaning schedules.
• Fire risk assessments, drill logs, and equipment maintenance records.
• Equipment servicing logs and LOLER certificates.
• Emergency plans, PEEPs, and business continuity plans.
• Staff training records for IPC, fire safety, and equipment use.

Worked Scenario: Fire Evacuation in a Supported Living Setting

During a routine fire drill in a supported living setting, it is discovered that one individual’s PEEP does not account for their recent mobility decline. The drill highlights delays in evacuating the individual safely. The Registered Manager updates the PEEP the same day, arranges additional staff training, and schedules a follow-up drill within one month to test the revised plan. This proactive approach demonstrates compliance with fire safety regulations and ensures the individual’s safety.

Common Pitfalls

• Failing to review risk assessments and emergency plans after changes in circumstances.
• Inadequate training or lack of refresher courses for staff.
• Missing or incomplete records of equipment servicing and fire drills.
• Poor communication of emergency procedures to temporary or agency staff.

By adhering to these procedures, the organisation ensures a safe environment for all individuals and demonstrates compliance with regulatory requirements.

6. Safeguards and Preventative Measures

Safeguards and preventative measures are essential to ensuring the safety and wellbeing of the persons we support, staff, and others who may be affected by our activities. These measures are designed to prevent harm by addressing potential risks before they materialise, in line with the Health and Safety at Work etc. Act 1974 and Regulations 12 and 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Effective safeguards reduce the likelihood of accidents, incidents, and near-misses, and demonstrate compliance with CQC’s expectations under the "Safe" key question.

Preventative measures must be embedded into daily operations and supported by a culture of safety. This includes ensuring staff are adequately trained, appropriate personal protective equipment (PPE) is available and used correctly, and regular safety checks are conducted. A failure to implement these measures could result in harm to individuals, regulatory breaches, reputational damage, and potential legal consequences. Good practice involves proactive identification of hazards, consistent application of controls, and ongoing monitoring to ensure their effectiveness.

Staff Training

Staff training is a cornerstone of harm prevention. All staff must be equipped with the knowledge and skills to perform their roles safely and to identify and mitigate risks. Training requirements include:

• Induction Training: All new staff must complete health and safety training during their induction, including fire safety, manual handling, infection prevention and control, and the correct use of PPE.
• Ongoing Training: Staff must complete refresher training annually or as required by their role. For example:
  • Manual handling training for staff involved in assisting persons with mobility needs.
  • COSHH training for staff handling hazardous substances.
  • Lone working training for staff who work independently.
• Specialist Training: Where specific risks are identified, staff must receive additional training (e.g., managing challenging behaviour, first aid, or evacuation procedures for persons with mobility impairments).

Training records must be maintained and updated by the [Designated Training Lead] to evidence compliance. Staff competency must be assessed periodically through supervision, observation, and audits.

Personal Protective Equipment (PPE)

PPE is a critical control measure for minimising exposure to hazards that cannot be eliminated or reduced through other means. The organisation must ensure:

• Availability: PPE is readily available, appropriate to the task, and compliant with relevant standards (e.g., gloves, aprons, masks, eye protection).
• Use: Staff are trained in the correct use, fitting, and disposal of PPE. For example:
  • Gloves and aprons must be worn during personal care tasks or when handling bodily fluids.
  • Masks and eye protection must be used where there is a risk of splash or airborne transmission of infectious agents.
• Maintenance: Reusable PPE (e.g., goggles) must be cleaned and stored according to manufacturer guidelines. Damaged or expired PPE must be replaced immediately.
• Monitoring: Supervisors must ensure PPE is used consistently and correctly during routine observations and audits.

Records of PPE distribution and usage must be maintained to ensure stock levels are adequate and to identify trends in usage.

Regular Safety Checks

Regular safety checks are essential for identifying and addressing hazards before they result in harm. These checks must be systematic, documented, and tailored to the specific risks of each setting. Key safety checks include:

• Daily Checks: Staff must conduct visual inspections of the environment, equipment, and any high-risk areas (e.g., kitchens, bathrooms) at the start and end of each shift. Any hazards identified must be reported immediately to the [Designated Health and Safety Officer].
• Weekly Checks: Fire alarms, emergency lighting, and first aid kits must be tested or inspected weekly. Any deficiencies must be rectified without delay.
• Monthly Checks: A more comprehensive inspection of the premises, including the condition of flooring, furniture, and fixtures, must be conducted monthly by the [Facilities Manager] or equivalent role.
• Annual Checks: Equipment requiring statutory inspections (e.g., hoists, lifts, fire extinguishers) must be serviced annually or as per manufacturer guidelines.

All checks must be recorded on the relevant forms (e.g., HS-SC-001: Daily Safety Checklist, HS-SC-002: Monthly Safety Inspection Form) and reviewed by the Registered Manager. Any identified risks must be added to the location’s risk register, with actions assigned and tracked to completion.

Worked Scenario

Scenario: A staff member notices a frayed electrical cable on a kettle in a communal kitchen during a daily safety check. They immediately unplug the kettle, place a sign to indicate it is out of use, and report the issue to the [Designated Health and Safety Officer]. The officer arranges for the kettle to be replaced within 24 hours and updates the risk register. The incident is reviewed during the next team meeting to reinforce the importance of daily checks.

Common Pitfalls:

• Failing to document safety checks or training, leading to gaps in evidence during inspections.
• Inconsistent use of PPE, particularly in high-risk tasks such as personal care or cleaning.
• Delayed action on identified hazards, increasing the risk of harm.

By implementing robust safeguards and preventative measures, the organisation ensures a proactive approach to health and safety, fostering a safe environment for all individuals involved in its services.

7. Roles & Responsibilities

Ensuring the health, safety, and welfare of all individuals within the organisation is a shared responsibility that requires clear delineation of roles and accountability. The Health and Safety at Work etc. Act 1974 and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 place legal obligations on providers to maintain a safe environment for staff, the people we support, and others who may be affected by our activities. Failure to meet these responsibilities can result in harm, regulatory action, reputational damage, and legal consequences. Therefore, it is essential that all stakeholders understand their specific duties and act in accordance with this policy.

Good practice in health and safety management involves a proactive approach where responsibilities are clearly defined, communicated, and monitored. This includes ensuring that staff at all levels are competent, trained, and supported to fulfil their roles. Effective implementation of health and safety measures requires collaboration between operational staff, managers, and external stakeholders such as contractors and visiting professionals. The following outlines the specific responsibilities of key roles within the organisation.

7.1 All Staff

All staff, including permanent, temporary, agency, and volunteers, have a duty to:

• Take reasonable care for their own health and safety and that of others who may be affected by their actions or omissions.
• Comply with the organisation’s health and safety policies, procedures, and risk assessments.
• Report any hazards, unsafe conditions, or near-misses immediately to their line manager or the designated health and safety lead.
• Use equipment, including personal protective equipment (PPE), in accordance with training and instructions.
• Participate in mandatory health and safety training and refresher courses as required.
• Cooperate with investigations into accidents, incidents, or near-misses and provide accurate information.

7.2 Line Managers and Supervisors

Line managers and supervisors play a critical role in embedding a culture of safety within their teams. Their responsibilities include:

• Ensuring that all team members are aware of and comply with health and safety policies and procedures.
• Conducting regular team briefings to discuss health and safety matters and address any concerns raised by staff.
• Ensuring that risk assessments are completed for all activities, reviewed regularly, and updated following any incidents or changes in circumstances.
• Monitoring staff adherence to safe working practices and addressing any non-compliance through supervision and performance management processes.
• Supporting staff to access appropriate training and development opportunities to maintain competence in health and safety matters.
• Reporting all incidents, near-misses, and hazards to the Registered Manager or health and safety lead within [insert timeframe, e.g., 24 hours].

7.3 Registered Manager

The Registered Manager holds overarching responsibility for health and safety within their service. Their duties include:

• Ensuring the implementation, monitoring, and review of this policy and associated procedures.
• Appointing a competent person to oversee health and safety matters, as required by the Management of Health and Safety at Work Regulations 1999.
• Ensuring all risk assessments are completed, documented, and reviewed at least annually or following any significant change or incident.
• Maintaining the service’s risk register and ensuring it is updated regularly.
• Investigating all incidents and near-misses within 48 hours and ensuring appropriate corrective actions are taken.
• Reporting RIDDOR-notifiable incidents to the Health and Safety Executive (HSE) within the required timescales.
• Ensuring that health and safety is a standing agenda item at team meetings and governance reviews.
• Allocating sufficient resources to ensure compliance with health and safety requirements, including training, equipment, and staffing levels.

7.4 Health and Safety Lead

The health and safety lead, appointed by the Registered Manager, is responsible for:

• Providing expert advice and guidance on health and safety matters.
• Supporting the completion and review of risk assessments, including COSHH and fire risk assessments.
• Conducting regular health and safety audits and inspections, documenting findings, and reporting to the Registered Manager.
• Coordinating health and safety training for all staff and maintaining training records.
• Ensuring that all health and safety equipment, such as fire extinguishers and first aid kits, is maintained and accessible.
• Liaising with external agencies, such as the HSE and local fire authorities, to ensure compliance with statutory requirements.

7.5 Contractors and Visiting Professionals

All contractors and visiting professionals must:

• Comply with the organisation’s health and safety policies and procedures while on site.
• Provide evidence of their own health and safety policies and risk assessments, where applicable.
• Report any hazards, incidents, or near-misses to the Registered Manager or health and safety lead immediately.
• Follow any specific instructions provided by the organisation regarding health and safety.

7.6 Governance and Oversight

The organisation’s senior leadership team is responsible for:

• Ensuring that health and safety is embedded within the organisation’s strategic objectives and operational plans.
• Reviewing health and safety performance through regular governance meetings and audits.
• Allocating adequate resources to support health and safety initiatives and compliance.
• Ensuring that the Registered Manager and health and safety lead are supported in fulfilling their responsibilities.

Evidence of Compliance

To demonstrate compliance with this section, the following records must be maintained and made available for inspection:

• Training records for all staff, including dates and content of health and safety training.
• Completed and reviewed risk assessments.
• Incident and near-miss reports, including investigation outcomes and corrective actions.
• Minutes of team meetings and governance reviews where health and safety was discussed.
• Records of equipment maintenance, servicing, and inspections.
• Evidence of RIDDOR notifications submitted to the HSE.

By clearly defining and adhering to these roles and responsibilities, the organisation ensures a robust framework for managing health and safety risks, promoting a culture of safety, and meeting regulatory requirements.

8. Monitoring, Audit & Review

Effective monitoring, auditing, and review processes are essential to ensure the ongoing compliance, effectiveness, and improvement of this Health and Safety and Risk Assessment Policy. Regular oversight not only ensures adherence to legal and regulatory requirements, such as those outlined in the Health and Safety at Work etc. Act 1974 and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, but also fosters a culture of safety and continuous improvement within the organisation. Failure to monitor and review health and safety practices can lead to non-compliance, increased risk of harm to individuals, reputational damage, and potential enforcement action by the Care Quality Commission (CQC) or the Health and Safety Executive (HSE).

Monitoring involves the routine collection and analysis of data to identify trends, gaps, or areas of concern. Auditing provides a structured and systematic evaluation of compliance with this policy and associated procedures. Reviewing ensures that the policy remains fit for purpose and reflects current legislation, guidance, and best practice. Together, these processes provide assurance to the organisation, the people we support, and regulators that health and safety risks are being effectively managed.

Monitoring

The organisation will implement ongoing monitoring mechanisms to ensure compliance with this policy and the identification of potential risks. Monitoring activities include:

• Daily Checks: Designated staff (e.g., team leaders or shift supervisors) will conduct daily visual inspections of the environment, equipment, and working practices to identify immediate hazards or non-compliance.
• Incident Reporting and Analysis: All accidents, incidents, near-misses, and dangerous occurrences must be reported promptly using the Incident Report Form (HS-IR-001). The Registered Manager will review incident reports within 48 hours to identify trends, root causes, and any required corrective actions.
• Health and Safety Metrics: Key performance indicators (KPIs), such as the number of reported incidents, near-misses, and completed risk assessments, will be monitored monthly by the Registered Manager and reported to senior management.

Auditing

The organisation will conduct formal audits to verify compliance with this policy and identify opportunities for improvement. Audits will be carried out as follows:

• Internal Health and Safety Audits: Conducted quarterly by the designated Health and Safety Lead or an appointed competent person. These audits will assess compliance with key aspects of the policy, including risk assessments, fire safety measures, COSHH compliance, and incident reporting.
• External Audits: Where required, external audits will be conducted by qualified health and safety consultants or other competent third parties to provide an independent assessment of compliance and identify best practices.
• Audit Records: All audit findings, actions, and outcomes will be documented in the Health and Safety Audit Log (HS-AUD-001). Action plans arising from audits must be completed within agreed timescales, with progress monitored by the Registered Manager.

Policy Review

This policy will be reviewed at least every three years or sooner if there are significant changes in legislation, guidance, or organisational practices. The review process will include:

• Annual Review of Risk Assessments: All risk assessments must be reviewed annually or following any incident, near-miss, or significant change in circumstances. This ensures that they remain current and effective.
• Consultation with Stakeholders: Feedback from staff, the people we support, and other stakeholders will be sought during the review process to ensure the policy remains practical and relevant.
• Approval and Dissemination: The reviewed policy will be approved by senior management and disseminated to all staff. Staff will be required to confirm their understanding and adherence to the updated policy.

Escalation and Reporting

• Any significant health and safety concerns identified during monitoring or audits must be escalated to the Registered Manager immediately.
• Quarterly health and safety reports, including audit findings, incident trends, and progress on action plans, will be presented to the organisation’s governance meetings.
• RIDDOR-reportable incidents must be notified to the HSE within statutory timescales, and the organisation will cooperate fully with any external investigations.

Evidence of Compliance

To demonstrate compliance with this section, the following records must be maintained and made available for inspection:

• Daily health and safety checklists.
• Completed Incident Report Forms (HS-IR-001) and investigation records.
• Health and Safety Audit Logs (HS-AUD-001) and associated action plans.
• Risk assessment reviews and updates.
• Minutes of governance meetings discussing health and safety.
• Records of policy dissemination and staff acknowledgements.

By embedding robust monitoring, auditing, and review processes, the organisation ensures a proactive approach to health and safety, reducing risks and promoting a safe environment for all.

9. References and Live Links

This section provides a comprehensive list of the legal, regulatory, and best practice guidance referenced in this policy. These references form the foundation of the organisation’s health and safety and risk assessment framework, ensuring compliance with statutory obligations and alignment with recognised standards. Staff and managers must be familiar with these sources to understand the rationale behind the policy’s requirements and to access further detail where necessary.

All references are current at the time of this policy’s publication. It is the responsibility of the [Policy Owner] to ensure these references are reviewed and updated as part of the policy review process or when significant legislative or regulatory changes occur. Live links are provided where available to facilitate access to the most up-to-date versions of these documents.

Statutory Legislation

1. Health and Safety at Work etc. Act 1974 (In force)
   The primary legislation governing workplace health and safety in the UK. It places a duty on employers to ensure, so far as is reasonably practicable, the health, safety, and welfare of employees and others affected by their activities.
   https://www.legislation.gov.uk/ukpga/1974/37

2. Management of Health and Safety at Work Regulations 1999 (In force)
   Requires employers to conduct risk assessments, implement preventative measures, and appoint competent persons to manage health and safety.
   https://www.legislation.gov.uk/uksi/1999/3242/contents/made

3. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (In force)
   Specifically, Regulation 12 (Safe care and treatment) and Regulation 15 (Premises and equipment) outline requirements for risk assessment and maintaining safe environments.
   https://www.legislation.gov.uk/uksi/2014/2936/contents/made

4. Regulatory Reform (Fire Safety) Order 2005 (In force)
   Establishes fire safety duties for employers and building owners, including the requirement for fire risk assessments and fire safety management.
   https://www.legislation.gov.uk/uksi/2005/1541/contents/made

5. Control of Substances Hazardous to Health (COSHH) Regulations 2002 (In force)
   Requires the assessment, control, and monitoring of hazardous substances to prevent harm to health.
   https://www.legislation.gov.uk/uksi/2002/2677/contents/made

6. Lifting Operations and Lifting Equipment Regulations (LOLER) 1998 (In force)
   Governs the safe use of lifting equipment, including regular inspections and maintenance.
   https://www.legislation.gov.uk/uksi/1998/2307/contents/made

7. Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 2013 (In force)
   Specifies the requirements for reporting work-related accidents, diseases, and dangerous occurrences to the Health and Safety Executive (HSE).
   https://www.legislation.gov.uk/uksi/2013/1471/contents/made

Regulatory Guidance

8. CQC Fundamental Standards (Regulator guidance)
   Includes requirements under the Safe domain, particularly S1 (Learning Culture of Safety) and S2 (Assessing Risk), which align with this policy’s objectives.
   https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulations-service-providers-managers

9. Health and Safety Executive (HSE) Guidance (Regulator guidance)
   Provides practical advice on complying with health and safety law, including risk assessments, COSHH, and RIDDOR.
   https://www.hse.gov.uk/

Best Practice Guidance

10. NICE Guideline NG211: Managing Medicines for Adults Receiving Social Care in the Community (Good practice)
    Offers guidance on safe medicine management, which intersects with health and safety considerations in community care settings.
    https://www.nice.org.uk/guidance/ng211

11. NICE Guideline NG140: Workplace Health: Management Practices (Good practice)
    Recommends effective health and safety management practices to promote workplace wellbeing.
    https://www.nice.org.uk/guidance/ng140

12. UK Health Security Agency (UKHSA) Infection Prevention and Control Guidance (Good practice)
    Provides infection prevention and control measures relevant to health and social care settings.
    https://www.gov.uk/government/organisations/uk-health-security-agency

Internal Documents

13. Health and Safety Procedure (UNI-MCP-015-PROC)
    Outlines the operational processes for implementing this policy, including templates for risk assessments and incident reporting.
    [Insert organisation-specific link or location]

14. Risk Assessment Form (HS-RA-001)
    Template for conducting and documenting risk assessments.
    [Insert organisation-specific link or location]

15. Incident Report Form (HS-IR-001)
    Template for reporting accidents, incidents, and near-misses.
    [Insert organisation-specific link or location]

Notes

• Staff should use the live links provided to access the most current versions of external documents.
• For internal documents, refer to the organisation’s [Intranet/Shared Drive/Policy Portal] or contact the [Policy Owner] for assistance.
• Any updates to the references listed above must be reflected in this section during the next policy review.